{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T16:07:24Z","timestamp":1788883644483,"version":"build-2803163510"},"reference-count":17,"publisher":"BMJ","issue":"9","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"accepted":{"date-parts":[[2026,7,7]]},"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Hypersensitivity reactions to implanted neuromodulation devices often mimic infection and result in device explants. Among device components, titanium is an infrequent immune irritant that can lead to implant rejection.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>This case report describes a patient with a history of prior lumbar spine surgery and refractory low back pain who had two intrathecal pump explants for suspicion of infection and who was ultimately diagnosed to have a type IV titanium hypersensitivity. An intrathecal drug delivery system was successfully reimplanted without rejection by encasing the pump with a pouch of expanded polytetrafluoroethylene (ePTFE) fabric.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Hypersensitivity to device components should be considered in patients with recurrent or unexplained pump site complications. The use of an ePTFE pouch may allow device reimplantation in patients with type IV hypersensitivity reactions to implanted neuromodulation devices.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/rapm-2026-108132","type":"journal-article","created":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T15:23:17Z","timestamp":1788880997000},"page":"1108-1110","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Diagnosis and management of hypersensitivity to titanium in implanted intrathecal pain pump: a case report"],"prefix":"10.1136","volume":"51","author":[{"given":"Jack","family":"Kiernan","sequence":"first","affiliation":[{"name":"Case Western Reserve University School of Medicine, Cleveland, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-3010-7528","authenticated-orcid":false,"given":"Cham","family":"Al Salak","sequence":"additional","affiliation":[{"name":"Anesthesiology and Perioperative Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haig","family":"Tcheurekdjian","sequence":"additional","affiliation":[{"name":"Internal Medicine and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA"},{"name":"Allergy\/Immunology Associates, Inc, Mayfield Heights, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9123-136X","authenticated-orcid":false,"given":"Michael D","family":"Staudt","sequence":"additional","affiliation":[{"name":"Case Western Reserve University School of Medicine, Cleveland, Ohio, USA"},{"name":"Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristin W","family":"Davis","sequence":"additional","affiliation":[{"name":"Anesthesiology and Perioperative Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna Marie L","family":"Anthony","sequence":"additional","affiliation":[{"name":"Anesthesiology and Perioperative Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7936-017X","authenticated-orcid":false,"given":"Salim Michel","family":"Hayek","sequence":"additional","affiliation":[{"name":"Case Western Reserve University School of Medicine, Cleveland, Ohio, USA"},{"name":"Anesthesiology and Perioperative Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,9,8]]},"reference":[{"key":"2026090808100895000_51.9.1108.1","doi-asserted-by":"crossref","DOI":"10.1007\/s11916-013-0388-x","article-title":"Intrathecal therapy for chronic pain: current trends and future needs","volume":"18","author":"Hayek","year":"2014","journal-title":"Curr Pain Headache Rep"},{"key":"2026090808100895000_51.9.1108.2","doi-asserted-by":"crossref","unstructured":"Deer TR , Hayek SM , Grider JS , et al . The Polyanalgesic Consensus Conference (PACC): Intrathecal Drug Delivery Guidance on Safety and Therapy Optimization When Treating Chronic Noncancer Pain. Neuromodulation 2024;1107\u201339. doi:10.1016\/j.neurom.2024.03.003","DOI":"10.1016\/j.neurom.2024.03.003"},{"key":"2026090808100895000_51.9.1108.3","doi-asserted-by":"crossref","first-page":"1029","DOI":"10.1016\/j.neurom.2024.08.006","article-title":"The Polyanalgesic Consensus Conference (PACC): Updates on Clinical Pharmacology and Comorbidity Management in Intrathecal Drug Delivery for Cancer Pain","volume":"28","author":"Deer","year":"2025","journal-title":"Neuromodulation: Technology at the Neural Interface"},{"key":"2026090808100895000_51.9.1108.4","doi-asserted-by":"crossref","unstructured":"Deer TR , Pope JE , Hayek SM , et al . The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks. Neuromodulation 