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Intrathecal Baclofen for Spasticity: Is There an Effect on Bladder Function? Report of Three Cases and Review of the Literature. Biomedicines 2022; 10:biomedicines10123266. [PMID: 36552022 PMCID: PMC9775073 DOI: 10.3390/biomedicines10123266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION traumatic brain injury (TBI) is very often associated with spasticity. Medical interventions may include medications such as baclofen, a Gamma-Aminobutyric Acid (GABA) -receptor agonist of poor lipid solubility. Intrathecal baclofen (ITB) administration is a contemporary treatment option which minimizes adverse effects in contrast with the oral form of the drug. Regarding low urinary tract dysfunction, TBI, as a suprapontine lesion, results in neurogenic detrusor overactivity. Frequency, urgency and urge incontinence are the predominant signs and symptoms of this condition. Our study aims to report the potential changes in bladder function in patients with spasticity, due to TBI, after the implantation of the baclofen pump and the control of spasticity. MATERIAL AND METHODS We report three cases of TBI whose spasticity responded well to ITB. We evaluated our medical reports regarding bladder function retrospectively, before and after baclofen pump implantation. We compared the data of bladder diaries and urodynamic parameters. RESULTS Bladder function was improved in all patients. Regarding bladder diaries; the number of incontinence and micturition episodes was decreased and the volume per void was slightly increased. Regarding urodynamic parameters; bladder capacity and reflex volume increased, Pdetmax decreased, PVR was the same and DLPP was slightly decreased. CONCLUSIONS Although the baclofen pump is implanted to treat spasticity, detrusor activity may be also affected. Therefore, patients' urologic profiles should also be reevaluated after ITB. Further prospective studies are required to investigate the effect of ITB on bladder function in the clinical field and also at the basic science level.
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Pittelkow TP, Bendel MA, Lueders DR, Beck LA, Pingree MJ, Hoelzer BC. Title: Quantifying the change of spasticity after intrathecal baclofen administration: A descriptive retrospective analysis. Clin Neurol Neurosurg 2018; 171:163-167. [PMID: 29913361 DOI: 10.1016/j.clineuro.2018.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 05/17/2018] [Accepted: 06/09/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVES Exploratory research quantifying the change of spasticity among patients who underwent baclofen intrathecal drug delivery system (IDDS) implantation. PATIENTS AND METHODS 88 patients with a baclofen IDDS were identified. Patient characteristics, spasticity scores pre/post intrathecal baclofen test dose, and IDDS perioperative implantation records were collected. The primary outcome was to quantify the extent to which there was a change in Modified Ashworth Scores (MAS) pre/post-intrathecal baclofen test dose administration. Secondary outcomes included the prevalence of perioperative IDDS implantation complications. RESULTS The mean age at IDDS implant was 44.2 years (range, 19-71), and 62.5% were male. 45.5% had spasticity of spinal cord origin, 9% of cerebral origin, and 45.5% of other upper motor neuron dysfunction. Reduction of MAS in the spinal cord origin group was 2.6 (mean, 3.5 to 0.9), cerebral origin group was 2.9 (mean, 3.3 to 0.4), and other origin group was 2.5 (mean, 3.6 to 1.1). In all patients, post dural puncture headache was the most commonly reported complication at 22.7%. CONCLUSION This report offers novel findings documenting a quantifiable change of at least two points on the MAS before and after intrathecal baclofen test dose as statistically significant and could prove to be useful information to enhance the decision making process to proceed with intrathecal baclofen beyond assessment of functional abilities.
