Intrathecal Baclofen Therapy: An Update

Potentially Life-Threatening Interaction between Opioids and Intrathecal Baclofen in Individuals with a Childhood-Onset Neurological Disorder: A Case Series and Review of the Literature

BACKGROUND

Spasticity and dystonia are movement impairments that can occur in childhood-onset neurological disorders. Severely affected individuals can be treated with intrathecal baclofen (ITB). Concomitant use of ITB and opioids has been associated with central nervous system (CNS) depression. This study aims to describe the clinical management of this interaction, based on a case series and review of literature.

METHODS

Four individuals with childhood-onset CNS disorders (age 8-24) and CNS-depressant overdose symptoms after the concomitant use of ITB and opioids are described. The Drug Interaction Probability Scale (DIPS) was calculated to assess the cause-relationship (doubtful <2, possible 2-4, probable 5-8, and highly probable >8) of the potential drug-drug interaction. A literature review of similar previously reported cases and the possible pharmacological mechanisms of opioid-baclofen interaction is provided.

RESULTS

After ITB and opioid co-administration, three out of four patients had decreased consciousness, and three developed respiratory depression. DIPS scores indicated a possible cause-relationship in one patient (DIPS: 4) and a probable cause-relationship in the others (DIPS: 6, 6, and 8). Discontinuation or adjusting ITB or opioid dosages resulted in clinical recovery. All patients recovered completely. In the literature, two articles describing nine unique cases were found.

CONCLUSION

Although the opioid-ITB interaction is incompletely understood, concomitant use may enhance the risk of symptoms of CNS-depressant overdose, which are potentially life-threatening. If concomitant use is desirable, we strongly recommend to closely monitor these patients to detect interaction symptoms early. Awareness and monitoring of the potential opioid-ITB interaction is essential to reduce the risk of severe complications.

AAPM&R consensus guidance on spasticity assessment and management

BACKGROUND

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) conducted a comprehensive review in 2021 to identify opportunities for enhancing the care of adult and pediatric patients with spasticity. A technical expert panel (TEP) was convened to develop consensus-based practice recommendations aimed at addressing gaps in spasticity care.

OBJECTIVE

To develop consensus-based practice recommendations to identify and address gaps in spasticity care.

METHODS

The Spasticity TEP engaged in a 16-month virtual meeting process, focusing on formulating search terms, refining research questions, and conducting a structured evidence review. Evidence quality was assessed by the AAPM&R Evidence, Quality and Performance Committee (EQPC), and a modified Delphi process was employed to achieve consensus on recommendation statements and evidence grading. The Strength of Recommendation Taxonomy (SORT) guided the rating of individual studies and the strength of recommendations.

RESULTS

The TEP approved five recommendations for spasticity management and five best practices for assessment and management, with one recommendation unable to be graded due to evidence limitations. Best practices were defined as widely accepted components of care, while recommendations required structured evidence reviews and grading. The consensus guidance statement represents current best practices and evidence-based treatment options, intended for use by PM&R physicians caring for patients with spasticity.

CONCLUSION

This consensus guidance provides clinicians with practical recommendations for spasticity assessment and management based on the best available evidence and expert opinion. Clinical judgment should be exercised, and recommendations tailored to individual patient needs, preferences, and risk profiles. The accompanying table summarizes the best practice recommendations for spasticity assessment and management, reflecting principles with little controversy in care delivery.

A Randomized, Double-Blind, Active Control, Multicenter, Phase 3 Study to Evaluate the Efficacy and Safety of Liztox® versus Botox® in Post-Stroke Upper Limb Spasticity

