1. 2008;11;369-373Intrathecal Granuloma in a Patient Receiving High Dose Hydromorphone
   Case Report
   Christian N. Ramsey, MD, Robert D. Owen, MD, William O. Witt, MD, and Jay S. Grider, DO, PhD.

Intrathecal granuloma formation has commonly been described with morphine therapy. It has been suggested that a high concentration of intrathecal morphine may be responsible for this complication. Much less commonly, intrathecal hydromorphone has been associated with intrathecal granuloma formation.

In the current case we report the evaluation and management of an intrathecal granuloma in a patient receiving a relatively high concentration of intrathecal hydromorphone.

A nonsurgical, conservative approach to management involves stopping the infusion and observing the patient for improvement as the granuloma mass often slowly resolves once the infusion is stopped. Cessation of the infusion or addition of clonidine to the IDDS admixture in conjunction with close clinical monitoring may be reasonable treatment options in patients with an asymptomatic or mildly symptomatic inflammatory mass. In the current study, rapidly declining neurologic function with a confirmed inflammatory mass adherent to the spinal canal necessitated urgent surgical intervention. 

Though use of intrathecal hydromorphone still represents an off label application, this opiate is commonly employed as an alternative first line analgesic agent. This case report highlights the potential of high-dose and high infusate concentration intrathecal hydromorphone to form an inflammatory granuloma.