Intrathecal Pump

The Intrathecal Pump

When all other Chronic Pain options (non-invasive and invasive options) have been properly implemented, but resulted in failure to control severe chronic pain, the intrathecal pump option may be the last option.

What is an Intrathecal Pump?

An Intrathecal Pump is an advanced pain therapy device surgically  implanted beneath the skin.  Also known as “Pain Pumps” and “intrathecal drug delivery systems (IDDS)”, an intrathecal pump delivers pain medication directly to the intrathecal space (area surrounding the spinal cord).

The intrathecal pump is actually 2 components: the pump and the catheter.  Both components are surgically implanted beneath the skin.

The pump component is about the size of a hockey puck.  It contains a reservoir for intrathecal medication (usually an opioid) along with the necessary miniature electronic “wizardry” to control the dispensing (flow rate) of intrathecal medication from the reservoir.  The pump is usually surgically implanted in the lower left or right abdominal quadrant, or in the upper right or left upper buttocks.

The catheter component is “tubing”  This “tubing” is connected to the pump with the opposite end (tip) surgically anchored at the appropriate level within the spinal intrathecal space.

Below is an image of an implanted Intrathecal Pump system:

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Intrathecal pumps are a relatively new technology

In 1898, soon after the discovery of cocaine as a local anesthetic, August Bier documented the first spinal analgesia by injecting cocaine into his own intrathecal space.  Continuous spinal analgesia was first used in the 1940s, but it was the discovery of opiate receptors in the spinal cord in 1973 that provided a scientific rationale for this form of treatment.

The development of infusion pumps in the early 1970s allowed for greater flexibility in administering intrathecal opiates. The first reported successful use of intrathecal morphine for the treatment of intractable cancer pain was in 1979.  The first use of an implantable intrathecal drug delivery system (IDDS) was reported in 1981 with the first externally programmable, battery-powered IDDS pump introduced in 1991.

During the past 24 years there have been continual improvements in intrathecal pumps.  Several new companies have entered the marketplace bringing “safer” features to intrathecal pumps with a wider range of intrathecal pump medications.

Here is a list of intrathecal pump medications:

* Morphine

* Hydromorphone

* Bupivacaine

* Clonidine

* Fentanyl

* Baclofen

* Ziconotide (Prialt)

It’s common practice to combine 2 or more intrathecal pain medications based upon an individuals cause, type and severity of chronic pain.

Here is a list of intrathecal pump devices:

 

Medtronic SynchroMed II infusion system (Medtronic Inc., Minneapolis, MN, USA)

-Largest market share and longest provider in the industry

-Wide range of programmability

-Personal Therapy Manager (PTM); patient bolus feature

-Shorter Battery Life; 4-7 years

-Peristaltic pump roller system; 85% Accurate

-MRI Compatible

 

Prometra II programmable pumps system (Flowonix Medical Inc., Mount Olive, NJ, USA)

-New provider; significant focus on patient safety

-New valve-gated dose regulation system; 97% Accurate

-15-20 self-checks done every cycle (about every 30 min); if any problem is detected (battery, flow, etc) pump shuts off and alarms

-Specific refill needle works in the refill port; accidentally filling via catheter port not possible.

-Natural Aspiration-avoids pocket fills

-Max Flow rate control of 10 mcl

-Personal Therapy Manager (PTM); patient bolus feature

-MRI Compatible

 

Medstream programmable infusion system (Codman and Shurtleff, Inc.)

-catheter design resists kinking and tearing, and uses compressed gas as  the driving force as well as a ceramic drive flow valve system to maintain  the infusion

-FDA Approved, but not available yet

 

Medallion (Alfred Mann Foundation, Los Angeles, CA, USA)

-negative pressure reservoir to reduce risk of pocket fill.

-unique pressure sensor at the catheter tip, thus alerting the patient/ physician to unanticipated changes in flow

-Awaits FDA Approval

 

To read more click on the following link:

Current Perspectives on Intrathecal Drug Therapy

 

Why would anyone need or want such an invasive, complicated device??

Good question.

If you or a loved one suffers from severe, unrelenting Chronic Pain then you should understand why an intrathecal pump may be an option to be seriously considered.

