Intrathecal Pump Longevity Begins in the Operative Room: Technical Strategies to Limit Revisions and Complications

BACKGROUND AND OBJECTIVE: Intrathecal drug delivery (IDD) is an established therapy for cancer-related pain, spasticity, and refractory noncancer-related chronic pain. Despite its clinical benefits, IDD implantation remains associated with a substantial complication burden, frequently necessitating revision surgery. Although complication rates are well described, operative strategies to mitigate these risks are inconsistently reported. We aimed to systematically map operative and perioperative strategies for IDD system implantation with a focus on complication mitigation, and to integrate practical technical insights into a standardized workflow with these data and our technical pearls garnered over 15 years. METHODS: A scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. PubMed/MEDLINE, Scopus, and Web of Science were searched from database inception through February 2026 for studies describing IDD implantation techniques, perioperative management, and associated complications. Eligible studies included randomized trials, observational studies, case series, and technical reports. Findings were synthesized qualitatively and organized according to the procedural workflow, including preoperative, intraoperative, and postoperative phases. RESULTS: A total of 45 studies met inclusion criteria. The most frequently reported complications included catheter-related malfunction, cerebrospinal fluid leaks, infection, and pump-related issues such as migration or rotation. Operative techniques to mitigate these risks are provided for catheter insertion approach, anchoring, and pump pocket construction. Infection prevention measures and standardized perioperative protocols also demonstrated an important role in reducing adverse events. We provide a workflow based on these data and our own experience. CONCLUSION: Complication risk in IDD implantation is strongly influenced by operative technique and perioperative management. Existing literature lacks standardization in both technical reporting and outcome definitions, highlighting the need for consensus frameworks. We provide a systems-based approach integrating procedural standardization, technical precision, and coordinated perioperative care may improve reproducibility and reduce complication rates.