Intrathecal Pump Research Articles

Procedural education for cancer-related pain in Pain Medicine fellowships: a national program survey

IntroductionCancer-related pain is ubiquitous. Targeted procedural interventions may be an important and underutilized method for improving cancer-related pain and quality of life. The goal of this study was to determine...

Postoperative Analgesic Efficiency of Quadratus Lumborum Block III versus Peritubal Local Infiltration in Patients Undergoing Percutaneous Nephrolithotomy Operation: A Randomized Controlled Trial

Abstract Background The postoperative pain after percutaneous nephrolithotomy (PCNL) can be managed by many peripheral blocks techniques (e.g., paravertebral and quadrates lumborum block), and local anesthesia infiltration. Therefore, this prospective study was conducted to evaluate the effect of quadratus lumborum type III versus peritubal local infiltrating on postoperative analgesia for patients undergoing PCNL under general anesthesia. Methods Eligible subjects after exclusion of COVID-19 patients, with renal stones less than 2 cm undergoing PCNL surgery under general anesthesia. Exclusion criteria were: 21<years of age or > 60 years of age; bleeding disorders; allergies to local anesthetics; psychiatric patients; and American Society of Anesthesia (ASA) physical status III and IV. Eighty patients were randomly allocated to 2 equal groups. In the Quadratus group, participant received 20 mL of bupivacaine 0.25% in the fascial plane between the quadratus lumborum and Psoas muscle; and in the peritubal group, patients received 10 mL of bupivacaine 0.25% around the nephrostomy tube at 6 and 12 o’clock positions (total 20 mL). The quadratus lumborum block and peritubal infiltration were performed by the primary investigator and the urologist, respectively. All patients received standard postoperative analgesia (paracetamol, ketorolac, and morphine via patient-controlled analgesia. Both patients and Data collecting staff were blinded to study group. Primary outcome was the visual analogue score at rest and on coughing or movement at 2, 4, 6, 12, and 24 hours. Secondary outcomes were 24 hours total morphine consumption, 1st use of morphine pump, incidence of side effects (pruritis and nausea and vomiting) and patient satisfaction. Results Data were analyzed from 78 patients (39 patients in each group). The mean resting VAS score in quadratus group at 6 and 12 hours was (3), while the mean VAS in peritubal group was (5) and (6) at 6 and 12 hours, respectively. Dynamic VAS score in peritubal group at 6 hours was (mean 6) with p<0.0001 when compared to resting value. The 24 hours’ morphine consumption was 8.5-11 mg and 1619 mg, in quadratus and peritubal group, respectively (the difference in mean of 9 at the 95% confidence interval; p<0.0001). patients start to use morphine pump after 121.4 min and 180.2 min in group peritubal and quadratus, respectively. Patients in group quadratus were statistically more satisfied, in both groups incidence of complication was low. Conclusion Quadratus Lumborum block was more effective than Peritubal LA infiltration regarding postoperative VAS score both at rest and during movement with lower postoperative morphine consumption and more satisfaction in patients undergoing PCNL surgery. Trial registration This prospective randomized trial was registered at Clinical Trials.gov in December, 2019. https://clinicaltrials.gov/ct2/show/NCT04215705.

Calcification of the pump pouch in patients receiving ITB therapy: A rare complication affecting refill procedure – Analysis of two cases

BackgroundIntrathecal baclofen therapy (ITB) is an effective treatment for reducing spasticity but can be associated with various complications, including infection and implant malfunction. MethodsThis retrospective cohort study analyzed refill reports, complications, and functional outcomes in 40 consecutive patients with intractable spasticity or dystonia undergoing ITB. ResultsAmong the 40 patients, 8 experienced complications, including two cases of calcification of the baclofen pump pouch and surrounding tissue, a rare complication not extensively described in the literature. DiscussionCalcification, in addition to port access difficulties, could lead to drug delivery failure. We hypothesize that calcification may result from microtrauma or needlestick injury to the subcutaneous tissue and muscle fascia. The length of time the pump stays in the pocket could also contribute to favoring this phenomenon. ConclusionAs the number of patients receiving ITB increases, physicians must be aware of potential life-threatening complications. The risk of pouch calcification should be further investigated and considered in managing patients undergoing ITB, as it could significantly impact patient care.

