What can go wrong
The Benefits of ITB
Intrathecal baclofen (ITB), delivered via an implanted pump, carries primary indications for the reduction of spasticity in children resulting from spinal cord injury, or associated with cerebral palsy or multiple sclerosis.
ITB has been shown to significantly improve functional outcomes in gait, sitting, and crawling, as well as upper extremities, which improves activities of daily living and quality of life among young children. However, these benefits must be weighed against the risk for complications associated with ITB therapy, estimated to be as high as 25% to 30%.
A 2014 study by Motta and Antonello found that 25% of pediatric patients experienced at least 1 complication over the course 14 years. Complications of ITB are usually directly related to 1 or more issues involving the surgical implantation procedure, mechanical failure of catheter/pump devices, and issues with the baclofen drug therapy, including withdrawal and overdose.
Facilities with strict protocols to prevent problems have been able to report significantly lower complication rates.
The first stage of ITB therapy involves neurosurgical introduction of a catheter under the skin into the intrathecal space (usually between the T8 and T10 vertebrae), which is then connected to a baclofen pump implanted under the skin to 1 side of the abdomen. Implantation complications resulting from the surgery or failure of the device usually arise within 6 months of the procedure.
The most common types of complications seen with ITB are catheter-related, involving infections (usually Staphylococcus aureus) at a rate of 1% to 5% within the first 6 weeks; a 5% to 15% rate of catheter migration; and an incidence of cerebrospinal fluid leaks of about 1% per month.
This is often a result of older catheters in patients, which sometimes have microtears or may disconnect or move out of the space. Newer catheters appear to be more reliable. For complications involving failure of the pump device itself, clinicians will manage symptoms and refer the patient back to neurosurgery for replacement of the pump.
Sudden interruption of baclofen therapy can result in baclofen withdrawal, which is recognized as a serious medical emergency. Catheter-related problems, infected pump removal, empty reservoir volume, end of battery life, and programming error are the main causes. Rebound spasticity is the earliest symptom.
A similarly serious complication is baclofen overdose.
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SOURCE: NeurologyAdvisor, September 25, 2018
Managing Complications of Intrathecal Baclofen Therapy
Paralympic canoeist moves baclofen pump to thigh
Competes the following week and medals
We present a challenging case of imminent metallic implant extrusion in a Paralympic athlete managed with a single-stage procedure using ‘Integra’ dermal (skin) substitute. The patient had hereditary spastic paraparesis, for which a baclofen pump delivering intrathecal medication was vital in the management of his condition.
The device had been most recently implanted into the thigh after previous complications. Integra provided robust soft-tissue coverage over the implanted baclofen pump in the thigh. Different operative management strategies were considered but the use of Integra was felt to offer the least morbidity and a quick recovery.
The patient was able to successfully compete in a Paralympic canoeing qualifying event the week following surgery and achieve medal success. To the authors’ knowledge, this is first case in which Integra has been used in such circumstances.
SOURCE: BMJ Case Rep. 2018 Nov 8;2018. pii: bcr-2018-226181. doi: 10.1136/bcr-2018-226181. PMID: 30413448
Use of Integra dermal substitute to prevent implantable device extrusion in an Olympic athlete.
1 Plastic Surgery Department, Royal Stoke University Hospital, Stoke-on-Trent, UK.