Those that live with severe Chronic Pain have a limited number of available options to help them manage and cope with their pain.  Click on the following mypainweb link to review the options:

mypainweb; interventions

When severe Chronic Pain continues and worsens despite implementing all available options, long term oral opioid therapy is a last resort.  Long term oral opioid therapy is a dismal option; full of complications and controversies.  Click on the mypainweb link below to read more:

mypainweb: Medication: The Good, The Bad, and the Ugly

One quickly sees that long term oral opioid therapy achieves only marginal relief while creating many serious opioid side effects that reduce quality of life, further complicating the painweb.

 

Enter in…the Intrathecal Pump option

The intrathecal pump uses only a fraction of the opioid medication which normally would be required with continual round-the-clock dosages of oral opioid pain medication, while yielding the same pain relief.  Converting opioid dosages involves some mathematical calculations.  The following conversion demonstrates how less intrathecal opioid is needed to achieve the same level of relief from oral form:

300 milligrams of oral morphine = 1 milligram of intrathecal morphine

Converting Opioids

 

Why is only a fraction of the opioid medication needed to achieve the same, and for many, even more pain relief?

It’s all about efficiency…..

Oral opioids must be absorbed systematically.  This means the oral opioid is absorbed via the gastric and duodenal mucosa after swallowing the opioid pill. It then has to be transported to the liver through the venous system where the opioid is metabolized.  From there the opioid finally enters systemic circulation as it crosses the blood brain barrier to interrupt pain signals.

Intrathecal opioids offers direct delivery to interrupt pain pathways at their source in the cerebrospinal fluid and spinal cord.

As you can see, the oral delivery route is inefficient and complicated. It requires significantly more opioid to be absorbed within our bodies.  This results in the many bothersome and dangerous side effects one experiences from oral opioids.

The direct delivery of opioids from an intrathecal pump is efficient. It eliminates the need for systemic absorption and thus greatly reduces, and for many, eliminates the unwanted opioid side affects while providing superior pain relief.

The following link provides more details about Opioid delivery routes:

Opioid Delivery

 

Understand that as simple as the intrathecal pump option sounds, it can become problematic due to a host of complications including:

-Doctor/Patient communication, understanding and patience is a must to continually work through intrathecal pump and intrathecal pump medication problems

-Usual post surgical complications including infections

-Device related malfunctions including battery problems along with under infusion and over infusion episodes which can be life threatening

-Additional surgery which is required to replace the battery

-Trialling many intrathecal medications may be needed until the best intrathecal medication (or combination of intrathecal medications) is reached.

-Implanted catheter may require additional surgical fine tuning in the event the catheter should migrate (move) or become blocked.

-Frequent monitoring. Regularly scheduled appointments with your Doctor to refill your intrathecal pump and make adjustments to medication flow rates are required.

As you can see, this is NOT a medical device which is simply implanted and forgotten. Both patient AND doctor must effectively work together to achieve the expected pain relief.  It’s not uncommon for new intrathecal pump patients to experience several weeks or even several months of frustration as they work through some of these complications as their Chronic Pain continues.

 

Who implants Intrathecal Pumps and How do they do it?

A Neurosurgeon or Pain Management Doctor who performs these procedures. It’s your choice.

It is very important that patients make sure that their doctor is certified by the appropriate board.  This ensures that the doctor has met the highest standards set by his or her peers and passed both oral and written examinations.  Click on mypainweb “Doctor Finder” to help you determine certifications.

Don’t be afraid to ask your surgeon about his or her training, practice focus, experience with whatever operation has been recommended, and whether you, the patient, have been presented with all of the options that exist (regardless of whether your surgeon performs all of them or not).  Don’t be afraid to speak up. It’s your body, your spine. Physicians place great value on educating patients to the best of their ability so that satisfactory decisions can be made and acceptable treatment initiated.

Here are a few good questions to ask your surgeon:

• Are you board-certified?

• How many surgeries like this did you do last year, and what were the results?

• Are the results (data) available to patients?

• Do you have a sense of how your patients do who choose surgery vs. those who choose not to have surgery?

• What makes you think that surgery is the right course of action?

• Will anything bad happen if I don’t have surgery?

• May I talk to one of your patients who underwent a similar operation about a year ago?

Click on the link below to watch an actual intrathecal pump implant surgery:

Intrathecal Pump Implant Surgery Video

 

My Intrathecal Pump journey:

Sharing my intrathecal pump journey takes you through the “ups and downs” associated with this intricate Chronic Pain Management strategy.