Botulinum toxin type A (BTX-A) injection is a commonly used therapeutic intervention for upper limb spasticity in stroke patients. This study was designed as a randomized, active-drug-controlled, double-blind, multicenter, phase 3 clinical trial to evaluate the safety and efficacy of Liztox® in comparison to onabotulinum toxin A (Botox®) for individuals with post-stroke upper limb spasticity. The primary outcome was the alteration in wrist flexor muscle tone from the initial assessment to the fourth week, evaluated using the modified Ashworth scale (MAS). Secondary outcomes included MAS score changes for the wrist at weeks 8 and 12 from baseline; MAS score changes for finger and elbow flexors; and changes in the Disability Assessment Scale (DAS), Subject's Global Assessment (SGA), the Investigator's Global Assessment (IGA), and Caregiver Burden Scale (CBS) at weeks 4, 8, and 12 from baseline. The MAS score for wrist flexor spasticity decreased by -1.14 ± 0.59 in the Liztox® group and -1.22 ± 0.59 in the Botox® group from baseline to week 4. The difference [97.5% confidence interval (CI)] between the test and control groups was 0.08 [-∞, 0.26], confirming the non-inferiority of the test group compared to the control group. Furthermore, there were consistent improvements in the IGA, SGA, and CBS scores across all assessment intervals, with no statistically significant variances detected between the two groups. No safety-related concerns were reported during the study. In conclusion, Liztox® injection proved to be a secure and efficacious intervention for managing upper extremity spasticity in post-stroke patients.

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

BACKGROUND

Intrathecal baclofen therapy (ITB) is an effective treatment for reducing spasticity but can be associated with various complications, including infection and implant malfunction.

METHODS

This retrospective cohort study analyzed refill reports, complications, and functional outcomes in 40 consecutive patients with intractable spasticity or dystonia undergoing ITB.

RESULTS

Among 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.

DISCUSSION

Calcification, 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.

CONCLUSION

As 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.

Interaction between a smartphone and intrathecal baclofen pump case report

INTRODUCTION

Intrathecal Baclofen (ITB) is used for the treatment of spasticity. Pump complications are most commonly related to surgical implantation or catheter dysfunction. Less common complications include catheter access port dysfunction, motor failure from excessive wear on motor gear shafts, or a complete stall of the motor.

CASE PRESENTATION

37-year-old with T9 motor complete paraplegia with ITB presented in baclofen withdrawal. Workup revealed that the pump's motor was not turning, requiring pump replacement. Questioning revealed that he had not undergone any MRI studies within the past six months, but that he recently purchased a new iPhone. The phone was 2-3 inches away from the pump for up to twelve hours a day, carried in a fanny pack around his waist.

DISCUSSION

We present a case of motor pump failure from long term exposure to a magnetic field from a new iPhone. The ability of iPhones to overpower an ITB pump magnet is not widely known. In 2021, the Food and Drug Administration published a report regarding the effects of magnets in consumer electronics on implanted medical devices, recommending that such electronics should be kept at least 6 inches from the device. Providers should be aware of the ability of new models of commonly used electronic devices to stall the ITB motor to avoid life-threatening complications of baclofen withdrawal.

In Support of Initial Parenteral Medical Management of Intrathecal Baclofen Withdrawal in Spasticity Patients

Background: Spasticity may present as a wide range of symptoms and conditions. With this protean presentation, a consensus regarding the best course of treatment does not exist. Those patients most severely affected may receive significant benefit from intrathecal baclofen delivery. However, this therapy may itself lead to patient injury in the event of withdrawal. Objective: Withdrawal from intrathecal baclofen may devolve rapidly into a situation in which the patient may incur significant morbidity and even death. A focused, prompt treatment plan would afford the patient the best possible outcome. Methods: The medical literature was reviewed for reports of plans of treatment of baclofen withdrawal and the results obtained. The nature of this problem does not lend itself to a typical study design, depending on case reports and basic pharmacological science application. The paucity of such reports severely limits categorical comparison of patient characteristics and clinical circumstances. Clinical situations, patient characteristics, and therapies were considered and compared. Outcomes of the varied treatments were evaluated for efficacy. Results: Inaccurate diagnoses, delayed correct diagnoses, and the absence of a consistent, treatment plan contributed to widely disparate outcomes. Prompt, correct diagnosis and intensive care unit-based continuous benzodiazepine infusion with titration led to a controlled clinical situation and maximized patient outcomes. Conclusions: Patients going through withdrawal from intrathecal baclofen achieved best outcomes when treated with a continuous infusion and titration of an intravenous benzodiazepine. A well-defined treatment protocol employing this management, reporting serial outcomes, would enable further refinement of the treatment of this clinical problem.

Isotopic Scintigraphy in Intrathecal Drug Delivery Failure: A Single-Institution Case Series

Background

The aim of this study was to assess the feasibility and diagnostic accuracy of an optimized ¹¹¹Indium‐diethylenetriamine‐penta‐acetic‐acid single‐photon‐emission computed tomography (CT) (¹¹¹In‐DTPA SPECT‐CT) examination in patients with suspected intrathecal drug delivery (ITDD) failure.