Example Radiation Oncology Policy for Managing Patients With Implanted Electronic Devices Other Than Implantable Cardiac Pacemakers or Defibrillators

This article describes a community-based hospital's policy for the management of patients with medical implanted electronic devices other than pacemakers or implanted cardiac defibrillators (ICDs). The policy may be adapted as needed for other radiation oncology groups requiring a practical solution for managing the care of patients with implanted devices, noting the need for changes for departments offering proton, neutron, heavy ion, or magnetic resonance-guided linear accelerator (MR-linac) treatment modalities. The policy was developed using a risk-based approach, with each patient's risk level determined based on the patient's dependence on the device, the anticipated dose to the device, and the type of treatment used. A similar approach is used for patients with pacemakers or ICDs, but this policy was designed to accommodate patients with other types of devices with care managed outside the department. Such devices include, but are not limited to, hepatic pumps, intrathecal pain pumps, neurostimulators, cochlear implants, and loop recorders. The resulting definitions, guidelines, and proposed workflow were presented at the institution's multidisciplinary radiation oncology quality assurance committee monthly meeting and adopted as department policy in 2022. Recommendations incorporated in the policy include levels of patient monitoring and timing of device interrogation to minimize the risk of device malfunction. The policy was written to guide the management of treatment of patients with a range of medical implanted electronic devices. This policy is currently in operation at a community-based hospital.

Intrathecal Baclofen to Improve Functional Status in ALS: A Case Report

Background: Intrathecal pumps are well known to benefit patients with chronic pain as well as spasticity. Intrathecal baclofen (ITB) can offer doses 100-1000 times smaller with similar efficacy, compared to oral baclofen. Only 2 previous reports detailed improvement in functional status after patients with amyotrophic lateral sclerosis (ALS) received ITB. Case Report: Our patient presented with progressive bulbar palsy, further progressing to ALS. His lower extremity spasticity and tremors continued to progress over 3 years despite increased baclofen. At the time of implant, he expressed whole body tremors and spasticity to bilateral lower extremities, complicated by falls. Prior to the trial, the patient ambulated 50 feet. ITB was started at a rate of 100 mcg/day. After the implant, the patient’s ambulation distance increased to 100 feet. Conclusion: The patient and his wife reported resolution of his tremors and improvement in spasticity. This report details the functional improvement obtained from ITB in a patient with ALS. Key words: Amyotrophic lateral sclerosis (ALS), intrathecal, baclofen, functional status, chronic pain, interventional pain

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.

Spinal Cord Stimulators and Intrathecal Pain Pump Removal Versus Retention During Posterior Lumbar Fusion: A Matched Cohort Analysis.

Retrospective cohort study. To determine risks associated with posterior lumbar arthrodesis after spinal cord stimulator (SCS) and intrathecal pain pump (IPP) insertion. SCS and IPPs aid in the management of chronic back and radicular pain. Little is known regarding the risks of subsequent fusion with these devices in place. The PearlDiver Mariner database was queried for spinal fusion between 2010 and 2020. Study groups were created for indwelling SCS or IPP and matched to a separate cohort without SCS or IPP. Subgroups were created for those who had their device removed and those who retained their device at the time of surgery. Complications up to 2 years postoperatively were reviewed and confounding variables were controlled using multivariable logistic regression. Four thousand five hundred three patients had an indwelling SCS/IPP and underwent posterior lumbar fusion. Compared with patients without history of an SCS/IPP, patients undergoing a lumbar fusion with an SCS/IPP which was removed or retained had higher rates of revision surgery at 1 year [7.3% vs. 5.0%, odds ratio (OR) =1.48, P <0.001] and 2 year (10.8% vs. 7.0%, OR =1.59, P <0.001). For all time intervals, there were higher odds of instrumentation failure (2y: OR =1.65, P <0.001), and pulmonary complications (2y: OR =1.18, P <0.001). At 2 years, there were higher odds of surgical site complications (OR 1.15, P =0.02) and urinary complications (OR=1.07, P =0.04). There were no differences in complications up to 2 years postoperatively in patients with an SCS/IPP who had their devices retained or removed ( P >0.05). Patients with a history of spinal cord stimulators and intrathecal pain pumps are at increased risk of mechanical complications and revision fusion compared with patients without these devices. Patients with an SCS or IPP have similar rates of complications during lumbar fusion whether the device is removed or retained.