What did I do?

Due diligence.  I spent countless hours researching these neuromodulation implanted medical devices prior to agreeing with my pain physician’s suggestion that I would benefit from an intrathecal pump.  I was confident that the benefits of the implanted intrathecal pump far outweighed their reported potential risks.

Interestingly, patients must meet specific selection criteria to receive an intrathecal pump.

I also realized that this was not a medical device that can be implanted and then I can just “forget it”.  On the contrary, I read stories from many intrathecal pump patients explaining how much energy and effort may be required to reach a level of reliable pain relief.  Many, despite the best efforts of both doctor and patient never achieve adequate pain relief.  Intrathecal pumps can be surgically removed (explanted) under those circumstances.

mypainweb.com brings you all the valuable information I uncovered about intrathecal pumps and many, many other Chronic Pain topics.  I communicate all this material in an easy-to-access website; written in an easy-to-understand “patient-centered’ style.   mypainweb.com is your valuable resource that helps you make the best decisions to take control of your painweb and improve your quality of life.

In the beginning…..

My first intrathecal pump was implanted in February, 2002.  Medtronic was the well known intrathecal pump device manufacturer at that time.  There was no real competition to Medtronic’s intrathecal pump, so they were the logical choice.  All the data, trial and feedback from doctors, industry trades and patients I researched concerning the Medtronic’s Intrathecal Pump was positive.

My first few years with my intrathecal pump, like many first-time intrathecal pump patient’s report, was filled with lackluster results and frustration.  Allergic reaction to some of the intrathecal pain medications, migrating catheter tip and improper catheter placement were some areas of frustration.

There must be open communication and close teamwork between the pain physician and patient to effectively work through issues such as these and to determine the most effective intrathecal pump pain medication(s).

Finding the most experienced Doctor to implant the intrathecal pump is absolutely critical.  It’s not unusual to have a surgical implant doctor like a Neurosurgeon perform the actual intrathecal pump implant surgery.  Another doctor, usually a Pain Management doctor, will then maintain your pump after the implantation surgery.  With that being said, there are Pain Management doctors that will perform the intrathecal pump implantation surgery and also maintain your pump.

Getting used to the routine……

Trialling and adjusting the concentration & flow rate of the intrathecal medication, or combination of more than one intrathecal medication within the pump can take several weeks to several months to “tweak”.

Part of the ongoing maintenance of your intrathecal pump is periodic “pump fills”. Over time, the pump’s reservoir must be refilled with intrathecal pump medication(s).  How does the pump medication(s) get into the implanted intrathecal pump?  A manual procedure done by the pain physician involves careful removal of excess medication from the intrathecal pump’s reservoir using a needle placed through the abdomen directly into a port located on the intrathecal pump.  Once the excess medication is removed from the intrathecal pump, the pain physician then carefully fills the pump though the needle with a new batch of intrathecal medication.

This pump refill process is repeated approximately every 4 weeks to every few months or longer.  Pump refill frequency is dependent upon type of intrathecal pump medication(s) used and delivery flow rate of intrathecal medication.  As you surmise, these are not medical devices that once they are implanted you can forget about it.  On the contrary, a significant commitment on behalf of the the pain physician and the patient are required to achieve success.  A high level of confidence in the safety and reliability of the implanted intrathecal pump is also a prerequisite.

The process of determining which intrathecal pump medication works best for you is an important “strand” within the “painweb” that deserves emphasis.  Your pain doctor will suggest the best intrathecal pump medication to start with.  What oral opioid medication you have been prescribed may correlate to which intrathecal pump medication is used.  The flow rate which is how much intrathecal pump medication is delivered from your pump may also be correlated based upon the dosage of your oral opioid medication as well.

It’s also common for your pain doctor to combine another 1 or even 2 additional intrathecal pump medications.

Refer to the list of intrathecal pumps medications above or click on the link below to read more about intrathecal pump medication:

Intrathecal Pumps: Highlights and Updates 

Search the mypainweb link for more information.

IMPORTANT:

Newer intrathecal pump medications like Prialt (ziconotide) are currently being developed and used. Prialt is a powerful, non-opioid pain medication that is synthetically produced from the poisonous venom of the Conus Magnus snail. It is highly controversial due to serious physical and psychological side effects. I personally discontinued Prialt therapy after using it for almost two years due to intense side affects.