Materials and Methods

Retrospective analysis of routinely collected observational data from a case series of patients in the setting of the academic Center for Pain Medicine, Departments of Radiology and Nuclear Medicine and Neurosurgery. Twenty‐seven patients participated between January 2014 and January 2019. Thirty‐six optimized examinations including standardized pump flow rate with additional SPECT‐CT imaging and a stepwise standardized analysis were performed. A 10 mL mixture of medication and 20 MBq 111In‐DTPA was injected into the pump reservoir. Planar and SPECT‐CT images were acquired at 24, 48, and 72 hours (h) after injection and at 96 hours and/or seven days, if needed. All images were reassessed by the first two authors using an optimized procedure.

Results and Conclusions

Twenty‐two abnormalities were identified in 21 examinations, with these abnormalities consisting of leakage (n = 7), spinal catheter obstruction (n = 7), and cerebrospinal fluid flow obstruction (n = 8). Interventions (n = 19) confirmed the cause of ITDD failure. A false‐positive finding at follow‐up (n = 1) and a false‐negative finding (n = 1) were encountered. Sensitivity was 95% (20/21) and the specificity 93% (14/15). A significant difference (p < 0.001) was found between the accuracy of the conventical and the optimized analysis. The optimized ¹¹¹In‐DTPA SPECT‐CT examination is a powerful diagnostic tool for detecting the cause of ITDD failure.

Intrathecal Baclofen Trial Before Device Implantation: 12-Year Experience With Continuous Administration

OBJECTIVE

To report our experience using continuous intrathecal baclofen (ITB) administration prior to a possible ITB device implantation.

DESIGN

Retrospective open label study. Mean duration of follow-up 64 months.

SETTING

Primary-care and referral center, ambulatory and hospitalized care.

PARTICIPANTS

Patients (N=116) undergoing continuous ITB trials between 2006 and 2017.

INTERVENTIONS

Continuous application of baclofen via a temporary intrathecal catheter connected to an external pump.

MAIN OUTCOME MEASURES

Assessment of the modified Ashworth Scale and range of movement prior versus end of ITB trial. According to the Barthel Index, definition of high-level patients (60-100 scoring points) and low-level patients (0-55 scoring points). Calculation of the Rivermead Mobility Index in high-level patients prior versus end of ITB trial. Evaluation of occurring adverse events.

RESULTS

A total of 119 ITB trials were performed in 116 patients (78 men, mean age 41±16), 113 patients completed the trials (31 of 113 high level, 82 of 113 low level). The median modified Ashworth scale improved from 4 (interquartile range [IQR] 3-4) to 2 (IQR 1-2; P≤.001), the range of movement from 2 (IQR 1-3) to 3 (IQR 3-3; P≤.001). The Rivermead Mobility Index increased from 9 (IQR 6-12) to 10 (IQR 7-12.5; P=.004) in high-level patients. Eighty-eight out of 113 patients (78%) were appropriate candidates for ITB device surgery, 75 of 88 (85%) proceeded to an implantation. A total of 69 adverse events occurred in 57 of 119 trials (48%), 37 of 69 (54%) were drug related, 32 of 69 (46%) were procedure related, and 42 of 69 (61%) were minor. The ITB device was implanted in 69 of 75 patients (92%) at last follow-up.

CONCLUSIONS

Continuous administration of ITB is an effective and useful alternative to ITB bolus application during ITB screening period. Half of the patients experienced adverse events; the majority were minor events.

Intrathecal Therapies

Intrathecal baclofen therapy is a well-established technique for spasticity management. This article briefly reviews the pharmacology of intrathecal baclofen as well as customary approach for utilization of this targeted drug delivery concept. Following these descriptions, four unusual presentations will be described, including the need for initial trialing, patient-directed boluses during chronic intrathecal baclofen therapy, use of medications other than baclofen for intrathecal therapy in spastic patients, and intraventricular baclofen delivery. These hypothetical cases are provided in an effort to expand the use of targeted drug delivery to larger population of spastic patients.