2017;155\u201376. doi:10.1111\/ner.12579","DOI":"10.1111\/ner.12579"},{"key":"2026090808100895000_51.9.1108.5","doi-asserted-by":"crossref","first-page":"1307","DOI":"10.1111\/ner.13332","article-title":"Allergy Considerations in Implanted Neuromodulation Devices","volume":"24","author":"Brown","year":"2021","journal-title":"Neuromodulation"},{"key":"2026090808100895000_51.9.1108.6","doi-asserted-by":"crossref","DOI":"10.15420\/aer.2022.23","article-title":"Hypersensitivity Reactions to Components of Cardiac Implantable Electronic Devices and Their Treatment: A Systematic Review","volume":"12","author":"Kealaher","year":"2023","journal-title":"Arrhythm Electrophysiol Rev"},{"key":"2026090808100895000_51.9.1108.7","doi-asserted-by":"crossref","first-page":"184","DOI":"10.2340\/16501977-0918","article-title":"Intrathecal baclofen pump: a foreign-body reaction case report and its solution","volume":"44","author":"Bernuz","year":"2012","journal-title":"J Rehabil Med"},{"key":"2026090808100895000_51.9.1108.8","doi-asserted-by":"crossref","first-page":"1925","DOI":"10.1111\/ans.19167","article-title":"Understanding immune-mediated titanium allergy to in situ orthopaedic implants: a narrative review of the current literature","volume":"94","author":"Chen","year":"2024","journal-title":"ANZ J Surg"},{"key":"2026090808100895000_51.9.1108.9","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1111\/cod.12565","article-title":"Titanium: a review on exposure, release, penetration, allergy, epidemiology, and clinical reactivity","volume":"74","author":"Fage","year":"2016","journal-title":"Contact Derm"},{"key":"2026090808100895000_51.9.1108.10","doi-asserted-by":"crossref","first-page":"974","DOI":"10.1053\/j.jfas.2018.11.031","article-title":"Type IV Cell-Mediated Hypersensitivity Reaction Caused by Titanium Implant Following Double Calcaneal Osteotomy and First Metatarsal-Cuneiform Arthrodesis: A Case Report and Review of the Literature","volume":"58","author":"Razzante","year":"2019","journal-title":"J Foot Ankle Surg"},{"key":"2026090808100895000_51.9.1108.11","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1111\/j.1600-0536.2006.00931.x","article-title":"Hypersensitivity to titanium osteosynthesis with impaired fracture healing, eczema, and T\u2010cell hyperresponsiveness in vitro : case report and review of the literature","volume":"55","author":"Thomas","year":"2006","journal-title":"Contact Derm"},{"key":"2026090808100895000_51.9.1108.12","doi-asserted-by":"crossref","first-page":"1299","DOI":"10.1111\/j.1540-8159.2006.00535.x","article-title":"Pacemaker contact dermatitis: The effective use of a polytetrafluoroethylene sheet","volume":"29","author":"Ishii","year":"2006","journal-title":"Pacing Clin Electrophysiol"},{"key":"2026090808100895000_51.9.1108.13","doi-asserted-by":"publisher","DOI":"10.1046\/j.1460-9592.2002.t01-1-00863.x"},{"key":"2026090808100895000_51.9.1108.14","doi-asserted-by":"publisher","DOI":"10.1016\/0142-9612(96)84946-5"},{"key":"2026090808100895000_51.9.1108.15","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1007\/s10047-012-0634-8","article-title":"Long-term results of a cardiovascular implantable electronic device wrapped with an expanded polytetrafluoroethylene sheet","volume":"15","author":"Yashiro","year":"2012","journal-title":"J Artif Organs"},{"key":"2026090808100895000_51.9.1108.16","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1111\/jce.70195","article-title":"Treatment Options, Regulatory Pathways and Global Patterns of Use for Cardiac Implantable Devices in Patients With Titanium Allergy","volume":"37","author":"Devathu","year":"2026","journal-title":"J Cardiovasc Electrophysiol"},{"key":"2026090808100895000_51.9.1108.17","doi-asserted-by":"publisher","DOI":"10.1510\/icvts.2007.169714"}],"container-title":["Regional Anesthesia &amp; Pain Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/rapm-2026-108132","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T15:23:38Z","timestamp":1788881018000},"score":1,"resource":{"primary":{"URL":"https:\/\/rapm.bmj.com\/lookup\/doi\/10.1136\/rapm-2026-108132"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9]]},"references-count":17,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9,8]]},"published-print":{"date-parts":[[2026,9]]}},"alternative-id":["10.1136\/rapm-2026-108132"],"URL":"https:\/\/doi.org\/10.1136\/rapm-2026-108132","relation":{},"ISSN":["1098-7339","1532-8651"],"issn-type":[{"value":"1098-7339","type":"print"},{"value":"1532-8651","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9]]}}}