Intrathecal Baclofen Infusion Research Articles

267 Risk Factors Associated With Baclofen Pump Infection in Children Translated Into Health-Care Costs: A Retrospective Analysis From the Children's Hospital of Pittsburgh Experience From 2009-2020

INTRODUCTION: Intrathecal baclofen infusion is often used as a therapy for spasticity in children and adults, with pediatric cases more associated with infections. Infection leads to the need for pump explantation and is associated with a significantly increased hospitalization cost. METHODS: We retrospectively reviewed demographic, clinical, and economic data for children who underwent surgery for intrathecal baclofen pumps at a single institution from 2009-2020. Bivariable analyses (chi-squared tests) were conducted to compare differences in clinical characteristics between patients with surgical site infection and those without. Mann-Whitney tests were performed to compare total charges per patient between patients who had an infection versus those who did not. RESULTS: A total of 199 patients undergoing 442 surgeries were included. The cohort was 64% male and 84% Caucasian, with a mean age of 13.3 years. The most common indication for placement was cerebral palsy. Infection occurred in 28 patients (14% infection rate). The most common organisms were methicillin-resistant and methicillin-sensitive staph aureus. The pump model, access site, and the number of surgeons scrubbed were not associated with infection. Total hospital charges (for all surgeries) were significantly higher for patients with an infection versus those who did not ($231,762 vs. $187,028, p=0.0078), with an average charge increase of $44,734 associated with surgical site infection. CONCLUSIONS: In our single-center series, the most common indication for baclofen pump placement was cerebral palsy, with an infection rate of 14%, close to other rates reported in the literature. Total hospital charges were higher for patients with an associated surgical site infection than those without one.

Generalized Tetanus Treated with Intrathecal Baclofen Infusion

Tetanus is a bacterial infection by Clostridium tetani. Its neurotoxin causes spastic paralysis and autonomic dysfunction. Intrathecal infusion of baclofen has been suggested as a pertinent treatment for generalized spasm. Our case describes a patient who had a severe generalized form of tetanus, and was effectively treated with intrathecal baclofen infusion. He showed cerebral and brainstem dysfunction during baclofen infusion, which were reversed without sequelae when baclofen was discontinued.

Spasticity and movement disorders in cerebral palsy.

To review the neurosurgical treatments of children with movement disorders associated with cerebral palsy (CP) during the previous decades, up to the present day. An extensive literature review was undertaken to identify important publications about this subject. My experience treating children with these disorders over the past three decades was included in the individual sections. Peripheral neurotomies have been developed for children with focal spasticity. For those with spastic paraparesis, selective lumbar rhizotomies were developed, and for those with spastic quadriparesis, intrathecal baclofen infusions were developed. Both effectively alleviate spasticity in the affected extremities. Generalized dystonia associated with CP has been treated with deep brain stimulation with mild improvement, but treatment with intrathecal baclofen and intraventricular baclofen improve those movements markedly. No effective treatment has been reported for children with athetoid CP. For those with choreiform CP, deep brain stimulation may be effective but intrathecal baclofen does not appear to be. Treatment of children with movement disorders associated with CP increased slowly in the 1970s and 1980s but accelerated rapidly in the 1990s with the introduction of lumbar dorsal rhizotomies and intrathecal baclofen. In the last 30years, tens of thousands of children with spasticity and movement disorders associated with CP have been treated by pediatric neurosurgeons, and their care has become an integral component of current pediatric neurosurgical practice.