Refill Procedures of Intrathecal Drug Delivery Systems With a Recessed Fill Port on the Pump Surface: A Prospective Comparison Study of Ultrasound-Guided vs. Blind Refill Technique

OBJECTIVES

Structural differences of implantable drug delivery systems (IDDSs) might have an impact on the efficiency of needle access to the reservoir fill port (RFP). The aim of this study was to assess the efficiency of RFP needle access with an ultrasound (US)-guided vs. a blind refill technique in IDDSs with a Recessed RFP (Recessed-RFP-IDDS).

MATERIALS AND METHODS

The primary outcome was the number of attempts needed to enter the RFP with a needle comparing the US-guided technique vs. the blind refill technique. The time to enter the RFP with the needle was a secondary outcome. We compared the amount of attempts between both techniques with the non-parametric Wilcoxon rank sum test.

RESULTS

Fourteen adult patients underwent a total of 75 refills of their Recessed-RFP-IDDS during a period of 24 months. The median number of attempts to enter the RFP did not differ significantly between the US-guided technique and the blind refill technique (2.0 (IQR: 1-5) vs. 1.5 (IQR: 1-5.0), p = 0.572). The median time to enter the RFP with the needle did not differ significantly between both techniques (35.0 sec (IQR: 26.0-58.0) vs. 41.0 sec (IQR: 25.5-46.8), p = 0.878).

CONCLUSION

The results of this study suggest that there is no difference in the RFP needle access efficiency between the US-guided and the blind refill technique in superficially located Recessed-RFP-IDDSs, if performed by experienced practitioners. However, the study did not address efficiency of the RFP needle access in IDDSs with aberrancy in pump location or refills performed by inexperienced staff.

Plain radiography in patients treated with intrathecal drug delivery using an implantable pump device

OBJECTIVES

Intrathecal drug administration using an implanted pump system is well established in intractable spasticity and pain. However, despite continuous advancements in manufacturing technology, adverse events related to the pump and catheter still occur. Most of them, such as migration, damage, disconnection and occlusion, are related to the spinal catheter. The aim of this overview is to update radiologists on how plain radiography of the implanted delivery system for intrathecal drug administration should be interpreted and to increase awareness for the need of urgent and timely multidisciplinary troubleshooting.

METHODS

Plain radiographic images of patients treated with intrathecal drug administration using an implantable drug delivery system were analysed in a multidisciplinary setting at our (university) referral centre for complications in intrathecal drug administration.

RESULTS

Examples of catheter-related adverse events are described and a proposal is made for stepwise interpretation of standard plain radiographic images.

CONCLUSIONS

Plain radiological images are the mainstay for the diagnosis of catheter-related adverse events in intrathecal drug delivery. Radiologists play an important role in an early diagnosis. An awareness of abnormal radiological findings seems important to avoid a life-threatening withdrawal syndrome.

TEACHING POINTS

• Untimely cessation of intrathecal drug delivery can lead to a life-threatening withdrawal syndrome. • Initially mild symptoms can lead to an exacerbation of a withdrawal syndrome. • Most intrathecal catheter-related problems are visible on plain radiography. • Common causes of catheter problems are migration, lacerations, occlusion and disconnection. • Knowledge on implanted intrathecal catheters is crucial for interpretation of plain radiography.

Baclofen Pumps: Uses and Complications

Intrathecal baclofen therapy, given via an implanted pump in the abdominal wall either as a continuous infusion or bolus dosing, has been used for more than 25 years to treat the spasticity and dystonia associated with various brain and spinal cord conditions. Pediatric clinicians occasionally encounter baclofen pumps, and in the pediatric setting, significant morbidity can arise from their use. This article presents the background, mechanism of action, uses, and complications of intrathecal baclofen therapy and discusses various management strategies should complications occur.

The Symptomatic Treatment of Acquired Dystonia: A Systematic Review

Background

Acquired dystonia is caused by an acquired or exogenous event. Although the therapeutic armamentarium used in clinical practice is more or less similar to that used for inherited or idiopathic dystonia, formal proof of the efficacy of these interventions in acquired dystonia is lacking.

Methods

The authors attempt to provide a comprehensive and systematic review of the current evidence for medical and allied health care treatment strategies in acquired dystonias. The PubMed, Cochrane Library, MEDLINE, Web of Science, PiCarta, and PsycINFO databases were searched up to December 2015, including randomized controlled trials, patient-control studies, and case series or single case reports containing a report on clinical outcome.

