A 56-year-old male sustained cervical spinal cord injury and developed C-4 complete tetraplegia in May 2001. He underwent implantation of a programmable pump for intrathecal delivery of baclofen, in the anterior abdominal wall in October 2001. This tetraplegic patient was prescribed warfarin to prevent deep vein thrombosis. He developed a spontaneous, right-sided, perinephric haematoma, which became infected with a resistant strain of Pseudomonas aeruginosa. The haematoma was located on the same side as the baclofen pump. We were unsure of the best approach for insertion of a percutaneous drainage catheter without unduly exposing the patient to the risk of the procedure per se, or risk of infection spreading from the perinephric space to baclofen pump.
The patient with cervical spinal cord injury had painful shoulders. He was also suffering from severe trigeminal neuralgia. He was a high-risk case for inhalation anaesthesia on account of his neurological level, gross obesity, poor venous access and especially so, in the setting of radiology department. Positioning this patient on his abdomen without anaesthetising him, for insertion of a catheter from behind into the perinephric space, was virtually impossible. In the prone position, his voluntary ventilation would have been inadequate. Further, a tube for delivery of baclofen from the pump located in the anterior abdominal wall, to the subarachnoid space, coursed around the abdomen to enter the theca posteriorly by the side of L-3 spine.
Since the perinephric collection was presenting in the lumbar region anteriorly, percutaneous drainage was carried out by an anterior approach while the patient was lying supine. The patient received 3/4 ml of Cyclimorph-10 (morphine tartrate 10 mg and cyclizine tartrate 50 mg per ml) as premedication. Target-controlled sedation with a plasma concentration of propofol of 0.5 microgram/ml was administered using a Graseby 3400 TCI pump during the radiological procedure, which lasted about ten minutes.
A size 8 Fr. pigtail catheter was inserted through the anterior abdominal wall into right perinephric space while the patient was lying supine. The site of entry of percutaneous catheter was close to the cephalic end of baclofen pump. The position of the catheter as it emerged anteriorly from the right perinephric space is shown in Figures 1 and 2. The direction of exit of the catheter from the perinephric space is quite different in this patient from that of a traditional approach for drainage of a kidney or perinephric haematoma. In the classical approach for drainage of a perinephric haematoma, the catheter would emerge posteriorly from the perinephric space. The proximity of the drainage catheter as it exits the anterior abdominal wall, to the cephalic end of baclofen pump, is shown in the CT scan of abdomen. (Figure 3). The catheter can be seen exiting to the right of the cephalic end of the baclofen pump.
Clinical photograph of front of abdomen of this tetraplegic patient shows the precise anatomical location of the catheter, as the catheter comes out of the anterior abdominal wall. (Figure 4). A two dimensional relationship of the pigtail catheter draining the perinephric haematoma to the baclofen pump may be appreciated in the scanogram taken during CT of abdomen (Figure 5). The classical way of placing a pigtail catheter from behind for drainage of a kidney is illustrated in figure 6. This photograph was taken from another tetraplegic subject, who had undergone percutaneous nephrostomy. For placement of a pigtail catheter in the renal pelvis, this tetraplegic subject was positioned on his abdomen and the puncture was made in the lumbar region posteriorly. When figure 6 is compared with figure 4, the differences between the anterior and posterior surgical approaches become very obvious.
Starting from the day of radiological intervention, this patient received colistin, two million units every eight hours, for eleven days. Eighteen days later, he was prescribed amikacin one gram, every 24 hours, for seven days. The skin around the pigtail catheter became slightly inflamed and red. (Figures 4). After he had received colistin and amikacin, a swab, taken from the site of pigtail catheter, showed a heavy growth of Pseudomonas aeruginosa, which was resistant to gentamicin, tazocin and tobramycin. The drainage fluid from the pigtail catheter turned purulent and culture yielded growth of Pseudomonas aeruginosa resistant to gentamicin and tobramycin. When the patient's clinical condition improved, we considered the option of resiting the catheter from behind. By then, the perinephric collection had become smaller; there were septa within the perinephric space. Therefore, we did not remove the catheter and resite it from the back.
The catheter was removed ten weeks after it had been inserted into the right perinephric space. Prior to removal of the catheter, microbiology of pus, drained by the pigtail catheter, showed a heavy growth of Pseudomonas aeruginosa sensitive to colistin, but resistant to gentamicin and tazocin. A swab taken from the site of entry of the catheter, which was inflamed, showed a heavy growth of Pseudomonas aeruginosa sensitive to colistin and amikacin, but resistant to tazocin, gentamicin and tobramycin. After removal of the catheter, the patient was prescribed amikacin 500 mg intravenously every 12 hours for five days and then, colistin 2 million units 12 hourly for seven days on the basis of the most recent microbiology reports. Twenty-five days later, a sample of urine was sent for microbiology. This showed growth of Pseudomonas aeruginosa sensitive to colistin, but resistant to ciprofloxacin, ceftazidime, imipenem and gentamicin. There has been no clinical evidence of infection of the baclofen pump with Pseudomonas aeruginosa.
