Intrathecal Baclofen Pump Placement Research Articles

Management of Cerebrospinal Fluid Leak After Intrathecal Baclofen Pump Procedures in Adolescents With Cerebral Palsy: A Retrospective Study.

Epidural blood patches (EBPs) are frequently performed in children with cerebral palsy (CP) to manage post-dural puncture headache (PDPH) due to cerebrospinal fluid (CSF) leak after intrathecal baclofen pump (ITBP) placement or replacement procedures. The purpose of our study was to review the incidence and management of CSF leak following ITBPplacement or replacement procedures in children with CP. The study was a retrospective review of 245 patients representing 310 surgical cases of baclofen pump insertion (n=141) or reinsertion (n=169) conducted at a 125-bed children's hospital with prominent specialty orthopedics surgical cases. Demographic and clinical information was obtained from the anesthesia pain service database on all new ITBP placement and subsequent replacements over an eight-year period. The overall incidence of CSF leak in our population was 16% (50 of 310) and 18% (25 of 141) with a new ITBP placement.Children with diplegia were associated with a threefold risk of developing CSF leak. Of patients who developed CSF leak (n=50), 68% (n=34) were successfully treated conservatively, while 32% (n=16) required EBPs.EBPs were successful in 87.5% (14 of 16) of patients at relieving PDPH on the first attempt. Conclusions:CSF leak is a known problem after ITBP placement and replacement. Most patients were successfully treated with conservative management and EBPs were successful in patients failing conservative therapy.Diagnosing PDPH in non-verbal patients can be challenging.

Does the Intrathecal Baclofen Dose Need to Be Changed after Spinal Fusion Surgery for Neuromuscular Scoliosis?

Patients with cerebral palsy (CP) may receive intrathecal baclofen (ITB) to reduce muscle spasticity and dystonia. It can be challenging to identify the proper dose of ITB, and anecdotally these dosing needs may change after spinal fusion surgery. This study aimed to evaluate the need for changes in ITB dosing following a spinal fusion in pediatric neuromuscular scoliosis (NMS) patients and identify predisposing factors for those changes. This was a retrospective case-control study of NMS patients with an ITB pump who later received a spinal fusion surgery. Dosing changes and the indications for the changes were postoperatively noted. Demographics, preoperative factors, and surgical factors were evaluated for correlation with dosing changes. A total of 49 patients were included in this study. Most had no change in ITB dose (71.4%), and others required a change that averaged about 10%. Male patients, those with larger pumps, and those that had a longer hospital stay were more likely to require a decrease in dose. Complications were similar between groups. Three catheters were revised during surgery: two continued on the same dose and one required an increase in dose after surgery. Spinal fusion after ITB pump placement is feasible and safe. Most patients did not require dosing changes after spine fusion; however, careful evaluation postoperatively remains prudent.

Pediatric Intrathecal Baclofen Pumps: A Descriptive Analysis of Hospital Course and Associated Costs

Introduction: The purpose of this study was to identify predictors of increased cost and postoperative length-of-stay (LOS) following intrathecal baclofen pump (ITBP) placement. Methods: Patients were derived from the 2009/2012 kids’ inpatient database. Inclusion criteria were selected for patients with ICD-9 codes 343.X (infantile cerebral palsy), 86.06 (infusion pump insertion), 03.90 (spinal catheter insertion), and elective hospitalizations. Nonparametric univariate analysis and subsequent gamma log-link general linear modeling were used to identify significant predictors of cost/LOS (p < 0.05). Results: 529 unweighted patients (787 with survey weights applied) met criteria. Median LOS was 3.00 days, and median cost was USD 23,284. Following multivariate modeling, predictors of increased LOS (in days) included increased hospital ITBP volume (p = 0.027), small hospital size (+0.55, p = 0.004), device complications (+0.95, p < 0.001), procedural complications (+1.40, p < 0.001), additional procedures (+0.86, p < 0.001), electrolyte abnormalities (+3.74, p < 0.001), and neurological comorbidities (+1.60, p < 0.001). Factors associated with decreased LOS were paralysis (−0.53, p < 0.001), Northeastern hospital region (−0.55, p = 0.018), and investor-owned hospital status (−0.75, p = 0.001). Similarly, predictors of increased cost included race of Hispanic (+USD 1,156, p = 0.033) or “other” (+USD 2,158, p = 0.001), Northeast hospital region (+USD 4,120, p < 0.001), small (+USD 4,139, p < 0.001) or medium (+USD 3,368, p < 0.001) hospital sizes, additional procedures (+USD 1,649, p < 0.001), neurological comorbidities (+USD 3,222, p = 0.003), and increased LOS (p < 0.001). Factors associated with decreased cost included Western hospital region (–USD 1,594, p = 0.001), government hospitals (–USD 1,391, p = 0.019), and investor-owned hospitals (–USD 2,057, p = 0.021). Conclusion: This study found multiple variables associated with increased cost/LOS following ITBP placement. Broadly, this analysis demonstrates national trends associated with increased cost following ITBP placement.