PHYSIOTHERAPEUTIC POTENTIAL BEFORE AND AFTER IMPLANTATION OF INTRATHECAL BACLOFEN INFUSION PUMP FOR TREATING SPASTICITY IN CHILD WITH CEREBRAL PALSY

Purpose: To monitor and analyze physiotherapeutic potential before and after implantation of an intrathecal baclofen infusion pump for treating spasticity in a child with cerebral palsy. Material: We present a 6-year-old girl with a massive spastic dystonic motor disorder, after hypoxic brain damage, based on an aspiration event in 2017. The first 6 months after the accident, the child is in a coma, 8 months in a state of awake coma. He has been conscious since the beginning of 2019. The diagnosis is bilateral spastic-dyskinetic paralysis, structural epilepsy, suspected cerebral blindness, subluxation of the hip joints bilaterally. For the period from coma to now, the child has received the following treatment: gastrostomy, replacement with Button, application of ventriculo-peritenoic shunt, botulinum toxin therapy, implantation of intrathecal baclofen infusion pump for treating spasticity. From the third month after the accident until now, physiotherapy is performed 3-4 times a week, monitoring the condition and changes in the functional capabilities of the child. Results: Before the baclofen pump, physiotherapy is mostly preventive against contractures and ankylosis. The child's functional capabilities and learning in motor activities are severely limited by central spasticity. 6 months after the placement of the baclofen pump, muscle tone decreased, and the child's physiotherapeutic potential increased. Conclusions: The physiotherapeutic potential is significantly increased after implantation of an intrathecal baclofen infusion pump, as muscle tone is significantly reduced.

Parents of Children With Medical Complexity Are Essential Health Care Personnel

* Abbreviations: CDC — : Centers for Disease Control and Prevention CMC — : children with medical complexity COVID-19 — : coronavirus disease 2019 The coronavirus disease 2019 (COVID-19) pandemic has created a national and global crisis. The United States has invested tremendous effort and resources to fast track severe acute respiratory syndrome coronavirus 2 vaccines from conception to market in 1 year, an amazing scientific achievement. Public health experts are now leading the distribution of COVID-19 vaccines. The Centers for Disease Control and Prevention (CDC) recommends that health care personnel be offered COVID-19 vaccination during the early phases of distribution. Health care personnel are broadly defined and include emergency medical service personnel, nurses and nursing assistants, physicians, technicians, therapists, dentists, dental hygienists and assistants, phlebotomists, pharmacists, students and trainees, contractual staff, dietary and food services staff, environmental services staff, and administrative staff. We strongly recommend that parents and family caregivers (collectively referred to as parents in this article) of children with medical complexity (CMC) be included in the early phases of vaccine distribution because they serve as essential frontline health care personnel. CMC have significant chronic health conditions that involve multiple organ systems, substantial health service needs, major functional limitations, and high health resource use. They have high levels of medical fragility, technology dependencies (tracheostomies, ventilators, feeding tubes, intrathecal baclofen infusion systems, and others), and psychosocial complexities. We identify CMC as those who have ≥3 organ systems affected (≥3 Feudtner … Address correspondence to Nancy A. Murphy, MD, FAAP, FAAPMR, Division of Pediatric Physical Medicine & Rehabilitation, Department of Pediatrics, School of Medicine, University of Utah, 81 North Mario Capecchi Dr, Salt Lake City, UT 84113. E-mail: nancy.murphy{at}hsc.utah.edu

Intrathecal baclofen pump exchange in multiple sclerosis. Factors affecting baclofen efficacy and dose adjustement. A case report

Multiple sclerosis is a neurological disease that presents with various symptoms; in some cases it is progressive and highly disabling, requiring invasive techniques to treat pain and spasticity. The use of intrathecal baclofen infusions is an effective and safe alternative for patients with severe and refractory spasticity. The therapy can improve quality of life, but must be performed in a pain unit by medical staff trained in the technique, its indications, pharmacology, and the potential risks of both the implant and the drug. The treatment can be individualized and patients must be followed up periodically.

Intrathecal baclofen pump replacements under local anaesthetic: rapid pathway implementation under COVID-19

Intrathecal baclofen pump replacements under local anaesthetic: rapid pathway implementation under COVID-19

Submuscular Placement of Baclofen Infusion Pumps: Case Series and Technique.