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Affiliation(s)
- Thomas P Pittelkow
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, United States.
| | - Markus A Bendel
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Daniel R Lueders
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Lisa A Beck
- Department Physical Medicine & Rehabilitation, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Matthew J Pingree
- Division of Pain Medicine, Departments of Anesthesiology and Perioperative Medicine and Physical Medicine & Rehabilitation, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
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Intrathecal Baclofen Therapy Prior to Spinal Fusion for Patients With Gross Motor Function Classification System IV-V Cerebral Palsy. Orthop Nurs 2018; 37:136-143. [PMID: 29570548 DOI: 10.1097/nor.0000000000000434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Patients with Gross Motor Function Classification System (GMFCS) IV-V cerebral palsy (CP) have significant spasticity and frequently develop scoliosis. Intrathecal baclofen (ITB) pumps are effective in managing spasticity. The effect of ITB therapy on the postoperative course following spinal fusion in patients with GMFCS IV-V CP has not been described. This study sought to compare postoperative recovery, including complications, in patients using ITB therapy with those with no ITB therapy. PURPOSE Evaluate the effect of ITB on the postoperative recovery for patients with GMFCS IV-V CP who undergo spinal fusion for scoliosis. METHODS Health records for patients with GMFCS IV-V CP who underwent a spinal fusion for scoliosis at a major quaternary-care children's hospital from January 2009 to October 2015 were reviewed and relevant data were abstracted. Descriptive statistics and regression models were used to compare patients. RESULTS Sixty-nine patients were included-19 ITB therapy and 50 no ITB therapy. Demographic and operative characteristics were similar across groups. The mean length of stay for patients in the ITB therapy group was 11.2 days and 14.3 days for the no ITB therapy group, with no difference between groups (p = .12). Pain scores in both groups decreased at the same rate, with scores in the ITB therapy group averaging one-half point lower (p = .32). The average amount of morphine equivalents (p = .71) and benzodiazepine equivalents (p = .53) used were similar between groups. Complication rates were significantly different between groups. Four (21%) of the ITB therapy patients had 1 or more complications whereas 28 (56%, p = .01) in the no ITB therapy group had 1 or more complications. The average number of complications per patient in the ITB therapy group was 0.3 (SD: 0.075, range: 0-3) and the no ITB therapy group was 1.1 (SD: 1.1, range: 0-6, p = .01). CONCLUSIONS There was no significant difference in length of stay, pain scores, or pain/spasticity medication use between groups after spinal fusion, but there was a significantly lower incidence of complications in the ITB therapy group.
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Sitthinamsuwan B, Phonwijit L, Khampalikit I, Nitising A, Nunta-Aree S, Suksompong S. Comparison of efficacy between dorsal root entry zone lesioning and selective dorsal rhizotomy for spasticity of cerebral origin. Acta Neurochir (Wien) 2017; 159:2421-2430. [PMID: 28920167 DOI: 10.1007/s00701-017-3322-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/31/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Severe spasticity adversely affects patient functional status and caregiving. No previous study has compared efficacy between dorsal root entry zone lesioning (DREZL) and selective dorsal rhizotomy (SDR) for reduction of spasticity. This study aimed to investigate the efficacy of DREZL and SDR for attenuating spasticity, and to compare efficacy between these two methods. METHODS All patients who underwent DREZL, SDR, or both for treatment of intractable spasticity caused by cerebral pathology at Siriraj Hospital during 2009 to 2016 were recruited. Severity of spasticity was assessed using Modified Ashworth Scale (MAS) and Adductor Tone Rating Scale (ATRS). Ambulatory status was also evaluated. RESULTS Fifteen patients (13 males) with a mean age of 30.3 ± 17.5 years were included. Eight, six, and one patient underwent DREZL, SDR, and combined cervical DREZL and lumbosacral SDR, respectively. Eight of ten patients with preoperative bed-bound status had postoperative improvement in ambulatory status. Spasticity was significantly reduced in the DREZL group (p < 0.001), the SDR group (p < 0.001), and in overall analysis (p < 0.001). SDR was effective in both pediatric and adult spasticity patients. A significantly greater reduction in spasticity as assessed by MAS score (p < 0.001) and ATRS score (p = 0.015) was found in the DREZL group. Transient lower limb weakness was found in a patient who underwent SDR. CONCLUSIONS DREZL is more effective for reducing spasticity, but is more destructive than SDR. DREZL should be preferred for bed-ridden patients, and SDR for ambulatory patients. Both operations are helpful for improving ambulatory status. Gait improvement was observed only in patients who underwent SDR. Adult patients with spasticity of cerebral origin benefit from SDR.