Comparison of the Effect of Injectable Acetaminophen with Injectable Ketamine by Morphine Pump on Reducing Acute Pain after Laparoscopic Cholecystectomy Surgery

Introduction: At the issues that have always been the concern of the surgical team is finding a way to better control post-operative pain, because pain controls a significant role in the length of time the patients stay in the hospital, the level of patient satisfaction, the recovery period and the patient's return to normal life activities. Millions of patients in the world undergo surgery every year, and most of them report unrelieved pain after the surgery. Aim: To compare the control and reduction of acute pain in patients after laparoscopic gallbladder surgery by injectable acetaminophen and injectable ketamine. Materials and methods: this RCT study, which was conducted as a non-blind randomized clinical trial, 50 laparoscopic gallbladder surgery patients who referred to the teaching hospitals of Qazvin University of Medical Sciences in 2022 were selected as available and as Injectable acetaminophen and injectable ketamine were randomly divided into two drug groups and pain reduction was investigated and analyzed. Results: this study, the average age group of patients (in two groups) was 49.34 ± 13.52, and the pain reduction in both groups was less in those under 30 years of age, and more pain reduction in those over 30 years old, so that over 50 years of age had the greatest pain reduction, and The reduction of pain in the acetaminophen group was more than that of ketamine and it was statistically significant (P = 0.02). The reduction in pain intensity in the patients in the injectable acetaminophen drug group after receiving the full dose of the drug showed a noticeable and greater decrease compared to the ketamine group. Therefore, injectable acetaminophen was seen as an effective drug in reducing pain after laparoscopic surgery and it was statistically significant. (P = 0.002). Conclusion: In this study, the effect of injectable acetaminophen was very effective in reducing the amount of pain and the intensity of pain after laparoscopic surgery, but ketamine not only does not reduce the effect of pain, but it also changes the effect of other.

Identification of risk factors for reconstructive hip surgery after intrathecal baclofen therapy in children with cerebral palsy.

This study aimed to determine the risk factors for reconstructive hip surgery after intrathecal baclofen pump application in children with cerebral palsy. Inclusion criteria were children with hypertonic (spastic or mixed spastic/dystonic motor type) cerebral palsy, intrathecal baclofen implantation <8 years of age, no reconstructive osteotomies prior to or concomitant with intrathecal baclofen implantation and at least a 5-year follow-up. Exclusion criteria included reconstructive osteotomies prior to or concurrent with intrathecal baclofen implantation, lack of at least 1 hip surveillance radiograph before intrathecal baclofen, lack of a 5-year follow-up, or having selective dorsal rhizotomy. In addition, patients with bony surgery plus last follow-up migration percentage ≥50% were labeled as required reconstruction hips. We identified 34 patients (68 hips). The mean follow-up was 9.2 ± 2.8 years. The mean age for intrathecal baclofen application was 6.4 ± 1.2 years. Seven patients were Gross Motor Function Classification System IV, and 27 were V. Eighteen patients (52.9%) with 31 hips (45.6%) were requiring reconstruction at the final follow-up. In multivariate analysis, male sex (odds ratio 12.8, P=.012), pre-intrathecal baclofen migration percentage (odds ratio 1.1, P=0.003), age at intrathecal baclofen implantation (odds ratio 0.24, P=.002), and delta migration percentage (odds ratio 1.1, P=.002) were significant risk factors for requiring reconstruction. Patients with intrathecal baclofen <6.2 years of age had a significantly higher rate of requiring reconstruction. A pre-intrathecal baclofen migration percentage >31% had a greater risk of progression to requiring reconstruction (P=.001). Delta migration percentage higher than 15% was significantly associated with progression to requiring reconstruction (P=.043). The risk of requiring reconstruction osteotomies after intrathecal baclofen was significantly increased in males, those younger (±migration percentage >31%) at the time of intrathecal baclofen implantation and those with an increased rate of migration percentage progression after intrathecal baclofen implantation. Level IV, Prognostic Study.