Baclofen pumps provide treatment of symptoms of spasticity for disease processes such as cerebral palsy and traumatic brain injury. These devices provide continuous infusion or periodic dosing of intrathecal baclofen (ITB). Traditionally, these pumps have been placed subcutaneously. Subcutaneous device placement has been associated with infection and extrusion. Baclofen pumps are large and range from 8 to 10 cm in diameter and 4 to 8 cm in width. Patients requiring device placement typically have a paucity of subcutaneous tissue. Cachexia coupled with the size and bulk of these devices leads to increased protusion and friction. Submuscular placement provides a well-vascularized pocket that directs the device inward eliminating protrusion and decreasing the potential for soft tissue breakdown. A retrospective chart review of ITB pump placement in a submuscular plane by a single plastic surgeon at a major academic center in conjunction with a neurosurgeon was performed. Inclusion criteria were cases of primary placement or replacement of ITB pumps and spasticity requiring ITB. Major complications included infection, extrusion, and reoperation. Five patients during a 5-month period were treated with submuscular placement of ITB pumps. Average age of patients included was 18.4 years. Average preoperative body mass index was 18.8 kg/m, with values ranging from 15.8 to 20.1 kg/m. Medical histories of patients included diagnoses of cerebral palsy and traumatic brain injury causing spasticity. The most frequently cited reason for plastic surgical consultation preoperatively was cachexia. Two patients had previous baclofen pumps placed subcutaneously. Average follow-up was 6 months and ranged from 3 to 13 months. There were no major complications. One patient had a small seroma that spontaneously resolved. No patient had wound healing problems, and there were no extrusions of implanted devices or reoperations. Submuscular placement of baclofen pumps provides a well-vascularized and stable environment for device placement that minimizes the dangers of pump extrusion and infection. Patients who require treatment with ITB commonly have severe cachexia, which makes subcutaneous device placement high risk. Submuscular placement should be performed in all patients with body mass index less than 20 kg/m.

Intrathecal Baclofen Infusion Pumps in the Treatment of Spasticity: A Retrospective Cohort Study in a Portuguese Centre.

Spasticity is a complex problem in patients with neurological disorders and may distress their quality of life. Intrathecalbaclofen infusion pumps reduce spasticity with low doses and minimal side effects but are not free from complications. We aimed toevaluate the efficacy and safety of intrathecal baclofen infusion pumps as well as patients' satisfaction. Retrospective cohort study including all intrathecal baclofen infusion pumps placed up to December 2015.Demographic characteristics, clinical diagnoses, date of placement or withdrawal/replacement of intrathecal baclofen infusion pumps,baclofen dosage and complications of intrathecal baclofen infusion pumps were collected. Assessments from the Ashworth and Penn'sscales, Katz index and patients' global satisfaction were analysed. In 19 years we placed 251 intrathecal baclofen infusion pumps in 155 patients. The mean age was 41.1 ± 15.8 years. Themost frequent conditions were: trauma (34%), cerebral palsy (14%), multiple sclerosis (12%) and stroke (12%). Eighty-five patients(55%) required a second pump, and eleven (7%) a third one. The lifetime of the first pump was 72 (36 - 89) and the total follow-uptime was 96 (9 - 132) months. The causes of withdrawal/replacement were: battery failure (57%), catheter migration/kinking (24%),infection (14%) and pump displacement/exteriorization (7%). The complication rate was 0.21 events/month. There was a significantimprovement in the Ashworth and Penn's scales after the placemen of intrathecal baclofen infusion pumps (p < 0.001 for all diagnoses)and the patients were satisfied with the treatment. The incidence of complications was within range of other international studies despite our long follow-up time. Events permonth, loss to follow-up, re-intervention rate, incidence of infection and mortality were similar to other studies. Intrathecal baclofen infusion pumps are safe and effective in the treatment of spasticity. Infusion pumps provide a highlevel of satisfaction regarding treatment and quality of life.