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Affiliation(s)
- Bunpot Sitthinamsuwan
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Luckchai Phonwijit
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Inthira Khampalikit
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Akkapong Nitising
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Sarun Nunta-Aree
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Sirilak Suksompong
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Cerebellar ataxia and intrathecal baclofen therapy: Focus on patients´ experiences. PLoS One 2017; 12:e0180054. [PMID: 28654671 PMCID: PMC5487051 DOI: 10.1371/journal.pone.0180054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 06/08/2017] [Indexed: 11/23/2022] Open
Abstract
Elucidating patients´ experiences of living with chronic progressive hereditary ataxia and the symptomatic treatment with intrathecal baclofen (ITB) is the objective of the current study. A multicenter qualitative study with four patients included due to the rare combination of hereditary ataxia and ITB therapy was designed to elucidate participants’ experiences through semi-structured interviews. The transcribed text was analyzed according to content analysis guidelines. Overall we identified living in the present/ taking one day at a time as the main theme covering the following categories: 1) Uncertainty about the future as a consequence of living with a hereditary disease; The disease; 2) Impact on life as a whole, 3) Influence on personal life in terms of feeling forced to terminate employment, 4) Limiting daily activities, and 5) ITB therapy, advantages, and disadvantages. Uncertainty about the future was the category that affected participants’ personal life, employment, and daily activities. The participants’ experience of receiving ITB therapy was expressed in terms of improved quality of life due to better body position and movement as well as better sleep and pain relief.
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Abstract
INTRODUCTION Children with cerebral palsy undergoing soft tissue and bony procedures often experience pain and spasticity postoperatively. Differentiation of pain from spasticity complicates management, so controlling spasticity with a continuous infusion of baclofen, an antispasmodic, through an already present indwelling epidural catheter holds interest. METHODS A retrospective chart review was performed of patients with cerebral palsy undergoing single event, multilevel lower extremity surgery at a single institution who received epidural analgesia with or without continuous baclofen infusion. Primary outcomes included need for supplemental narcotic analgesics and benzodiazepines postoperatively. Duration of hospitalization, pain scores, and complications were also evaluated. RESULTS Forty-four patients were identified, ranging in age from 3 to 17 years, 19 of whom received epidural baclofen. No differences were found in use of supplemental narcotic analgesia, benzodiazepines, or duration of hospitalization. Differences in pain scores were not statistically significant (0.82±0.95 for baclofen vs. 1.48±0.99 for controls) (P=0.391). Mean arterial pressure was lower in patients receiving baclofen (P=0.004). No potential side effects attributable to baclofen were noted. CONCLUSIONS Continuous epidural baclofen infusion seems unlikely to alter the pain-spasm cycle experienced by patients with cerebral palsy following orthopaedic surgery to a clinically significant degree. More effective, and cost-effective, measures at assessing and controlling pain and muscle spasm should be explored to benefit cerebral palsy patients postoperatively. LEVEL OF EVIDENCE Level III-therapeutic study.