Cost-Effectiveness and Cost–Utility Analyses in Thailand of Continuous Intrathecal Morphine Infusion Compared with Conventional Therapy in Cancer Pain: A 10-year Multicenter Retrospective Study

ABSTRACT Background Because of the high initial cost of intrathecal drug delivery (ITDD) therapy, this study investigated the cost-effectiveness and cost–utility of ITDD therapy in refractory cancer pain management in Thailand over the past 10 years. Methods The retrospective study was conducted in patients with cancer pain who underwent ITDD therapy from January 2011 to 2021 at three university hospitals. Clinical outcomes included the numerical rating scale (NRS), Palliative Performance Scale, and the EQ-5D. The direct medical and nonmedical as well as indirect costs were also recorded. Cost-effectiveness and cost–utility analyses were performed comparing ITDD therapy with conventional therapy (extrapolated from costs of the same patient before ITDD therapy) from a societally oriented economic evaluation. Results Twenty patients (F:M: 10:10) aged 60 ± 15 years who underwent implantation of an intrathecal percutaneous port (IT port; n = 15) or programmable intrathecal pump (IT pump; n = 5) were included. The median survival time was 78 (interquartile range = 121–54) days after ITDD therapy. At 2-month follow-up, the incremental cost-effectiveness ratio (ICER)/pain reduction of an IT port (US$2065.36 (CA$2829.54)/2-point NRS reduction/lifetime) was lower than for patients with an IT pump (US$5479.26 (CA$7506.58)/2-point NRS reduction/lifetime) compared with continued conventional therapy. The ICER/quality-adjusted life years (QALYs) gained for an IT port compared with conventional treatment was US$93,999.31(CA$128,799.06)/QALY gained, which is above the cost-effectiveness threshold for Thailand. Conclusion The cost-effectiveness and cost–utility of IT port therapy for cancer pain was high relative to the cost of living in Thailand, above the cost-effectiveness threshold. Prospective cost analysis studies enrolling more patients with diverse cancers that investigate the benefit of early ITDD therapy with devices over a range of prices are warranted.

Intrathecal Drug Delivery Systems for Cancer Pain Control: Insights on Current Contemporary Practices in the US

ObjectivesAmong patients with cancer with moderate to severe, intractable pain, intrathecal drug delivery using an intrathecal drug delivery system (IDDS) offers effective pain control. In this study, we evaluate the trends of IDDS therapy among patients with cancer, associated comorbidities, complications, and outcomes, using a large representative US administrative inpatient data base. Materials and MethodsThe Nationwide Inpatient Sample (NIS) data base contains data from 48 states and the District of Columbia. The NIS was used to identify patients with cancer who underwent IDDS implantation between 2016 and 2019. Patients with cancer with intrathecal pumps for the treatment of chronic pain were identified using administrative codes. Baseline demographics, hospital characteristics, type of cancer associated with IDDS implantation, palliative care encounters, hospitalization costs, length of stay, and prevalence of bone pain were evaluated in the study. ResultsA total of 22,895 (0.32%) individuals with hospital admission for IDDS surgery were included for analysis among 7.06 million individuals with cancer in the final cohort. The IDDS cohort consisted of patients predominantly in the 65-to-79 years age group (40.49%), female sex (50.42%), and Caucasian ethnicity (75.82%). The top five cancers in patients receiving IDDS were lung (27.15%), colorectal (24.9%), liver (16.44%), bone (8.01%), and liver (7.99%) cancer. In addition, the length of stay was six days (interquartile range [IQR] four–nine days) and the median cost of hospital admission was $29,062 (IQR $19,413–$42,261) in the patients who received an IDDS. These factors were greater than those in patients without IDDS. ConclusionsA very few patients with cancer received IDDS in the US during the study period. Despite recommendations supporting its use, there are significant racial and socioeconomic disparities in IDDS use.