Intrathecal baclofen trial using a temporary indwelling intrathecal catheter – A single institution experience

Intrathecal baclofen infusion trial is a sophisticated tool for selecting patients for permanent intra thecal baclofen infusion therapy We report our clinical experience of fifteen patients with refractory spasticity who underwent a continuous ITB trial using a temporary intraspinal indwelling catheter prior to permanent pump implantation.Patients underwent placement of a temporary intrathecal catheter that was connected to an external pump. Multisource feedback was obtained from the various healthcare professionals involved (Staff Nurse, Specialist nurse, physiotherapist, Doctor, family members, patient) regarding progress of test over 48–72 h.Average Modified Ashworth score after the trial was less than 2. Some degree of dose related minor adverse events (AEs) occurred in 8 patients, with the most common being nausea, constipation, urinary retention and hypotension. 10 patients received pump implant. 5 patients did not receive a pump because of AEs or because the goals were not met. 1 patient had pump removed after 4 years because of infection.

Protocolo diagnóstico y terapéutico de la espasticidad

Spasticity is a motor disorder caused by several conditions of the nervous central system (cerebral or spinal cord origin) (NCS). Symptomatology encompass contractures, pain, stiffness and, in general, deterioration of neurological status. In patients with spasticity after spinal cord injury, removing all aggravating factors and stablishing a physical rehabilitation treatments to reduce spastic component are mandatory. Treatment schedule is as follows: prevention of complications that may worse spascticity, physical rehabilitation, orthosis, oral pharmacologic interventions, botulinum toxin injection for focal spasticity and continuous intrathecal baclofen infusion

Case Series: Intrathecal Baclofen Therapy in Stiff-Person Syndrome

Stiff-person syndrome (SPS) is associated with axial rigidity superimposed on sustained muscle spasms. These symptoms commonly interfere with the performance of activities of daily living including ambulation. This retrospective case series evaluates the outcomes of screening tests and chronic infusion of intrathecal baclofen (ITB) in patients diagnosed with SPS treated in our spasticity clinic. Patients were identified from an institutional review board-approved clinical registry of ITB therapy. Data from clinical encounters were extracted from the registry and from the patients' electronic medical record. All patients with medically refractory spasticity related to SPS screened with an ITB injection were included. In addition to pertinent demographic and clinical information, data from validated outcome measures routinely used in the clinic were collected: pain Numeric Rating Scale, Spasm Frequency Scale, lower extremity Modified Ashworth Scale (MAS), and Timed 25 Foot Walk. Outcomes data for chronic ITB infusion were assessed at early (<6 months) and late follow-up (6-12 months) visits after surgery. Nine patients were included, and seven received chronic ITB infusion. MAS scores were improved at early and late follow-up, and five patients experienced a reduction in pain scores. Walking performance remained stable in previously ambulatory patients. Four patients experienced complications related to ITB implantation, which resolved with medical or surgical treatment. Consistent with other case series, our results suggest that ITB is an effective therapy for medically intractable spasticity due to SPS, and symptom reduction can be achieved without compromising ambulation.

Intrathecal Baclofen Infusion: A Treatment for Spasticity and Secondary Generalized Dystonia

Dr. Lake is Assistant Professor, Department of Neurological Surgery, and Director, Adult Functional and Stereotactic Neurological Surgery, University of Wisconsin-Madison Department of Neurological Surgery, 600 Highland Ave, Mail Code 8660, Madison, WI 53792; E-mail: [email protected]. The author, faculty, and staff in a position to control the content of this CME activity, and their spouses/life partners (if any), have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations related to this CME activity.Category: Functional and Stereotactic, SpineLippincott Continuing Medical Education Institute, Inc, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.Lippincott Continuing Medical Education Institute, Inc, designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed form, answering at least 70% of the quiz questions correctly. This activity expires on September 29, 2020.