Sleep-related breathing disorders associated with intrathecal baclofen therapy to treat patients with cerebral palsy: A cohort study and discussion.

Patients with cerebral palsy and other static encephalopathies (CP) are known to be at increased risk of sleep-related breathing disorders (SRBD). Few studies have reviewed whether intrathecal baclofen (ITB) can contribute to SRBD. To assess the prevalence of SRBD in patients with CP receiving ITB by using nocturnal polysomnography (NPSG). We performed a retrospective chart review of patients receiving ITB who had NPSG at Children's Hospital Colorado (CHCO) and Seattle Children's Hospital (SCH) from 1995 to 2019. The Gross Motor Function Classification System (GMFCS) measured the severity of motor disability. Screening sleep questionnaires collected subjective data and NPSG provided objective data of SRBD. All patients except one were GMFCS 4 or 5 with median age at ITB pump placement of 9.7 years. The screening questionnaire for SRBD detected one or more nighttime symptoms in > 82% of all patient groups. Pre-ITB criteria for a SRBD was met in 83% of patients at CHCO and 91% at SCH. Post-ITB prevalence remained similarly high. NPSG identified a high prevalence of SRBD in these cohorts from CHCO and SCH. Our study showed neither improvement nor worsening of SRBD in patients receiving ITB.

Microsurgical DREZotomy in Spastic Cerebral Palsy: Poor Man's Baclofen Pump

Using an intrathecal baclofen (ITB) pump for severe refractory spastic cerebral palsy is not a viable option in resource-constraint settings. Therefore authors assessed the role of microsurgical dorsal root entry zone-otomy (MDT) as an alternative for patients in whom the circumstances did not allow ITB pump placement. A prospective clinical study was conducted from August 2016 to July 2020. All patients of spastic cerebral palsy (with III-IV Ashworth grade) who underwent MDT were included. Preoperative and postoperative Ashworth grade and Gross Motor Function Classification System level were assessed along with any change in power, sensation, and bladder functions postoperatively. At last follow-up, the patients' main care providers were asked to rate the effect of surgery (on scale of 0-5) on ease of providing care related to 6 activities of daily living. Seven patients (5 males, 2 females) of spastic cerebral palsy with an age range of 6-21 years underwent MDT over the study period. Six patients had spastic diplegia, and 1 had spastic hemiplegia. Preoperative Ashworth grade in all patients was 3-4 in various involved muscle groups. Four patients with spastic diplegia underwent MDT at L3-S1 level bilaterally, 2 patients with spastic diplegia and spastic bladder underwent MDT at L3-S4 level bilaterally, and 1 patient with right-sided spastic hemiplegia underwent MDT at C5-T1 level and L3-S1 level on the right side. Postoperative Ashworth grade in all patients improved to 0-1. The improvement in mean Ashworth grade was from 3.14 ± 0.378 preoperatively to 0.29 ± 0.488 (P value= 0.000). Most care providers reported improvement in their ability to do physiotherapy, position, clothe, ambulate, and maintain patient's personal hygiene. Care providers of 6 patients reported that they were likely to recommend MDT to another similar patient. MDT is a cost-effective tool in deceasing limb spasticity in spastic cerebral palsy, especially for those who cannot afford ITB placement.

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.

Musculoskeletal Pain Outcomes Pre- and Post Intrathecal Baclofen Pump Implant in Children With Cerebral Palsy: A Prospective Cohort Study

ObjectiveTo characterize musculoskeletal pain intensity, duration, frequency, and interference with activities of daily living in children with cerebral palsy (CP) before and after intrathecal baclofen pump placement. DesignProspective cohort study. SettingChildren’s tertiary hospital. ParticipantsParticipants were children with CP (N=32; 53% male; mean age, 9.9y; age range, 4-17y). The majority of participants had a CP diagnosis of quadriplegia (76%) and relied on wheeled mobility (91%). InterventionsAssessments were completed pre- and post intrathecal baclofen pump implant. Main Outcome MeasuresBecause of considerable patient heterogeneity, both pain measures (Brief Pain Inventory, Dalhousie Pain Interview) were completed by proxy (parent) report at the time of the procedure and approximately 6 months after intrathecal baclofen (ITB) pump placement. ResultsPrior to implant, 31% of participants were living with constant pain, which reduced to 6% post ITB implant (P<.001). Based on Wilcoxon signed rank tests, pain duration significantly decreased post ITB pump implant (P<.01). ConclusionsThis prospective analysis supports the anecdotal and retrospective evidence that musculoskeletal pain decreases in CP following ITB pump implant. The greatest effect appears to be on the duration of pain experience. Pain did not decrease for all individuals, and it would be worth further investigation to better understand the relation between patient characteristics and pain outcomes.