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Zdolsek HA, Olesch C, Antolovich G, Reddihough D. Intrathecal baclofen therapy: benefits and complications. JOURNAL OF INTELLECTUAL & DEVELOPMENTAL DISABILITY 2011; 36:207-213. [PMID: 21830852 DOI: 10.3109/13668250.2011.595707] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Spasticity and dystonia in children with cerebral palsy has been treated with intrathecal baclofen therapy (ITB) at the Royal Children's Hospital, Melbourne, Australia (RCH) since 1999. METHODS The records of children having received or still receiving ITB during the period September 1999 until August 2005 were studied to evaluate complications and side effects. Parents answered a questionnaire focused on the health and functional impact in the children. RESULTS There were 18 first insertions of pumps, 6 removals, and 4 reinsertions. The longest treatment was 5 years and 11 months and was still ongoing. Seventeen complications occurred in 14 out of 18 children. Despite the high complication rate and the lack of significant functional improvement, 11 out of 12 parents agreed that ITB was beneficial. CONCLUSION ITB treatment at RCH over the years has resulted in some complications, mostly occurring shortly after pump insertion. For the majority of children there are substantial benefits.
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Affiliation(s)
- Helena Aniansson Zdolsek
- Department of Developmental Medicine, Royal Children's Hospital, and University of Melbourne, Melbourne, Australia
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Morant A, Noé E, Boyer J, Escamilla B, Trénor C, Ferri J, Chirivella J. Paralytic ileus: A complication after intrathecal baclofen therapy. Brain Inj 2009; 20:1451-4. [PMID: 17378237 DOI: 10.1080/02699050601082016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Baclofen is frequently used in the management of spasticity. When the therapeutic benefit of oral baclofen is not satisfactory, intrathecal administration should be considered. This method reduces side effects due to a reduction in dosage compared to oral administration. CASE DESCRIPTION This study presents a 52-year-old man with tetraplegia after a brainstem stroke. Four days after the placement of a Synchromed II infusion pump (100 mcg per day), the patient presented a paralytic ileus. The treatment was conservative and the dosage of intrathecal baclofen was reduced to lowest drug flow. After 15 days of treatment the ileus was resolved and the dosage progressively increased without incident. CONCLUSION Ileus should be considered as a rare side effect after intrathecal baclofen administration, especially in cases of brainstem injury because baclofen seems to act directly over vegetative brainstem nuclei. Based on this case, it is strongly recommended to decrease the dose of intrathecal baclofen as one of the main therapeutic options.
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Affiliation(s)
- Amparo Morant
- Servicio de Daño Cerebral, Hospitales Nisa, Instituto Valenciano de Neurorrehabilitación, Valencia, Spain
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Andreani JCM, Guma C. Lateral Cord Stimulation Decreases Spastic Electromyographic Spreading: Responses in a Brain-Damaged Pig Preparation. Neuromodulation 2008; 11:202-7. [DOI: 10.1111/j.1525-1403.2008.00167.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Dalton C, Keenan E, Stevenson V. A novel cause of intrathecal baclofen overdosage: lessons to be learnt. Clin Rehabil 2008; 22:188-90. [DOI: 10.1177/0269215507081962] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Case presentation: A serious intrathecal baclofen overdose occurred in a 45-year-old woman with primary progressive multiple sclerosis following a catheter dye study with concomitant change in baclofen concentration. The pump and catheter were emptied of baclofen 2000 μg/mL, refilled and primed with baclofen 1000 μg/mL. No correction was made for the `dead space' between the reservoir and catheter access port, which contained baclofen 2000 μg/mL. Failure of the priming bolus to account for the residual baclofen concentration within the dead space resulted in a serious overdose. Action: Amendments are being made to both our local and the Medtronic protocols. Conclusion: We hope that by reporting this incident the risk of this potentially fatal error re-occurring is minimized.