Intrathecal Baclofen Infusion: A Treatment for Spasticity and Secondary Generalized Dystonia

Intrathecal Baclofen Infusion: A Treatment for Spasticity and Secondary Generalized Dystonia

Efficacy of a second “drug holiday” in the treatment of intrathecal baclofen tolerance – A case study

Spasticity and muscle spasms are common complications following a SCI. Intrathecal baclofen (ITB) infusion is an effective treatment for severe spasticity of spinal cord origin. However, concerns over tolerance remain controversial. It is manifested by an escalation of dose required to produce a previously obtained effect or by a given dose of drug with continued administration. To combat baclofen resistance, a drug holiday is an effective method, interrupting the trend of accelerated dosage by weaning off the baclofen during 4–6 weeks. We report a case of a 45-year-old patient who suffered an accident on 1996 with SCI. He has incomplete tetraplegia AIS B, motor level C5 and sensitive L1. Due to severe uncontrolled spasticity (MAS = 4), he was implanted with a ITB pumb in 2002. Since than, it remained controlled (MAS = 2) with 310 ug/day. In 2009, because the resurgence of severe spasticity (MAS = 5), resistant to a fast increase on daily dose of baclofen until 360 ug/day, drug tolerance was suspected. We conducted a drug holiday over 4weeks and reintroduce baclofen. With 220 ug/day he showed a good control of spasticity (MAS = 1). During 2017, he presented an increase in spasticity (MAS = 4), combined with clonus of lower limbs [Spasm Frequency Scale (SFS) = 2]. We tried to control it, increasing the daily dose of baclofen, without response. He was admitted in CMRA for a second drug holiday. After 4 weeks without any baclofen, we gradually refill the pump. With 60ug/day we noticed an improvement on lower limbs spasticity (MAS = 2) and a decrease on muscle spasms (SFS = 0). He was discharged with this dose, appreciably below from admission. The use of ITB is increasing so we want to highlight the importance of being aware for cases of tolerance to baclofen. In this case, both drug holidays were effective, as measured by MAS and SFS.

Placement of baclofen pump catheter through a C1–2 puncture: technical note

Intrathecal baclofen has been suggested as an effective and safe treatment for intractable spasticity and dystonia. Techniques of lumbar and intraventricular catheter placement have been previously described. The purpose of this study was to describe a technique to implant catheters for intrathecal baclofen infusion through C1-2 puncture. Four of 5 consecutively treated patients underwent successful placement of catheters for intrathecal baclofen. There were no instances of infection, CSF leak, or catheter migration seen during a follow-up period of at least 6 months; furthermore, there were no occurrences of vertebral artery or spinal cord injury. All patients had an effective stabilization or reduction of their upper-extremity, lower-extremity, or trunk tone. There were no cases of worsening hypertonia. The authors' preliminary experience with C1-2 puncture for placement of the intrathecal baclofen catheter seems to indicate that this is a safe and efficacious technique. Lessons learned from the failed attempt at C1-2 puncture will be delineated.

A Pediatric Case of Intractable Cerebrospinal Fluid Leakage after Implantation of an Intrathecal Baclofen Pump

Intrathecal baclofen(ITB)infusion can offer a useful treatment for severe spasticity;however, numerous complications have been reported. We report a pediatric case in which intractable cerebrospinal fluid(CSF)leakage associated with several inconvenient symptoms arose after implantation of the ITB pump system. A 10-year-old girl with spastic quadriparesis and athetoid cerebral palsy underwent implantation of an ITB delivery system. After discharge, she presented with fluid collection surrounding the pump in the abdomen. The volume of fluid increased and was percutaneously aspirated every other week. However, conservative management failed to relieve fluid collection, which was suspected to be due to CSF leakage. She underwent additional purse-string suture of the point inserted catheter insertion in the back, epidural blood patch, and subfascial implantation of an anchor. However, none of these therapies proved effective. Progressive enlargement of the accumulated fluid was observed. Furthermore, symptoms of ITB withdrawal appeared. Lumbar-peritoneal shunting was performed, and the subcutaneous fluid collection was relieved postoperatively. The course after shunting was uneventful;hence, the dose of baclofen was stabilized. No recurrence of fluid collection was encountered for two years. Intractable CSF leakage was thought to be caused by wasting, occult hydrocephalus, and twisted movements. This case indicates that care is required in the management of CSF leakage after ITB pump implantation.

