On Intrathecal Pumps and Early Attendinghood

I remember speaking with a seasoned attending before starting my pain medicine fellowship. The topic of intrathecal pumps came up, and he shot me an incredulous look.

"You don't actually want to implant intrathecal pumps, right?"

In truth, I was not even sure what this meant. At that time, I had little understanding of how to use a fluoroscope, let alone an appreciation for the complexities of intrathecal pumps and their management. However, one thing was clear: they seemed controversial.

"Avoid intrathecal pumps at all costs," I was told.

It was not until I started my pain medicine fellowship at Brigham and Women's Hospital that I began to understand what intrathecal pumps were and how they could help patients. It also became clear why they generated such strong opinions within our field. Pumps can provide remarkable benefits, but they also carry real risks. There are also historical concerns about opioid prescribing, patient selection, and variable practice standards that add to the controversy.

As my training progressed, I found myself becoming more interested in the therapy rather than less. I sought out mentors with extensive experience managing pumps, attended educational meetings dedicated to intrathecal pump management, and spent time learning from clinicians whose practices included intrathecal drug delivery. While I still have much to learn, I came to appreciate why many experienced pain physicians view pumps as an important tool for carefully selected patients.

I have since encountered patients in my own practice whom I believe could benefit from intrathecal therapy, and these experiences have reinforced the importance of understanding this treatment option. Like many areas of pain medicine, the challenge is not only in determining whether a therapy works, but also in identifying the patients that are most likely to benefit from it.

The purpose of this post is not to discuss patient selection, pump management, or the many nuances of intrathecal therapy. Rather, it is to encourage young pain medicine attendings to develop their own informed opinions about the potential role of intrathecal pumps in practice.

As a new attending, I certainly do not consider myself an expert in intrathecal therapy. What has surprised me, however, is how different my perspective is on intrathecal pumps from when I first heard those pointed warnings several years ago. Rather than avoiding pumps altogether, I think young pain physicians should take the time to understand them - including their benefits, risks, and the patients for whom they may be uniquely valuable. The controversy surrounding intrathecal pumps is real, but so too are the patients whose lives continue to be meaningfully improved by them.

Jacob M. Lurie, MD, MPH

Orthopaedic Specialty Group

Fairfield, CT