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Affiliation(s)
| | | | - Val Stevenson
- National Hospital for Neurology and Neurosurgery, London, UK
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Guillaume D, Van Havenbergh A, Vloeberghs M, Vidal J, Roeste G. A Clinical Study of Intrathecal Baclofen Using a Programmable Pump for Intractable Spasticity. Arch Phys Med Rehabil 2005; 86:2165-71. [PMID: 16271565 DOI: 10.1016/j.apmr.2005.05.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2004] [Revised: 04/15/2005] [Accepted: 05/25/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the impact of intrathecal baclofen (ITB) therapy on outcomes of functional independence, pain, subjective improvement, performance, and standard measures of spasticity. DESIGN A noncomparative, multicenter, prospective cohort trial of patients with implanted pumps followed up over a 12-month period for the assessment of spasticity, pain, and function. SETTING Twenty-four European centers of neurology or rehabilitation familiar with implantable pump technique participated. PARTICIPANTS Patients with intractable spasticity (N=138) who responded positively to a trial dose of baclofen (n=133) and who began ITB therapy (n=129) were enrolled. INTERVENTION Implantation of a Medtronic SynchroMed Infusion System with the administration of ITB therapy. MAIN OUTCOME MEASURES Ashworth Scale assessment, Penn Spasm Frequency Scale scores, pain assessment, FIM instrument scores or WeeFIM scores for children, Canadian Occupational Performance Measure (COPM), and subjective ratings of overall relief were the tools administered. RESULTS Muscle tone, spasm scores, and pain intensity reductions were observed. Overall FIM scores increased significantly in cognitive and motor function. COPM scores for both performance and satisfaction also improved significantly. Patients reported increased relief from pain and spasticity, supported by physician reports. Forty-three percent of patients reported adverse events, mostly related to patients' underlying conditions (20%), the device implant surgery (10%), or complications with the catheter (9%). CONCLUSIONS ITB therapy using a programmable pump is clinically effective and well tolerated, despite a seemingly high level of adverse events, in patients with intractable spasticity of spinal or cerebral origin and may offer improvements in pain relief and function.
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Affiliation(s)
- Daniel Guillaume
- Centre Neurologique et de Réadaptation Fonctionnelle, Fraiture-en-Condroz, Belgium
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Faaberg J, Koulousakis A, Staats PS. Clinical Protocols for Titrating Constant Flow Implantable Pumps in Patients with Pain or Spasticity. Neuromodulation 2005; 8:121-30. [DOI: 10.1111/j.1525-1403.2005.00228.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rainov NG, Buchser E. Making a Case for Programmable Pumps Over Fixed Rate Pumps for the Management of Fluctuations in Chronic Pain and Spasticity: A Literature Review. Neuromodulation 2002; 5:89-99. [DOI: 10.1046/j.1525-1403.2002.02013.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Marugán L, Revuelta E, Lorda E, Gómez MS. A method for reducing the pocket complications of the internal infusion pumps in pediatric patients: a case report. Neuromodulation 2002; 5:100-2. [PMID: 22151848 DOI: 10.1046/j.1525-1403.2002.02014.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Internal infusion pumps are increasingly used as a safe method to deliver drugs in adult patients. However, a formal contraindication of this mode of therapy is the presence of a imbalance between the pump volume and the size of the abdominal wall as occurs in pediatric populations. We describe a method of implantation of an intrathecal infusion pump for baclofen therapy in a 10-year-old patient with cerebral palsy. Before the pump implantation we inserted a subcutaneous expander with a reservoir that was filled with saline solution every week. After three sessions, a pocket similar in size to an internal infusion pump was obtained. The result was a pump pocket with soft shaping and no edges that would not generate pressure sores or tissue tension after the pump insertion. This method could extend the use of internal infusion pumps in pediatric populations.
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Affiliation(s)
- L Marugán
- Departments of Anesthesiology Pain Relief Unit, and Surgery, Marina Baixa Hospital, Villajoyosa, Alicante, and Department of Plastic Surgery, General University Hospital, Alicante, Spain
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Ivanhoe CB, Tilton AH, Francisco GE. Intrathecal Baclofen Therapy for Spastic Hypertonia. Phys Med Rehabil Clin N Am 2001. [DOI: 10.1016/s1047-9651(18)30039-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Krames E. Introduction. Neuromodulation 1999. [DOI: 10.1046/j.1525-1403.1999.00053.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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