Decompression for lumbar spinal stenosis at the intrathecal catheter insertion site during intrathecal baclofen therapy: a case report

BackgroundIntrathecal baclofen therapy can substantially improve symptoms in most patients with severe spasticity due to traumatic spinal cord injury, multiple sclerosis, or cerebral paresis. To the best of our knowledge, decompression surgeries at the intrathecal catheter insertion site in patients with a preexisting intrathecal pump for drug delivery have not been reported.Case presentationWe report the case of a 61-year-old Japanese man with lumbar spinal stenosis who underwent intrathecal baclofen therapy. We performed decompression for lumbar spinal stenosis at the intrathecal catheter insertion site during intrathecal baclofen therapy. The yellow ligament was removed by partial resection of the lamina under a microscope to avoid damage to the intrathecal catheter. The dura mater was distended. No obvious cerebrospinal fluid leakage was observed. Postoperatively, lumbar spinal stenosis symptoms improved, and spasticity remained well controlled with intrathecal baclofen therapy.ConclusionsThis is the first reported case of lumbar spinal stenosis decompression at an intrathecal catheter insertion site during intrathecal baclofen therapy. Preoperative preparation is necessary, as the intrathecal catheter may be replaced during surgery. We performed surgery without removing or replacing the intrathecal catheter, taking care not to damage the spinal cord by migrating the intrathecal catheter.

An in vivo analysis of implanted programmable device interference during magnetically controlled growing rod lengthenings: a story of 129 lengthenings.

Early-onset scoliosis (EOS) is often treated with magnetically controlled growing rods (MCGR) which can be lengthened with a magnetic external remote control (ERC). Many individuals with EOS have concomitant medical conditions which are managed with other implanted programmable devices (IPD). Some providers are concerned that the magnetic field generated during MCGR lengthening may interfere with other IPD, such as ventriculoperitoneal shunts (VPS), intrathecal baclofen pumps (ITBP), vagal nerve stimulators (VNS), and cochlear implants (CI). The aim of this study was to evaluate the safety of MCGR lengthenings in patients with EOS and other IPD. This single-center, single-surgeon case series followed 12 patients with 13 IPD as they underwent treatment with MCGR. Post MCGR lengthening, monitoring of patient symptoms, and interrogation of IPD were conducted to evaluate for magnetic interference. After 129 MCGR lengthenings, post-lengthening VPS interrogation found 2 instances of potential interference in settings (both in Medtronic Strata shunts); however, no pre-lengthening interrogation was completed to confirm if these changes occurred prior to or during the lengthening procedure. ITBP interrogation found no changes, and there were no patient-reported adverse effects related to VNS or CI function. It is safe and effective to utilize MCGR in patients with IPD. However, the possibility of magnetic interference must be considered, particularly in individuals with VPS. We recommend approaching with the ERC from a caudal direction to minimize potential interference and all patients be monitored during treatment. If possible, IPD settings should be assessed pre-lengthening, confirmed afterwards and readjusted if necessary. Level IV.

ID: 217145 Intrathecal Pump for the Treatment of Complex Regional Pain Syndrome After Failed Interventional Modalities

Intrathecal drug delivery systems have been utilized for decades. Although techniques may vary among providers, intrathecal pump placement is commonly used for cancer and chronic pain patients. At this time its utilization still lags behind other pain control modalities. Intrathecal infusion pumps may offer an excellent alternative for patients receiving poor analgesia with alternative interventional or pharmacological techniques, as well as reduce overall opioid requirements and reduce side effects. We provide a case in which a patient diagnosed with chronic cervical pain in the form of complex regional pain syndrome in unilateral extremity who previously received minimal relief with alternative modalities found significant pain reduction after both intrathecal pump trial and permanent pump placement.

ID: 217168 Intrathecal Pump Refill Leading to Altered Mental Status: Diagnosis and Management of a Pocket Fill

An 83 year-old male was admitted to the ICU from an outside hospital secondary to altered mental status in the setting of an intrathecal pump. The family reported the patient was in his usual state of health until four days prior when a home health nurse refilled his intrathecal pump with hydromorphone. At the time of pump refill, there was concern for drainage from the pump site and the usual difficulty of fill due to scar anterior to the device. The patient presented that evening to a local hospital due to being sluggish but was sent home with no clear etiology identified or trigger for admission. Three days later, he returned to the local hospital due to altered mental status felt to be medication overdose. Narcan was given causing severe agitation necessitating treatment with ketamine, morphine, and lorazepam. He was then transferred to Emory University for further critical care management and evaluation for possible intrathecal pump infection versus system failure.