Please visit the following website below to learn more about Prialt side affects: Prialt side effects.

I do not personally recommend Prialt under any circumstances.

Things that made me go hmmmm…..  

Given the high-tech, mechanical nature of intrathecal pumps, they are prone to occasional performance problems.  One of my earlier pumps was on Medtronic’s recall list for battery related issues.  The pump had to be replaced in year 3 despite a normal life cycle of  7-9 years.

Even with all of the aforementioned issues I did experience periods of time when the intrathecal pump provided the expected pain relief.   During those periods all that was required was the usual maintenance such as pump refill appointments and follow up visits to adjust the flow rate.

An added feature called a PTM (Personal Therapy Manager) made the intrathecal pump even more effective.  The PTM is a handheld device which allows the patient to administer a bolus (increase in intrathecal pump pain medication) during times of breakthrough pain, thus providing greater control over their pain management.  Bolus parameters are preset by the pain physician.

 

Below is a picture of the Medtronic myPTM:

 

 

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It’s common for this technology to display occasional Error Codes.  I’ve included the following Error Code reference information:

 

Medtronic PTM (PERSONAL THERAPY MANAGER) ERROR Codes

 

Sample Error Code displayed on PTM screen:

 

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Below are a list of PTM Error Codes for reference.  Contact your Doctor and/or Medtronic if your PTM should display an Error Code.

 

8428      End of service

8532      Stopped pump duration exceeded

8286      Empty reservoir

8474      Pump reset

8475      Motor open

8476      Motor stall

8477     Critical memory error

8478     Safe rate in use

8479     Communication error

The above codes will accompany an audible Critical Alarm.   The Critical Alarm is a repeating 3-second, dual-tone alarm from the pump. A Critical Alarm indicates imminent termination of therapy.

 

8254        Low reservoir

8615        ERI (Elective Replacement Indicator)

8324        Next refill date or adjusted refill date

8621        Communication attempted with incorrect pump

8230        Patient-activated dose feature is disabled

8159        Non-critical memory error

8309        Incorrect Personal Therapy Manager software

8047       Stopped pump

8503       Physician bolus in progress

The above codes will accompany an audible Non-Critical Alarm.   The Non-Critical Alarm is a repeating single-tone alarm from the pump.  A Non-critical Alarm indicates a physician’s attention is required but does not signal imminent termination of therapy.

 

Call your Doctor and/or Medtronic anytime you hear an audible alarm from your pump along with any Error Code displayed on your PTM.

 

 

One of my biggest fears realized……

During the week of December 8, 2012 my intrathecal pump experienced a serious device-related performance problem resulting in pain medication over-infusion.  I experienced this episode not once, but twice in the same week.

The over-infusion of pain medication created a medical emergency, which required urgent treatment.

The side effects I experienced from the over-infusion of pain medication was swift and potentially life threatening.  Within just a few minutes I was completely numb from my chest to my toes.  No feeling. No sensation.  Unable to move.  Panic then set in as I found myself having great difficulty in just taking a breath.  This episode happened on two separate occasions during the week of December 8, 2012.

What caused the unexpected over-infusion of pain medication?

Neither my doctors, nor Medtronic , nor Attending ER doctor could provide any reasons as to why my intrathecal pump malfunctioned and over-infused on either occasions.

My pain doctor thought the problem may have been the result of a compounding error.  The combination of intrathecal pain medications that I required was manually compounded at a pharmaceutical lab.  He felt it was possible that human error was the culprit when my batch of intrathecal pain medication was formulated.  As a result, my pain doctor quickly removed the remaining intrathecal pump medications and sent it out to be tested by an independent lab.  The independent lab test results came back normal.  The medications had been formulated correctly.

Ultimately, the problematic intrathecal pump was surgically removed (explanted) and tested by Medtronic.  The intrathecal pump was found, according to Medtronic’s findings, to be operating “normally”.

The general consensus was that it was an “anomaly”.  I was told such an occurrence was “unheard of”.  I remained cautiously optimistic, agreeing to having a new pump implanted.

Confidence shaken to the core….

Even after this new pump was implanted, I experienced prolonged periods of anxiety due to an impending feeling that another pump malfunction, similar to what I experienced months before, could happen at any time.

Further complicating this matter was discovering the following media article reporting serious health problems and deaths caused by the same model pump as mine.