Results

There are level 3 practice recommendations for botulinum toxin injections and globus pallidus pars interna deep brain stimulation for tardive dystonia and dystonic cerebral palsy as well as intrathecal baclofen for dystonic cerebral palsy. There are insufficient and conflicting data on the effect (vs. the hazard) of other pharmacological interventions, and limited work has been done on other forms of neurostimulation and allied health care. Because no class A1 or A2 studies were identified, level 1 or 2 practice recommendations could not be deducted for a specific treatment intervention.

Conclusions

To improve the current medical and allied health care treatment options for patients with acquired dystonia, high-quality trials that examine the efficacy of therapies need to be performed.

Evaluation of intrathecal baclofen delivery system malfunction by computed tomography scan

AIM

To describe the computed tomography (CT) findings encountered when catheter patency is questionable. The role of CT in directing treatment is evaluated.

METHOD

Records of children with intrathecal baclofen pump management were reviewed. Only patients with CT evaluation who had revision pump/catheter surgery were included.

RESULTS

From 295 patients, 27 had CT contrast study; in three of them, baclofen could not be aspirated and the procedure was stopped, eight had normal scan and did not need surgery and 16 patients were reported. Four patients had normal CT (free contrast formed a perfect crescent shape), and had surgery because the pump battery was close to expiration. Five patients had inadequate fluid pooling (fluid was seen without a crescent shape). Five patients had fluid leak (fluid was seen around the pump or in the lumbar canal below catheter entrance level or outside the canal in the lumbar region). Two patients had catheter occlusion (fluid loculation around the catheter tip with no free flow).

INTERPRETATION

CT contrast study is safe and effective for locating defects in intrathecal baclofen delivery system. When catheter patency is questionable, CT plays an important role in directing the next step of management.

Clinical Experience With Continuous Intrathecal Baclofen Trials Prior to Pump Implantation

OBJECTIVE

To report our clinical experience using continuous intrathecal baclofen (ITB) trials prior to permanent pump implantation.

DESIGN

Retrospective chart review.

SETTING

An inpatient neurosurgery unit and outpatient physical medicine and rehabilitation clinics.

PARTICIPANTS

Fifty-seven patients with refractory spasticity who underwent a continuous ITB trial during the years 2006-2012.

METHODS

Patients underwent placement of a temporary intrathecal catheter that was connected to an external pump. A successful trial was defined as a one-level reduction in lower limb modified Ashworth scores in key spastic lower limb muscles identified for each individual patient. Subjective improvement in function or ease of performing functional tasks also were monitored.

MAIN OUTCOME MEASURES

Modified Ashworth scores, functional mobility in ambulatory patients only, and the incidence and severity of adverse events during the trial and up to 1 year after implantation.

RESULTS

Spasticity significantly decreased during the trial. Average ambulation distance was unchanged, although 34% of ambulatory patients progressed to a less restrictive assistive device by trial completion. Adverse events (AEs) occurred in 26 patients. Minor AEs were seen in 18 patients, with the most common being nausea, transient urinary retention, and headache. Pumps were implanted in 86% of patients; 14% did not receive a pump because of AEs or because goals were not met. Six patients had their pump removed at 12 months for the following reasons: pump malfunctions (3), skin breakdown around the pump (1), infection (1), and expectations not met (1).

CONCLUSIONS

Continuous trials via an external catheter could be an option if patients and clinicians desire a comprehensive assessment of systemic and functional effects of ITB before pump implantation. The majority of AEs were minor and resolved spontaneously, and the most effective starting intrathecal dose was determined by pump insertion.

The Accuracy of Template-Guided Refill Technique of Intrathecal Pumps Controlled by Fluoroscopy: An Observational Study

OBJECTIVES

Intrathecal drug therapy is being utilized increasingly for the treatment of chronic refractory pain. However, performing the regular pump refill procedures caries the potential risk of medication injection into the subcutaneous tissue. The aim of this study was to assess the accuracy of this template-guided refill technique by means of fluoroscopic evaluation.

MATERIALS AND METHODS

In 23 patients, the difference between the identification of the reservoir fill port center using the manufacturer's template and fluoroscopic guidance was assessed on four consecutive refill procedures by a two physicians. A distance surpassing that between the center and the margin of the port (3.5 mm) was considered a clinically relevant deviation. Analyses were performed with a one-sample t-test, with p < 0.05 indicating statistical significance.