ID: 207123 When to Evaluate for Catheter Revision/Replacement in Long-Term Intrathecal Baclofen Pump Users: A Case Series

Baclofen withdrawal is a life-threatening issue that has been demonstrated in patients with intrathecal baclofen use with catheter-related dysfunction. Prior to 2012, Medtronic baclofen pumps used traditional silicone catheters. In 2012, Medtronic introduced a new coated catheter designed to increase catheter strength and reduce kinking and occlusions. According to a 2016 review comparing traditional silicone catheters vs the coated catheter in children, 18% compared with 1.1% had catheter-related complications in the traditional and coated catheter groups respectively1. According to a 2020 Product Performance Report, there were 700 catheter-related events out of 5475 catheters (12.79%) and 277 events out of 2779 catheters (9.97%) in the old and new catheter models, respectively2.

ID: 209325 Post-Laminectomy Intrathecal Pump Explant Complicated by Unforeseen Opiate Withdrawal

Introduction: A 53-year-old female with a history of post-laminectomy syndrome and pancreatic cancer treated with intrathecal pump placement presented to the clinic requesting to have it removed due to side effects. She was experiencing nausea, and though it was uncertain if this was from the pump or her previous cancer history, she requested that it be removed. She was receiving 200mcg/mL hydromorphone and 30mg/ml bupivicaine through her pump and was able to be weaned down to 9.61 mcg/day hydromorphone over 2 months before explant. The evening after the pump was removed, she began experiencing pain at her surgical site and took 4 tablets of Oxycodone 5mg all at once, but she began having nausea, shivering, and AMS and was brought to the ED. She was found to be alkalotic, which was attributed to hyperventilation. A CT abdomen/pelvis was unremarkable, and a CT of her lumbar spine showed minimal gas at L3, which decreased the concern for an infective etiology for her symptoms. Her symptoms were attributed to a most likely opiate withdrawal vs sepsis, and her mental status markedly improved with 2mg hydromorphone. She was started on a PCA with subsequent oxycodone taper. However, there was concern for aspiration pneumonia due to her AMS, so she was transferred to the ICU and her pain needs were managed in addition to her pulmonary needs.

ID: 212438 Catheter Access Port Aspiration of Intrathecal Baclofen and Its Unforeseen Clinical Benefits: A Case Report

Intrathecal baclofen (ITB) pump therapy is a mainstay in the treatment of severe or intractable spasticity and dystonia in patients with upper motor syndromes such as stroke, spinal cord injury, and cerebral palsy. While effective, intrathecal pumps present with their own unique complications, most commonly related to catheter dysfunction or breakage [1-4], which requires systematic troubleshooting [5]. Catheter access port (CAP) aspiration is a gold-standard diagnostic test in the protocol to evaluate catheter integrity.

ID: 210395 Intrathecal Drug Pump Implantation in Prone-to-Supine Position: Surgical Time and Complications of 32 Consecutive Patients

Although intrathecal drug delivery system (IDDS) implantation is usually performed in lateral position, it is not easy for some patients with severe deformities. We describe our unique procedure performed in prone-to-supine position and analyzed the surgical time and complications.

ID: 216982 An Atypical Cause for Intrathecal Drug Delivery System Malfunction After Pump Replacement

Intrathecal Baclofen (ITB) is a well-recognized treatment for spasticity refractory to medications. However, intrathecal drug delivery systems (IDDS) are prone to complications due to multiple factors that require revision or exchange. IDDS malfunction may occur at the level of the pump or catheter. At the pump, common issues include battery exhaustion, pump defect, or infection1. At the catheter, issues include dislocation of the catheter tip, catheter leakage, catheter occlusion, granuloma at the catheter tip and infection1. Malfunction of ITB pumps are associated with serious consequences, such as withdrawal or overdose. This case discusses troubleshooting a patient with worsening spasticity after a pump replacement.