Poster 276: Anxiety and Panic Disorder Following Intrathecal Baclofen Pump Placement: A Case Report

Poster 276: Anxiety and Panic Disorder Following Intrathecal Baclofen Pump Placement: A Case Report

A rare case of pseudomonas meningitis following intrathecal baclofen pump placement in a 28-year-old paraplegic patient

A rare case of pseudomonas meningitis following intrathecal baclofen pump placement in a 28-year-old paraplegic patient

Readmission and complications within 30days after intrathecal baclofen pump placement.

To describe 30-day outcomes after intrathecal baclofen (ITB) pump placement in children and identify risk factors for readmission, reoperation, and perioperative complication using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database. Patients aged 0 to 18years who underwent ITB pump placement (2012-2014) comprised the study cohort defined in the database. Multivariate regression analysis was performed using preoperative and perioperative data from the American College of Surgeons' NSQIP-P database. Outcomes of interest within 30 days of surgery were (1) unplanned reoperation; (2) unplanned readmission; and (3) composite postoperative event, including complication, reoperation, and/or readmission. We identified 423 surgeries; 246 (58.2%) patients were male, 177 (41.8%) patients were female. Median age was 12years and 11months. Median operative time was 70minutes (interquartile range 56-97min). Mean length of stay was 3.8days. The patient population had a high number of medical comorbidities. The overall readmission rate was 7.3%; mean postoperative admission date was 14.1days after surgery. Of readmitted patients, 64.5% underwent reoperation. The most common indication for reoperation was surgical site infection. Female sex was associated with decreased risk of readmission (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.09-0.65; p=0.01); American Society of Anesthesiologists Classification of greater than or equal to 3 was associated with decreased risk of unplanned return to surgery (OR 0.26, 95% CI 0.11-0.66; p=0.04); length of stay greater than or equal to 3days at index surgery was associated with increased risk of composite 30-day perioperative event (OR 2.33, 95% CI 1.29-4.20; p=0.01). Our data provide national perspectives on 30-day perioperative outcomes for ITB pump placement in children. Results illustrate NSQIP-P database collection methodology and highlight opportunities for quality improvement in clinical practice. Seven percent of patients who underwent intrathecal baclofen pump placementrequired readmission within 30days. The most common indication for reoperation was surgical site infection.

1226 Two cases of central sleep apnea in patients on intrathecal baclofen (ITB)

Central sleep apnea (CSA) has been reported in association with baclofen, a GABAB receptor agonist. Few studies have described CSA in patients using intrathecal baclofen (ITB). Here we describe two such patients seen in sleep clinic. A 32-year-old male was referred for snoring and gasping sensations. History was significant for treated childhood astrocytoma and strokes resulting in left hemiparesis, spasticity and functional deficits. He had been on ITB for nine years prior to presentation. Apnea-hypopnea index (AHI) was 154.3 events/hour, including 332 central apneas. CPAP failed to resolve central apneas, but adaptive servo-ventilation (ASV) at 9 cm H2O resolved both obstructive and central apneas. A 40-year-old male with spastic tetraplegia from a traumatic brain injury (TBI) in 1995 was seen for unrefreshing sleep and excessive daytime sleepiness. He had been using an ITB for 10 years prior to presentation. A polysomnography (PSG) showed an overall AHI of 42, predominantly from 238 central apneas, which improved after treatment with ASV. CSA has previously been described in patients on baclofen therapy for alcohol withdrawal, but few studies have described CSA in patients with ITB for spasticity. Baclofen decreases minute ventilation in animals, but the mechanism by which it does so is unclear at this time. A pilot study revealed bolus administration of ITB can worsen pre-existing sleep apnea, whereas a continuous infusion did not significantly affect previous sleep disordered breathing. It may be important to perform PSG in patients prior to ITB pump placement. Another study demonstrated changes in sleep architecture and minor decreases in mean oxygen saturations following administration of oral baclofen, but limited effects on sleep-disordered breathing (SDB). It is possible that TBI and/or stroke may have contributed to the SDB observed in our patients. Our patients experienced improvement in CSA following ASV.