RESULTS

The mean difference distance between identification markings of the target with fluoroscopic guidance and with the template was 8.2 mm, with limited variance (2.7 mm). For all individual refill procedures, the port center identification accuracy differed significantly from zero (all p < 0.001) and from the clinically relevant cut-off point of 3.5 mm (all p < 0.001). Only seven attempts (6.4%) were within the margins of the fill port.

CONCLUSIONS

Our results suggest poor accuracy of insertion point identification using the template. This highlights the potential risk of errors related to identification of the puncture site using the template-guided technique.

Patient experiences with intrathecal baclofen as a treatment for spasticity - a pilot study

PURPOSE

This study describes how patients experience intrathecal baclofen (ITB) treatment.

METHODS

Data were collected from interviews with 14 patients (19-76 years old) who were diagnosed with spinal cord injury (SCI), multiple sclerosis (MS), or cerebral palsy (CP). Data were analyzed using conventional content analysis.

RESULT

The analysis resulted in 16 subcategories arranged into five main categories: procedures before treatment, the effect of ITB on daily life and activities, continuous follow-up, expected and unexpected consequences of ITB, and overall level of satisfaction with ITB. Together these categories described the patients' experiences with ITB treatment. When the patients were asked whether they would undergo ITB again, they all stated that they would.

CONCLUSION

Patients stated that they were highly satisfied with the ITB treatment. However, the patients identified several areas that could be improved. Specifically, the patients wanted more information about the different steps in the treatment process and what to expect from ITB treatment.

Managing loss of intrathecal baclofen efficacy: Review of the literature and proposed troubleshooting algorithm

Spasticity is a debilitating symptom associated with numerous neurologic conditions. While intrathecal baclofen therapy (ITB) is an established treatment for spasticity, complications can lead to loss of efficacy (LOE) and baclofen withdrawal. Untreated withdrawal syndrome can be fatal. Prompt diagnosis and management of LOE is essential. Numerous methods have been described in the literature for diagnosing the cause of LOE. Many of the methods require equipment not readily available in the outpatient setting. Furthermore, there is no established consensus on the sequencing of these diagnostic tests. Herein, we review ITB literature on troubleshooting LOE for applicability to the managing clinician. Using this information and our clinical experience, we propose an algorithm with management recommendations to simplify and expedite the troubleshooting process in the outpatient setting.

"Sonology" of programmable intrathecal pumps

OBJECTIVE

The study aims to demonstrate the unique sonographic features of the commercially available intrathecal drug delivery systems.

METHODS

"Not-for-human-use" pumps were obtained, placed in a tray, and covered with an ultrasound phantom gel. The anterior surface of each pump was scanned and the sonographic features were observed and recorded.

RESULTS

All systems have a centrally located reservoir port (RP) and a peripherally located catheter access port (CAP) that are observable on ultrasound. The RP of the SynchroMed II system (Medtronic, Minneapolis, MN, USA) appears as an anechoic depression and a break in the bright echogenic line of the superior pump surface. The CAP appears as smaller diameter conical depression outside the circular perimeter of the pump. The RP of the MedStream system (Codman & Shurtleff, Inc., Raynham, MA, USA) has a dome-shaped appearance. The CAP appears as a smaller dome-shaped object that is off center but still contained within the circular perimeter of the pump. Similarly, the RP of the Prometra system (Flowonix Medical Inc, Mt. Olive, NJ, USA) is a dome-shaped object. The CAP visually appears similar to the reservoir access port of the SynchroMed II system, namely a small depression and a break in the bright echogenic line of the pump surface, outside the perimeter of the pump.

CONCLUSION

In all programmable intrathecal pumps, the RP can be readily identified sonographically. Potentially, the dome-shaped configuration of RP for the Prometra and MedStream systems make the access easier, when compared with SynchroMed II system. Ultrasound could potentially be utilized to localize the RP and CAP for all the systems as each of the three systems has a unique sonographic appearance.

The use of intrathecal baclofen in pain management

SUMMARY Intrathecal therapy involves the subarachnoid delivery of medications where the administered agents have enhanced potency and diminished systemic exposure compared with oral administration. Baclofen exerts its therapeutic action by enhancing the inhibition produced by the endogenous neurotransmitter GABA. While well-established within the armamentarium of tools for spasticity management, the role of intrathecal baclofen for the management of chronic pain is less certain. The purpose of this review is to describe the pharmacology of intrathecal baclofen, relate the role of intrathecal baclofen in neurologic and non-neurologic conditions, and report upon the potential utility of coadministering baclofen with other agents via the intrathecal route of delivery.

