Non-healing wound over an IT pump

[Force440]

I'm looking for some advice on how to handle this case.

I have a 76 year old male with a history of numerous low back surgeries. He is fused from L3-S1 and has conservative therapies. I implanted a pump in March. His 10 day post-op visit was unremarkable. 2 weeks after the implant, he fell, sliding off of his bed onto the floor and sustained abrasion to the skin over his pump, well below the incision line. I saw him back for a recheck in early June and he had developed a remarkable eschar directly over the ITP. He was sent to wound care and for the last 7 weeks they've been treating him. They removed the eschar but since then there has been excessive fibrinous slough that has needed to be debrided. They don't want to debride any more for fear of opening the pump pocket.

Clinically, the patient looks good. There is no evidence of infection (erythema, drainage, fevers, chills, etc . . . ). His pain is well controlled on hydromorphone 0.32 mg/day via his ITP.

Should I just excise the diseased skin and re-approximate healthy tissue, or should I explant and get better quality sleep at night?

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[lobelsteve]

More and better pics.
Edges look healed and scarred, would make it unlikely to heal further.
Will take some effort to close this up. Could punt to plastics or work with general surgery in OR to clean it up/debride margins.
Get an Epifix 4x4 in the wound bed, or hylomatrix type stuff. Needs cleaning up.

 

[drrosenrosen]

Agree this is advanced wound management, outside of your realm as a pain doctor/sometimes surgeon. Get some other eyes on it if you don't want to take it out. Also, isn't that wound right over his refill port?

 

[Ronin1]

I would explant. Otherwise it’s going to torture u. He’s on a fairly low dose of IT meds

 

[Orin]

It's a wide elliptical incision or Z-plasty to excise that defect. You can do it if you're comfortable with the surgical technique but it's a good case for a surgeon. Academic shop so easy for me to consult plastics or general surgery to help.

I'd also consider explant and reimplant in another pocket. There's something not right in that tissue.

I would wean the dose as I'd worry about seeding the device if you go through that. When's the refill due?

 

[Force440]

I sincerely appreciate the input!

Yes, the wound is directly over the pump refill port, and there is no way I'd refill through that wound. Fortunately, he's on a very low dose and converting him to orals should not be problem.

The plan is to explant via wide elliptical incision. I spoke with a local surgeon who I've operated with several times over the years. He's comfortable with me explanting with this approach and didn't feel that he needed to scrub in, but is willing to poke his head into the OR during my case.

 

[bedrock]

It has to be said that this is a good example of why pumps don’t make sense outside of terminal cancer or severe spasticity.

 

[MitchLevi]

I'm def not about to say anything bc I just had to pull a stimulator out for an infxn. Haha.

 

[Orin]

It has to be said that this is a good example of why pumps don’t make sense outside of terminal cancer or severe spasticity.

Nothing about this is specific to a pump, as it could just as easily be an SCS.

 

[Ducttape]

i would agree that you should explant, have the surgeon repair the eschar, and put the pump somewhere else.

i cannot see how you plan on refilling that pump over the next 20 years by going through that tissue.

Nothing about this is specific to a pump.

well, the fact that you have to inject through that area once every 2-3 months might be.

 

[lobelsteve]

i would agree that you should explant, have the surgeon repair the eschar, and put the pump somewhere else.

i cannot see how you plan on refilling that pump over the next 20 years by going through that tissue.

well, the fact that you have to inject through that area once every 2-3 months might be.

When the pump opening is visible, you can never miss.

 

[bedrock]

Nothing about this is specific to a pump, as it could just as easily be an SCS.

I agree. However, unnecessary pumps are avoidable. That is the take home message.

If a therapy doesn’t work well and has a high risk of complications or just a high risk of ER calls to you every time your geriatric patient gets a UTI, then it’s best to never go down that road at all.

 

[epidural man]

I don’t do pump management so…

But I agree with others

1. Move the pump
2. Plastics consult
3. EpiFix

 

[Baron Samedi]

Nothing about this is specific to a pump, as it could just as easily be an SCS.

The complication itself isn't specific to a pump, but the long term management is. If that was a terminal cancer pt with a 6mo prognosis I would consider just doing wound care, then come refill time bring them to the OR and open up the pocket and refill that way with a more concentrated solution so you never have to do it again.

 

[Centurion38]

Probably have a small hematoma or seroma under there which is preventing adequate healing of the wound. Will be interesting to see when you get in there. You can ellipse that out but you'll have to take a fairly wide margin to get out the scar and unhealthy tissue. Make sure to get really good hemostasis and close skin with nylons.

 

[Asclepius186]

Nothing about this is specific to a pump, as it could just as easily be an SCS.

Coming from someone who doesn’t manage pump…

While this could happen to a stimulator, The size of pumps seem to make these more common in pump implants. Seen several oddball things like this in partners pumps. Hardly ever in SCS generator sites…