An investigation of the relationship between autonomic dysreflexia and intrathecal baclofen in patients with spinal cord injury

Objective: To study the relationship between autonomic dysreflexia and intrathecal baclofen in patients with spinal cord injury.Design: Retrospective chart review.Setting: Inpatient and outpatient acute rehabilitation facility.Participants: Thirty-four subjects.Interventions: We reviewed patients’ medical records to ascertain the presence of symptomatic autonomic dysreflexia (AD) prior to and after implantation of an intrathecal baclofen (ITB) pump for spasticity in spinal cord injury patients. We recorded risk factors for autonomic dysreflexia including kidney and bladder stones, heterotopic ossification (HO), and ischial / sacral pressure ulcers.Outcome Measures: Presence of autonomic dysreflexia pre and post-intrathecal baclofen pump placement, presence of risk factors associated with autonomic dysreflexia including (1) kidney or bladder stones, (2) heterotopic ossification, and (3) pressure ulcers.Results: Of the 34 subjects, 25 (73.5%) experienced AD prior to ITB pump placement and only 2 (5.9%) after placement. Four subjects (11.8%) had kidney or bladder stones, of which, all had AD prior to placement and none had AD afterwards. Twenty-six subjects (76.5%) had pressure ulcers, of which, all experienced AD prior to placement and only one (0.02%) afterwards. Six patients (17.6%) had HO, of which 5 (83%) had AD prior to placement and none afterwards. Additionally, three patients (8.8%) had at least 2 of the above risk factors, of which, all had AD prior to ITB placement and none afterwards.Conclusion: This study showed a significant reduction of symptomatic episodes of autonomic dysreflexia after spinal cord injury, even in those with additional risk factors for development of autonomic dysreflexia.

Poster 90 Intrathecal Baclofen Pump Placement in a Patient with Stiff Person Syndrome: A Case Report

Poster 90 Intrathecal Baclofen Pump Placement in a Patient with Stiff Person Syndrome: A Case Report

Efficacy of intraoperative vancomycin powder use in intrathecal baclofen pump implantation procedures: Single institutional series in a high risk population

We aimed to assess the efficacy of intraoperative vancomycin powder in intrathecal baclofen pump placement patients, a high risk population. A retrospective review was conducted using prospectively collected data at an academic tertiary care unit. The neurosurgical adult patient population was queried for all intrathecal baclofen pump implantation procedures. Patients were then reviewed for the use of intraoperative crystalline vancomycin powder. Those with a history of prior surgical site infection, chronic systemic infections or osteomyelitis were excluded. Anhydrous, crystalline vancomycin was utilized in the wound bed after completion of implantation, distributed evenly in the case of multiple incisions. Patients received 500mg or 1000mg of crystallized vancomycin, evenly distributed through the wound layers based on a 70 kg weight cutoff. Intraoperative institutional standards of infection prophylaxis were unchanged throughout the study period. Infection rate of baclofen pump placement prior to the use of vancomycin powder from 2001–2009 at the same institution was monitored. Wound infection rate was tracked for a 12month postoperative period. Six patients out of 26 baclofen pump implantations (23%) in this cohort were identified to have seven infections despite vancomycin powder placement in the lumbar and catheter wounds. Prior infection rates have been investigated for intrathecal drug delivery systems from 2001 to 2009 at the same institution with an overall infection rate of 3% (8/274). The use of vancomycin powder in patients with implants in this series did not reduce infection rates compared to published historical controls, and was elevated compared to institutional controls. Further prospective study of this high risk patient population is warranted.

Complications of Intrathecal Baclofen Pumps in Children: Experience from a Tertiary Care Center

Background/Aims: Intrathecal baclofen (ITB) therapy is useful in treating spasticity and dystonia but it has many complications, more so in children. The main aim of the study was to look at the complications of ITB pumps in children with the goal of future prevention. Methods: Charts of all patients ≤21 years with an ITB pump, implanted by a single pediatric neurosurgeon, at a single center, between 1996 and 2011 were reviewed retrospectively. Data regarding an ITB test trial were also recorded. Results: During 1996-2011, 119 children (mean age 13.2 years) underwent ITB pump placement; 84% had spastic quadriplegic cerebral palsy. The gross motor function classification system level was ≥4 for most. The pump was removed in 5 (4.2%) patients due to inefficacy. The mean follow-up was 38 months. Mechanical complications requiring pump and/or catheter revision occurred in 19.3% and infections in an additional 21.8%. Seven patients (6%) had meningitis. No complication was noted after 72 months of initial pump insertion, even after pump reinsertion. Conclusion: There is a need for better infection control as well as better pump, catheter and surgical technology to lower the complications of ITB pumps in children.