Click on the following link to read more about this report:  Medtronic Pain Pump blamed for 14 Deaths.

Medtronic posts ongoing Product Advisory / Recall Notifications on their website.  I occasionally reviewed them, but still felt somewhat confident that intrathecal pump benefits outweigh the risks.  However; my confidence in the intrathecal pump device technology was already shaken after 2 malfunctions I experienced during December 2012 as I learned of the Medtronic Recall by the FDA.

The following link contains Medtronic Advisory / Recall History: Medtronic Advisory / Recall History

Although the SynchroMed pump , my particular intrathecal pump model, has been classified by the Food and Drug Administration as a Class I recall, meaning there was a “reasonable probability” that it could cause serious health problems or even death, the company (Medtronic) is not recommending that the pump be removed.

Then this……

Medtronic Over-infusion Product Advisory and Medtronic Over-infusion letter.

The confidence pendulum had now swung to the other side.  While I understand Medtronic reports an acceptable “low incident rate of intrathecal pump malfunction”, the odds were too great for me to justify continuation of intrathecal pump pain therapy.

This latest potential intrathecal pump problem, as self-reported by the device manufacturer Medtronic, is the last in a series performance/reliability problems during the past few years that pose a real question of risk with this technology. In my mind, and in my own personal opinion, this risk far outweighs the benefit of some pain relief.

The links below will familiarize you with these problems plaguing Medtronic’s Synchromed II Intrathecal Pump:

Medtronic Synchromed II Intrathecal Pump Product Advisories

Medtronic Synchromed II Over Infusion Advisory

FDA Medtronic Synchromed II Recall-June 2013

The April 15, 2015 FDA Consent Decree with the Medtronic Synchromed II Intrathecal Pump raises questions about the accusations and charges being filed against Medtronic. This Consent Decree cites manufacturing concerns and questionable complaint reporting/investigating practices.  This latest development lowered my confidence even further.

FDA Files Consent Decree with Medtronic-April 2015

The 2 over infusion episodes I experienced in 2012 along with the Advisories, Recalls and FDA Consent Decree brought me to the decision to have my Pump surgically removed in May 2014.

I have returned to an opioid pain management approach with my pain management doctor, along with revisiting & fine tuning other Chronic Pain strategies and tactics.   You will find these strategies in the sections on mypainweb.

Torn between Technology-June 2015

I recently learned from my Pain Management Doctor that a new Intrathecal Pump Technology has been introduced and is beginning to be implanted.  The device manufacturer is a new company called Flowonix, located out of New Jersey.  The Intrathecal Pump is called Prometra.

Flowonix has created a pump delivery system which claims significantly superior infusion accuracy as compared to Medtronic’s Synchromed II pump.  This is huge news!

What I sorely miss is the pain relief the intrathecal pump delivered when it did work as expected.  Unfortunately, for me, the benefit did not outweigh the potential risks involved, as at least 14 people have died from the same Medtronic Synchromed II over infusion malfunction that I experienced.

Oral opioids have been my primary source of pain relief.  The level of pain relief from my current opioid dosage no longer provides effective pain relief due to the tolerance factor associated with long term opioid use.  The only option is to increase the opioid dosage or switch to a stronger opioid.  I resist this tact as absorbing stronger opioids will result in potential dangerous side effects including addiction and depression.

I’ve reduced even further my activity levels in an effort to manage the pain levels. This has proven to be futile as being sedentary brings another set of frustrating side effects.  Once again, mypainweb’s complication grows.

This is when having a partnership with your Pain Doctor is crucial.  My Pain Doctor understands my complicated Chronic Pain history.  The easy way out would be for my Pain Doctor to simply encourage me to increase the oral opioid dosage or switch to a much stronger oral opioid.  Fortunately, my Pain Doctor shares my conservative and cautious approach to long term opioid therapy.  His suggestion of seriously considering returning to Intrathecal Pump therapy using this new technology has me initiating due diligence in learning as much as I can about the Flowonix Prometra intrathecal pump.

A closer look at the new Technology…..

