Does an intrathecal baclofen pump impact scoliosis progression and complicate posterior spine fusion in patients with cerebral palsy?

Baclofen pumps do not increase risk of complications following spinal fusion

PURPOSE

To assess the complication risks associated with intrathecal baclofen (ITB) pumps in cerebral palsy (CP) patients undergoing posterior spinal fusion (PSF) and to determine if timing of pump implantation before or during PSF impacts the risk of complications.

METHODS

A prospectively collected multicenter database was retrospectively reviewed to identify CP patients undergoing PSF from 2008 to 2023. Patients were divided into 2 cohorts: those with an ITB pump (ITB cohort) and those without (non-ITB cohort). The ITB cohort was further categorized by placement of the pump prior to or during PSF. Cohorts were then compared in terms of postoperative complications, perioperative complications, and need for revision surgery.

RESULTS

Four hundred six patients (ITB n = 79 [53 prior to, 26 during PSF], non-ITB n = 326) were included in this analysis. At an average follow-up of 4.0 years (range 2-10 years), there were no significant differences between the ITB and non-ITB cohorts in the rate of perioperative complications (5.0% vs 6.5%, p = 0.80), revision surgeries (2.5% vs 4.6%, p = 0.54), or any complication type, regardless of whether pumps were placed prior to or during PSF, aside from longer surgical times in the latter group.

CONCLUSION

Complication rates are similar for ITBs placed prior to and during PSF. Patients with spastic CP may safely be treated with ITB pumps without increased risks of complication or further reoperation/revision following PSF.

LEVEL OF EVIDENCE

Level III.

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

Introduction

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.

Methods

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.

Results

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.

Conclusions

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.

Effect of Intrathecal Baclofen Pump on Scoliosis in Children With Cerebral Palsy: A Meta-Analysis

OBJECTIVE

To systematically review the effect of intrathecal baclofen pump insertion in children with cerebral palsy (CP) with respect to scoliosis.

METHODS

A systematic literature search was conducted in PubMed, Embase, Cochrane Library, and Google Scholar databases up to June 2022. The inclusion criteria were as follows: (1) studies with a quantitative study design; (2) studies with a study group of children with CP; (3) studies comparing scoliosis in children with and without an intrathecal baclofen pump; and (4) studies with Cobb's angle as a parameter.

RESULTS

Of the 183 studies found, four studies, all of which were retrospective comparative studies, met the aforementioned inclusion criteria. All studies were homogeneous (I2=0%, p=0.53) and intrathecal baclofen pump insertion accelerated the progression of scoliosis (standard mean difference=0.27; 95% confidence interval=0.07-0.48).

CONCLUSION

Intrathecal baclofen pumps have been used to alleviate spasticity in children with CP, thus aiding their daily activities and movements. However, their advantages and disadvantages should be reviewed after sufficient time considering the pumps' negative effect on the course of scoliosis.

Baclofen Pump Use: Complications After Growth-friendly Instrumentation for Early-onset Scoliosis

BACKGROUND

Patients with early-onset scoliosis (EOS) and spasticity may receive treatment with an intrathecal baclofen pump. We assessed how baclofen pumps are associated with the odds of complications and secondary interventions after growth-friendly (GF) spine surgery for EOS and analyzed infectious complications within the pump cohort.

METHODS

Using a prospectively maintained, international multicenter database, we studied patients with neuromuscular EOS with baclofen pumps who underwent GF spine surgery from 2002 through 2019 (n=25). Baclofen pumps were implanted before GF instrumentation in 18 patients, during in 2 patients, and after in 5 patients. Patients with existing pumps at initial GF spine surgery were matched 1:3 with 54 patients (control group) without pumps according to treatment center, year of surgery, diagnosis, surgery type, and preoperative curve magnitude. Univariate analysis and multivariate logistic regression were performed to compare complications and secondary interventions between the 2 cohorts.

RESULTS

Patients with baclofen pumps had 4.8 times the odds [95% confidence interval (CI): 1.5-16] of experiencing any complication within 1 year after initial GF spine surgery compared with controls. During mean follow-up of 6.9±4.3 years, they had 4.7 times the odds (95% CI: 1.3-16) of deep surgical site infection and 5.6 times the odds (95% CI: 1.2-26) of spinal rod removal after any complication. Differences in rates of mechanical complication, such as rod migration and breakage, were nonsignificant between the 2 groups. For the 9 patients (50%) with pumps who experienced infections, the most common microorganisms were Staphylococcus aureus (4 patients) and Pseudomonas aeruginosa (2). The pump/catheter was revised or removed, in addition to antibiotic therapy or surgical irrigation and debridement, in 2 patients.

CONCLUSIONS

Among patients with neuromuscular EOS, those with baclofen pumps are much more likely to experience complications within 1 year after GF spine surgery. They are also more likely to have deep surgical site infections, with S. aureus and P. aeruginosa being the most common causative organisms, and to require spinal rod removal.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Adult Scoliosis Following Intrathecal Baclofen Therapy

In this case report, we present an adult case of scoliosis following intrathecal baclofen (ITB) therapy. A 56-year-old female with stroke-induced right spastic hemiparesis for seven years underwent implantation of an ITB pump. Satisfactory spasticity control was achieved using 30 µg/day of baclofen; however, she began to complain of lumbar pain in the postoperative year (POY) 1. Scoliosis, which was not recognized preoperatively, was confirmed in POY 2 (Cobb angle of 19 degrees). It further progressed into a walking disturbance in POY 5 (Cobb angle of 28 degrees). Hence, posterior fusion with decompression was planned. Following the removal of the ITB pump, spasticity management was replaced by Botox injection. However, the progression of scoliosis and neurological conditions stabilized after the removal, and decompression surgery was electively performed in POY 6. Scoliosis remained stable during the two-year follow-up period (Cobb angle of 28 degrees). This case demonstrates the potential risk of ITB-induced scoliosis in an adult patient. Careful preoperative investigations and postoperative follow-up are recommended for patients on ITB therapy.

Trends in publications about cerebral palsy 1990 to 2020

Cerebral palsy (CP) is associated with complex health care needs and, although improved, a continued shortened life expectancy. In order to quantify and understand advances in the diagnosis and management of CP, systematic literature searches of key word groupings in the PubMed database were completed and revealed a recent increased incidence of publications focusing on quality of life, physical activity, exercise, and treatment options. Our bibliometric exploration revealed growing emphasis on function, performance, aging, and health compared to earlier studies when diagnostic features and brain pathology dominated research. Our findings highlight the transition from diagnosis and identification to management of specific conditions and providing guidance for the continuum of needs our patients experience over the course of a lifetime. The field must be prepared to advance our understanding of best practices and implement evidence-based interventions and management options.