Poster 377 Acute Postoperative Complications With Intrathecal Baclofen Pump Placement at a Regional Pediatric Specialty Hospital: A Case Series

Poster 377 Acute Postoperative Complications With Intrathecal Baclofen Pump Placement at a Regional Pediatric Specialty Hospital: A Case Series

Poster 442 Urinary Retention Secondary to an Intrathecal Baclofen Pump Placement: Case Report and Literature Review

Poster 442 Urinary Retention Secondary to an Intrathecal Baclofen Pump Placement: Case Report and Literature Review

Poster 318: Functional Improvement in Swallowing and Social Cognition After Intrathecal Baclofen Pump Placement in a 4-Year-Old Boy With Quadriplegic Cerebral Palsy Secondary to Shaken Baby Syndrome: A Case Report

Poster 318: Functional Improvement in Swallowing and Social Cognition After Intrathecal Baclofen Pump Placement in a 4-Year-Old Boy With Quadriplegic Cerebral Palsy Secondary to Shaken Baby Syndrome: A Case Report

Poster 390: Efficacy of Early Intrathecal Baclofen Pump Placement in the Management of Stroke Related Spastic Hypertonia: A Case Report

Poster 390: Efficacy of Early Intrathecal Baclofen Pump Placement in the Management of Stroke Related Spastic Hypertonia: A Case Report

Progression of Scoliosis in Patients With Spastic Quadriplegia After the Insertion of an Intrathecal Baclofen Pump

Medical and radiographic review of 19 consecutive patients with spastic quadriplegia before and after intrathecal baclofen pump insertion with special attention paid to progression of scoliosis. Many orthopedic surgeons who treat spastic quadriplegic patients have noticed a trend of marked scoliosis progression after the administration of intrathecal baclofen (ITB) via subcutaneous pump and catheter. The purpose of this study is to quantify scoliosis progression in this patient population before and after baclofen administration and compare this to published natural history data. The authors had noted rapid progression of scoliosis in spastic quadriplegic patients after intrathecal baclofen pump insertion. This had been noted at other centers, but no significant statistical analysis had been done comparing prepump to postpump scoliosis progression in these patients. To document the magnitude and rate of scoliosis progressions after the placement of an ITB pump, the charts and radiographs of 19 consecutive nonambulatory patients with spastic quadriplegia and an ITB pump were reviewed. To document the rate of scoliosis progression, each patient had at least 2 pre and 2 postpump insertion spinal radiographs made. All radiographs were made with the patients in the supine position without orthoses. A board-certified orthopedic surgeon reviewed these radiographs. Skeletal maturity was assessed using Risser grading. Catheter tip location and rate of baclofen administration were recorded. For 19 patients with complete radiographic data, average Cobb angles were 10.2 degrees before pump insertion and 25 degrees at an average of 20.9 months after pump insertion (P < 0.0001). These 19 patients had a mean rate of change in their Cobb angles of 1.825%/year before pump insertion and 10.95 degrees /year at an average of 23.9 months after pump insertion (P = 0.024). These results represent a 6-fold increase in the curve progression rate after pump insertion. There was no association between catheter tip location or rate of Baclofen infusion on curve progression. In published data, the rate of progression of scoliosis in skeletally immature nonambulatory patients with cerebral palsy was 4.5 degrees /year. In this study, the average rate of progression of the scoliosis for the immature was 9.02 degrees /year. For the skeletally mature bed-ridden patients, the worst-case natural history progression was 4.4 degrees /year. The comparable rate of change in skeletally mature (Risser 5) nonambulatory patients (n = 6) in this study was 28.4 degrees /year. This study demonstrates a significant increase in the rate of scoliotic curve progression after ITB pump placement when compared with published natural history data. The evidence of the beneficial effects of ITB on spasticity has been confirmed, and as larger, prospective randomized studies are conducted, the authors think that support for continued use of this treatment will increase. However, early bracing and spinal fusion may be warranted to prevent significant increases in spinal deformity if scoliosis is anticipated to progress more than 10 degrees /yr for patients with spastic quadriplegia and ITB pump. The authors are now performing spinal fusions for curves that exceed 40 degrees to 50 degrees in the presence of an ITB pump as recommended by previous reviews of scoliosis and accompanying quadriplegia.