Indium 111 diethylenetriamine pentaacetic acid scintigraphy in the identification and management of intrathecal pump malfunction

BACKGROUND

Intrathecal drug-delivery systems have become widely used tools in the management of refractory chronic pain and spasticity. Because increasing numbers of patients are using these systems, rehabilitation specialists frequently are the initial care providers who identify clinical signs and symptoms indicating possible complications relating to the implanted system. Identification of a pump malfunction often presents a diagnostic challenge. Distinguishing among progression of disease, new organic problems, and/or drug-device complications is critical. The use of nuclear medicine indium 111 diethylenetriamine pentaacetic acid (DTPA) studies represents a highly effective, straightforward, minimally invasive way to assess implant function and drug distribution.

OBJECTIVE

To identify patients with suspected intrathecal pump malfunction and to determine whether the use of indium 111 DTPA is effective in identifying the source of failure.

DESIGN

A retrospective review was performed from 2011 to 2012.

SETTING

The study was performed at Georgia Health Sciences University.

PATIENTS

The 23 selected patients had implanted devices for either spasticity or pain and were experiencing symptoms of a possible pump malfunction despite normal radiographic imaging. Twenty-four scintigraphic studies were performed, with malfunction documented in 19 patients.

METHODS

A standard refill technique was used to inject 0.3 mL of indium 111 DTPA into the pump reservoir. Radionuclide images were reviewed at varying time points up to 48 hours after injection. The extent of radionuclide progression from the pump reservoir to the intrathecal space was evaluated. In cases in which a problem with the implant was identified, correlation with operative findings is described.

RESULTS

Normal results of studies ultimately correlated with other clinical issues and confirmed an alternative etiology for the clinical changes noted. In studies with abnormal results, several patterns of failure were identified: restriction of the radionuclide to the pump reservoir, extravasations of tracer into the pump subcutaneous pocket, failure of the tracer to migrate from the subcutaneous catheter to the intrathecal space, and pooling of the tracer in the subcutaneous tissues. In all cases, surgical findings confirmed the suspected mechanism of malfunction as determined by the study.

CONCLUSIONS

Indium 111 DTPA scintigraphy is a safe, straightforward way to identify and characterize clinical changes associated with intrathecal drug-delivery systems and to guide appropriate and clinical surgical management.

Patient safety in the rehabilitation of children with traumatic brain injury and cerebral palsy

With the advent of newer and better therapies available, patient safety is emerging as a new topic. Pediatric patient safety is relatively new, in that there are few guidelines available. Safety in children with traumatic brain injury (TBI) given the incidence of TBI is very vital. This is an attempt to identify the key points in TBI.

Use of intrathecal baclofen therapy in ambulant children and adolescents with spasticity and dystonia of cerebral origin: a systematic review

AIM

Studies on the use of intrathecal baclofen (ITB) for ambulant adults with spasticity and/or dystonia of cerebral origin are scarce, and are even more limited for children and adolescents. This systematic review investigates the use of ITB to improve walking, transfer ability, and gross motor activities in ambulant children and adolescents with spasticity and/or dystonia of cerebral origin.

METHOD

Electronic databases (MEDLINE, CINAHL, PsycINFO, EMBASE, full Cochrane Library, and PEDro) were searched from the earliest date available until March 2011 using combined subject headings and free text if supported by the databases. Studies were included if they had examined individuals who: (1) received ITB therapy by any method (bolus injection, an external delivery system, or an implanted pump); (2) had spasticity and/or dystonia of cerebral origin; (3) were able to ambulate with or without a walking device, i.e. individuals with cerebral palsy (CP) who were in levels I to III of the Gross Motor Function Classification System or individuals with similar functional mobility if they did not have CP; and (4) were aged 18 years or under. Publications in English in peer-reviewed journals reporting any type of research design, except reviews and expert opinions, were included. Studies were excluded if participants had spasticity and/or dystonia of spinal origin and if baclofen was administered only orally. Studies that compared ITB with other interventions such as botulinum toxin were also excluded.