Percutaneous Endoscopic Gastrostomy in a Patient With Continuous Intrathecal Baclofen Infusion Therapy

Percutaneous endoscopic gastrostomy (PEG) is the method of choice in patients requiring long-term enteral tube feeding. In patients with intrathecal baclofen infusion therapy (IBT) pump implantation, infection via the skin and soft tissue may be an issue of concern. The introducer technique for gastrostomy tube insertion may be useful in reducing the risk of peristomal infection. Although the presence of a PEG tube has been reported as a risk factor for implantation site infection (for newly inserted IBT pumps), whether existing IBT pumps are at risk for infection during or after the placement of a PEG tube is not clear. We report a case where PEG was successfully performed using the introducer technique on a patient with an IBT pump implant.

Complications of intrathecal baclofen therapy

To analyze complications of intrathecal baclofen therapy and identify high-risk groups. We implanted 52 pumps to spastic patients for chronic intrathecal baclofen infusion. Two groups of patients were distinguished: 23 patients with spinal spasticity (group 1) and 29 patients with cerebral spasticity (group 2). The mean patient age was 37.2±14.6 years in group 1 and 17.3±10.3 years in group 2. Surgery was performed according to a standard procedure. A Medstream (Codman) pump was implanted in 10 cases, and a Synchromed II (Medtronic) pump was implanted in the remaining 42 cases. Complications developed in 12 (23%) patients. We divided complications into 3 groups: baclofen underdose, baclofen overdose, and others. Insufficiency of intrathecal therapy was observed in 7 cases, which was caused by catheter migration (5 cases) and pump dysfunction (2 cases). In one case, baclofen overdose was observed after air travel. Other complications included 4 cases of persistent peri-implant seroma and infectious complications. Groups with a high risk of complications were identified based on an analysis of the results. Patients with severe dystonia of the trunk muscles have an increased risk of spinal catheter migration. Pronounced communicating hydrocephalus is associated with the risk of cerebrospinal fluid leak through a catheter shaft channel. Weakness of the axial musculature can lead to progression of scoliotic deformity. In some cases, chronic intrathecal baclofen therapy can be accompanied by various complications. This technique should be carefully used in patients from high-risk groups.

Unexpected Baclofen Subdural Infusion in a Patient who Carries an Internal Pump for Intrathecal Infusion: A Case Report

Objective: We report a case of intrathecal baclofen infusion pump implantation complicated by migration of the catheter tip. Subdural migration, of the intrathecal catheter tip, in who has been having an infusion pump for years and is experiencing swinging dosage related effects it is not the first thing one takes into consideration. A case of subdural migration of intrathecal catheters is presented. Methods: Subsequent X-ray and computed tomography evaluations of the catheter system revealed pooling of contrast medium outside of the intrathecal space, in the lumbar subdural region of the vertebral channel and therefore migration of the pump catheter tip. Results: The spinal catheter was subsequently revised, and the patient made a full recovery. From few days after surgery, the patients spasticity improved and up to now (six months later), he has been experiencing no further complications, is requiring an average baclofen dosage of 150 mcg/day. Conclusion: The possible migration of an intrathecal catheter into the subdural space should be included as differential diagnosis in a patient who experiences a lack of drug effect, despite increases in dosage, after years from pump implantation. We recommend the use of the CT scan, after contrast injection, to detect the distal catheter tip and confirm a normal diffusion into the subarachnoid space.