Without getting too technical, here are the main difference between Medtronic’s Synchromed II pump and Flowonix’s Prometra II pump:

 

Medtronic SynchroMed II

-Peristaltic pump roller system (motors/gears); 85% Accurate

-Wide range of programmability

-Personal Therapy Manager (PTM); patient bolus feature

-Shorter Battery Life; 4-7 years

-MRI Compatible

 

Flowonix Prometra II

-New valve-gated dose regulation system; 97% Accurate

-15-20 self-checks done every cycle (about every 30 min); if any problem is detected (battery, flow, etc) pump shuts off and alarms

-Specific refill needle for refill port & Natural Aspiration-avoids potential “pocket” fills    (unintended injection of intrathecal medication into the “pocket” where the pump is     instead of the pump’s reservoir).

-Max Flow rate control of 10 mcl

-Battery Life; 10+ years

-Personal Therapy Manager (PTM); patient bolus feature

-MRI Compatible

 

Here’s a few pictures of both Intrathecal Pumps:

Medtronic Synchromed II:

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Flowonix Prometra:

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Need to know more about the 2 types of intrathecal pumps?

 

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Click on the following link to learn more about the Medtronic peristaltic pump (Synchromed) compared to the Flowonix valve-gated pump (Prometra II):

 

Intrathecal Pump Technology Comparison

 

While I’m interested in the prospect of the Prometra Intrathecal Pump, my Pain Management Doctor and I agree to carefully move forward in this direction. Given the relative newness of Prometra and the fact that Flowonix will be soon  announcing a new Prometra II model, there is no reason to move too quickly. This will also give me time to reach out to patients that have implanted the Prometra Intrathecal Pump to get their feedback.

 

A lot can change in 3 months for those of us living with Chronic Pain

Since my June 2015 update my Chronic Pain has continued to worsen.  Scaling back most activities does nothing to manage the Chronic Pain.  Current level of my prescribed oral opioid medication no longer even knocks the Chronic Pain Levels by one or two points.

I’ve spent a considerable amount of time learning all that is available about the new Flowonix Prometra Intrathecal Pump.  I was pleasantly surprised to learn that the newest Flowonix Pump has been released and is now available.  The Prometra II Pump is loaded with safety features (scroll above to review).

I reached out to Flowonix and established a relationship with their Technical Professional.  He has been very helpful and informative with my questions.  He even arranged for me to speak with a Flowonix Engineer in an effort to respond to my specific questions related to the Prometra II accuracy rating and safety features.  My conversation with the Flowonix Engineer confirmed all the safety features the literature highlights.  The Flowonix Engineer listened patiently and understood the reasons causing my low confidence in Intrathecal Pump Device Technology.  By the end of our conversation I felt reassured that the Prometra II Intrathecal Pump can deliver what it claims.

Another positive indicator is that my Pain Management Doctor already has implanted the Prometra II Intrathecal Pump and the patient, thus far, is completely satisfied.

The last step in the process is to discuss surgically implanting the Prometra II Pump.  My Pain Management Doctor referred me to a highly skilled Neurosurgeon.  After two appointments with the Neurosurgeon along with a joint meeting with the Flowonix Technical Professional and my family, we all agreed that given my 21 year complicated history with Chronic Pain that moving forward with the Prometra II Intrathecal Pump is my best option.

My Pain Management Doctor is certain that given my spine conditions and age, my level of Chronic Pain will continue to worsen.  My only other option is aggressive medical management involving more powerful oral opioids.

Without question, more powerful oral opioids is not an option.  In light of the new Flowonix Prometra II Intrathecal Pump’s advancement in key safety feature I am awaiting the surgery implantation date.

More to follow as I continue on with my Intrathecal Pump journey…..

 

Prometra II Pump Implantation

On Monday, October 12,2015 Dr. Shehadi implanted the Flowonix Prometra II Intrathecal Pump.  The pump was filled with a sterile saline solution.  The first fill is scheduled for Tuesday, October 20, 2015 with Dr. Soin.

Experiencing the expected post-surgical swelling and soreness at the implant site.  The pump was implanted in the same lower-left abdominal area where my previous pump was located.  A small amount of additional catheter prep was needed to connect the existing Medtronic catheter with the Flowonix Prometra II pump.

Frequent icing and wearing a binder helps minimize swelling.  Two Percocet 325 taken every 6 hours for pain was started on Monday afternoon then discontinued (my choice) Thursday evening, October 15, 2015.

 

Click on mypainweb journal blog below to follow my latest intrathecal pump status and developments:

 

mypainweb journal blog

 

 

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