RESULTS

Two independent reviewers scored 16 studies against the guidelines for developing systematic reviews from the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM).

INTERPRETATION

Fifteen studies were of levels IV or V evidence and only one of level II according to the evidence levels of the AACPDM guidelines, but all were of low quality. No study was found on the use of ITB in ambulant children or adolescents with dystonia of cerebral origin. Not all studies used objective outcome measures to assess the ambulation, transfer ability, and gross motor activities of the participants. A proportion of participants showed improvement in all these areas but adverse events were common. A proportion of participants compromised their ambulatory and transfer abilities after ITB. There was no evidence to support the clinical use of ITB in ambulant individuals with hypertonicity without further rigorous longitudinal studies.

Combined C-arm fluoroscopy and C-arm cone beam computed tomography for the evaluation of patients with possible intrathecal baclofen delivery system malfunctions

BACKGROUND

Evaluating intrathecal baclofen (ITB) delivery systems for potential malfunction can be challenging. The catheter systems are prone to myriad complications that are frequently difficult to ascertain by conventional imaging techniques. Newer imaging technologies and their combinations can be used to identify such problems, define surgical indications, and focus operative planning. C-arm fluoroscopy and C-arm cone beam CT performed in one imaging session represents one such combination that has great utility.

OBJECTIVE

We present a case series of ITB catheter evaluations using combined C-arm fluoroscopy (CF) and C-arm cone beam CT (CCBCT).

METHODS

We retrospectively analyzed 7 pediatric patients who underwent ITB catheter systems evaluations by the use of combined CF and CCBCT. Study variables included indications for evaluation, imaging results, interventions, correlation of surgical findings with imaging, and clinical outcome.

RESULTS

Three patients had intact and patent catheter systems. Four patients demonstrated various problems of the catheter systems, including disconnection, microfracture, fracture with segment migration, and subdural migration. Dosage adjustments improved all patients with normal studies. Surgery was guided by the imaging, and all operative patients improved after targeted interventions. Intraoperative findings correlated perfectly with imaging.

CONCLUSION

Combined CF and CCBCT proved highly effective in the evaluation of our patients with potential ITB system malfunctions. This technique is advocated for such evaluations because it accurately defines problems with connectivity, integrity, and position of catheter systems. When surgical intervention is required, this information aids in operative planning.

Imaging evaluation of intrathecal baclofen pump-catheter systems

ITB pumps are widely used in the treatment of intractable spasticity for many clinical indications, including cerebral palsy and spinal cord injury. High-dose intrathecal administration places the patient at significant risk for withdrawal in the event of device malfunction, necessitating rapid and complete evaluation of the pump-catheter system. This article reviews the approach to imaging evaluation of ITB pump-catheter systems, with specific emphasis on radiography, fluoroscopy, CT, and nuclear scintigraphy.

Review: Procedure- and Device-Related Complications of Intrathecal Baclofen Administration for Management of Adult Muscle Hypertonia: A Review

Background. Intrathecal baclofen (ITB) effectively reduces muscle hypertonia; however, associated complications influence its utility and acceptance. Objective. To systematically review the literature on procedure- and device-related complications associated with ITB infusion therapy for adult muscle hypertonia of spinal or cerebral origin. Methods. The authors searched the PubMed database for full-length articles published in English that reported ITB-associated complications in adults. Of 147 articles retrieved, 32 full-length manuscripts and 10 case reports were reviewed in detail. Results. Overall, 558 complications were reported after 1362 pump implants (0.41 per implant). Methods for characterizing complications varied greatly between studies, as did complication rates, ranging from 0 to 2.24 per implant. Of the 558 complications, 148 (27%) were related to surgical procedures, 39 (7%) to pump problems, and 369 (66%) to catheter malfunctions. The overall complication rate was higher for studies that followed patients for more than 18 months on average (mean 0.56/implant) versus studies with shorter follow-up (0.23/implant, P < .05). Although correlation between the number of implants and the number of complications was significant ( r = .58), the goodness of linear fit was poor because of clusters with varied complication rates. Conclusions. Catheter problems are relatively common and more frequent than pump or surgical procedure complications after ITB pump implantation. Higher complication rates should be expected in centers that follow patients for a longer period of time. Standardized data collection and complication-reporting procedures along with appropriate training should be implemented in centers offering ITB treatment for management of muscle hypertonia.