Pain pumps (intrathecal drug delivery)

A pain pump, also called an intrathecal drug delivery system, is a round device about the size of a hockey puck. It sits under the skin of the belly and is connected to a thin, soft tube (catheter). The catheter runs under the skin to the back and into the intrathecal space, the fluid-filled space around the spinal cord.

Because the medicine goes straight to the spinal cord, where pain signals pass on their way to the brain, it does not have to travel through the whole body first. A dose of morphine in the spine can be roughly 300 times smaller than the same effect by mouth. That usually means less drowsiness, confusion, nausea and constipation.

The pump is programmed with a small computer tablet held over the skin. Many systems also come with a handheld remote that lets you give yourself a small extra dose within safe limits your doctor sets.

On an X-ray, the pump looks like a round metal disc in the belly, and the catheter is a thin line that curves around the side and enters the spine in the lower back.

Pain pumps are for severe, long-lasting pain that other treatments have not controlled, or when pain pills work but cause side effects you cannot live with. They are especially helpful for cancer pain. In a well-known trial of people with cancer pain, those who received a pump had better pain control and fewer drug side effects than those on medicines alone.

For people with a limited life expectancy from cancer, a pump can still make sense when pain is severe. Your care team, including your oncologist or palliative care team, helps weigh the benefit against the recovery time.

Other choices include a spinal cord stimulator, nerve blocks such as a celiac plexus block for pancreatic cancer pain, and targeted procedures described on our cancer pain treatment page.

Before a pump is implanted, you try the medicine in your spine to see how well it works. The most common trial is a single injection, similar to a lumbar puncture. You lie on your side or stomach, the skin of the lower back is numbed, and a thin needle places a small dose into the spinal fluid under X-ray guidance. It usually takes 15 to 30 minutes.

You are then watched for several hours, sometimes overnight, while nurses check your breathing, blood pressure and pain. Some doctors instead place a temporary catheter and give the medicine over a few days. The trial is considered a success if your pain drops by about half or more without side effects you cannot tolerate.

During a trial with opioids, your usual pain pills may be reduced to keep you safe. Follow the plan your team gives you exactly.

More general advice is on before your procedure.

1. 1
   Preparing

   You get antibiotics through an IV and general anesthesia or deep sedation. You lie on your side so both the back and belly can be reached.

2. 2
   Placing the catheter

   Through a small incision in the lower back, a needle is guided into the spinal fluid under X-ray. The thin catheter is threaded up to the right level and anchored in place.

3. 3
   Placing the pump

   A second incision is made on the side of the belly, and a pocket is made under the skin. The catheter is tunneled under the skin around your side and connected to the pump, which is already filled with medicine.

4. 4
   Closing and programming

   Both incisions are closed with stitches and skin glue. The pump is programmed to start at a low dose before you wake up.

The implant usually takes 1 to 3 hours. Many people stay in the hospital overnight or for a day or two so the dose can be adjusted safely and breathing can be watched.

1. First few days
   Soreness at both incisions is normal. A tight abdominal binder may help. Lie flat if you get a headache when sitting up, and let us know.
2. First 2 weeks
   Keep incisions clean and dry. No baths, hot tubs or swimming. A wound check visit is usually 1 to 2 weeks after surgery.
3. First 6 weeks
   Avoid heavy lifting, bending and twisting so the catheter can settle. Walking is encouraged.
4. First few months
   The dose is adjusted at clinic visits until you have the best balance of relief and side effects. Your pain pills are usually lowered slowly.
5. Every 1 to 3 months
   Refill visit. The pump is refilled through the skin with a needle in about 20 to 30 minutes.

At a refill visit, the pump is located under the skin, the skin is cleaned, and a needle is passed into the center port of the pump. The old medicine is removed and new medicine is added. It feels like a quick shot. The pump then tells the team how much medicine is left and when to come back. The battery usually lasts about 5 to 7 years, and the pump is then replaced in a shorter procedure using the same catheter.

Most people who have a successful trial get meaningful pain relief from the pump and can take far fewer pain pills, or stop them. The pump does not remove the cause of pain, and the dose often needs adjusting over time.

When I talk with someone about a pain pump, I ask what the pain pills are taking away from them, whether it is clear thinking, appetite or time awake with family. The pump is a commitment to regular refills, so I want patients and families to understand that part as well as the benefits. For many people with cancer pain, being able to think clearly again matters as much as the pain score.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos