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Masrour M, Zare A, Presedo A, Nabian MH. Intrathecal baclofen efficacy for managing motor function and spasticity severity in patients with cerebral palsy: a systematic review and meta-analysis. BMC Neurol 2024; 24:143. [PMID: 38678195 PMCID: PMC11055284 DOI: 10.1186/s12883-024-03647-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 04/19/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Spasticity can significantly affect a patient's quality of life, caregiver satisfaction, and the financial burden on the healthcare system. Baclofen is one of only a few options for treating spasticity. The purpose of this study is to investigate the impact of intrathecal baclofen (ITB) therapy on severe40.23 spasticity and motor function in patients with cerebral palsy. METHODS We conducted a systematic review in PubMed, Scopus, Ovid, and the Cochrane Library in accordance with the PRISMA guidelines. We included studies based on eligibility criteria that included desired participants (cerebral palsy patients with spasticity), interventions (intrathecal baclofen), and outcomes (the Ashworth scales and the Gross Motor Function Measure [GMFM]). The within-group Cohen's d standardized mean differences (SMD) were analyzed using the random effect model. RESULTS We screened 768 papers and included 19 in the severity of spasticity section and 6 in the motor function section. The pre-intervention average spasticity score (SD) was 3.2 (0.78), and the post-intervention average score (SD) was 1.9 (0.72), showing a 40.25% reduction. The SMD for spasticity reduction was - 1.7000 (95% CI [-2.1546; -1.2454], p-value < 0.0001), involving 343 patients with a weighted average age of 15.78 years and a weighted average baclofen dose of 289 µg/day. The SMD for the MAS and Ashworth Scale subgroups were - 1.7845 (95% CI [-2.8704; -0.6986]) and - 1.4837 (95% CI [-1.8585; -1.1088]), respectively. We found no relationship between the participants' mean age, baclofen dose, measurement time, and the results. The pre-intervention average GMFM (SD) was 40.03 (26.01), and the post-intervention average score (SD) was 43.88 (26.18), showing a 9.62% increase. The SMD for motor function using GMFM was 0.1503 (95% CI [0.0784; 0.2223], p-value = 0.0030), involving 117 patients with a weighted average age of 13.63 and a weighted average baclofen dose of 203 µg/day. In 501 ITB implantations, 203 medical complications were reported, including six new-onset seizures (2.96% of medical complications), seven increased seizure frequency (3.45%), 33 infections (16.26%), eight meningitis (3.94%), and 16 cerebrospinal fluid leaks (7.88%). Delivery system complications, including 75 catheter and pump complications, were also reported. CONCLUSION Despite the risk of complications, ITB has a significant impact on the reduction of spasticity. A small but statistically significant improvement in motor function was also noted in a group of patients.
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Affiliation(s)
- Mahdi Masrour
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Zare
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ana Presedo
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France.
| | - Mohammad Hossein Nabian
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France.
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Nuru M, Maglinger B, Vessell M, Simon JE, Daniels MW, Anderson D, Mutchnick I. Infectious Complications and Operative Management of Intrathecal Baclofen Pumps in the Pediatric Population: A Systematic Review and Meta-Analysis of 20 Years of Pooled Experience. World Neurosurg 2022; 163:e59-e72. [PMID: 35219917 DOI: 10.1016/j.wneu.2022.02.078] [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: 11/16/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Intrathecal baclofen (ITB) is a treatment modality used to improve the quality of life of patients with intractable spasticity and dystonia. Although it is an effective solution in patients failing oral interventions, it is associated with potential infectious complications. It is known that pediatric patients with ITB have significantly higher infection rates compared with adult patients. The cause of these higher rates in pediatric patients remains unclear. In the present study, we performed a meta-analysis focusing on the incidence of infection, and clarification of potential risk factors for infection in pediatric patients with ITB. METHODS This meta-analysis was performed in accordance with the PRISMA guidelines. An electronic database search was performed through PubMed, Web of Science, Embase, and Cochrane Library databases. Eligibility criteria and bias assessment were applied before statistical analysis. RESULTS The 17 studies identified yielded 2238 pediatric patients treated with implanted ITB pumps between 1994 and 2014. Infection comprised 34% of observed complications, second only to catheter malfunction. Pediatric ITB primary infection ranged between 0% and 44% among included studies (interquartile range, 4.85%-18.85%). A linear mixed-effects regression model showed that subfascial implantation had 12% lower primary infection rates compared with subcutaneous implantations across the literature. The relative risk of infection was 56% lower in pediatric patients with subfascially implanted ITB pumps. CONCLUSIONS Surgeons and clinicians should use these data to better assess patient risk-benefit when considering ITB pump implantation.
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Affiliation(s)
- Mohammed Nuru
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA; Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA.
| | - Benton Maglinger
- University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Meena Vessell
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Joshua E Simon
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Michael Wesley Daniels
- Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Kentucky, USA
| | - Douglas Anderson
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Ian Mutchnick
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA; Norton Neuroscience Institute/Norton Children's Hospital, Norton Healthcare, Louisville, Kentucky, USA
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Bonouvrié LA, Lagendijk KE, Beckerman H, Slot KM, van de Pol LA, Buizer AI. Surgical complications of intrathecal baclofen in children: A single centre, 20-year retrospective cohort study. Eur J Paediatr Neurol 2022; 37:94-97. [PMID: 35180559 DOI: 10.1016/j.ejpn.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 08/18/2021] [Accepted: 02/10/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Complications of intrathecal baclofen treatment (ITB) with an implanted pump can be severe and require surgery. Surgical implantation techniques and catheter materials for continuous ITB treatment have improved over the past years with the aim to reduce complications. OBJECTIVE To assess: 1) the type and rate of complications of ITB that require surgical intervention, 2) which risk factors influence the occurrence of complications, and, specifically, 3) whether complication rate is influenced by type of catheter used. METHODS A retrospective cohort study was conducted including all children (<18 years old) in one university medical center with pump implantation between 2001 and 2017. All complications requiring surgery were recorded. Risk factors for surgical intervention were determined using multiple logistic regression analysis. Catheter related complications between two types of catheters (silicone vs coated) were compared. RESULTS In total, 88 complications of ITB treatment requiring surgery were found in 47 (36.2%) out of 130 children. These included catheter-related complications (55.7% of all complications), infections (21.6%), cerebrospinal fluid leakage (14.8%), and pump-related complications (7.9%). The silicone catheter type, used until 2012, was found to be a significant risk factor for complications (Odds Ratio 3.75; 95% CI: 1.30-10.83). Since the introduction of the coated catheter type, in 2012, the rate of catheter-related complications decreased, from 0.15 to 0.10 complications per pump year. CONCLUSION The rate of surgical complications of intrathecal baclofen in children is high, and most frequently catheter-related. The number of complications decreased since the introduction of a new, coated, catheter in 2012. This study helps to inform children and their caregivers about the risk of possible complications of ITB, and to identify directions for future improvement of ITB care.
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Affiliation(s)
- Laura A Bonouvrié
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands.
| | - Karen E Lagendijk
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
| | - Heleen Beckerman
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
| | - K Mariam Slot
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Laura A van de Pol
- Department of Child Neurology, Amsterdam UMC, Vrije Universiteit, Amsterdam Neuroscience Research Institute, Amsterdam, the Netherlands
| | - Annemieke I Buizer
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands; Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
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Complications of intrathecal baclofen pump treatment in children with spastic cerebral palsy. A comparative analysis of patients weighing over or under 20 kg at the time of implantation. J Pediatr Orthop B 2022; 31:202-207. [PMID: 33448748 DOI: 10.1097/bpb.0000000000000848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The purpose of this study was to investigate the incidence of complications in pediatric spastic cerebral palsy (CP) patients weighing less than 20 kg at the time of intrathecal baclofen (ITB) pump implantation and to compare it with spastic CP patients heavier than 20 kg. Twenty-seven patients with spastic CP (14 males) treated with ITB implantation at our institution between January 2002 and January 2018 were retrospectively reviewed. Eight of the 27 patients had a bodyweight below 20 kg (group A) and 19 had weight above 20 kg (group B). Group A had a significantly more important proportion of patients with the Gross Motor Function Classification System V compared to group B (88 vs. 42%). The median follow-up was respectively 2.5 (1.8-4.6) and 4.6 (1.9-10.0) years in groups A and B. Median age at the time of ITB implantation was 7.4 (2.8-12.8) and 13.7 (6.5-16.8) years in groups A and B (P = 0.002). The proportion of patients with complications or reoperation was NS between groups A and B (P > 0.05). No postoperative infections were recorded in any of the groups. During follow-up, five patients died (63%) in group A and three (16%) in group B (P = 0.049) within 3.8 years on average after ITB implantation. ITB therapy in spastic CP patients weighing less than 20 kg seems to be as well tolerated and effective as it is in heavier (>20 kg) pediatric patients.
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Saleh ES, Vasileff CC, Omari AM, Khalil JG. The Diagnosis and Management of Pediatric Spine Infections. Cureus 2021; 13:e16748. [PMID: 34345570 PMCID: PMC8323075 DOI: 10.7759/cureus.16748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2021] [Indexed: 12/29/2022] Open
Abstract
The management of pediatric spine infections requires a multidisciplinary approach that includes orthopedic surgeons, infectious disease specialists, interventional radiologists, and others. The prevalence of the disease has increased in frequency, virulence, and degree of soft tissue involvement over the past several years; there has also been a resurgence of some types of infections, such as tuberculosis, fungal, and viral pathogens. The diagnosis can often be reached with a detailed history, physical examination, laboratory tests, and imaging studies. Pathologies mimicking infection require a more invasive approach for diagnosis, including core or open biopsy. The treatment of discitis, spondylodiscitis, vertebral osteomyelitis, spinal epidural, and intramedullary abscesses in children is at times complex, and although many infections can be treated non-surgically with antibiotic therapy, some more extensive infections require surgical management. A timely diagnosis is important as it allows the initiation of the appropriate antimicrobial therapy and would decrease the complexity of the subsequent surgical intervention.
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Affiliation(s)
- Ehab S Saleh
- Department of Orthopedics, Oakland University William Beaumont School of Medicine, Rochester, USA
| | - Christopher C Vasileff
- Department of Orthopedics, Oakland University William Beaumont School of Medicine, Rochester, USA
| | - Abdullah M Omari
- Department of Orthopedics, William Beaumont Hospital, Taylor, Taylor, USA
| | - Jad G Khalil
- Department of Orthopedics, Oakland University William Beaumont School of Medicine, Rochester, USA
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Koljonen PA, Chan SHS, Liu T, Ho ACC, Chim S, Tsoi NS, Wong YW. Intrathecal Baclofen Pump Infection With Meningitis: Effective Treatment by Radical Debridement and Intrareservoir Baclofen-Vancomycin Co-Infusion. Neuromodulation 2021; 24:1223-1228. [PMID: 33538029 DOI: 10.1111/ner.13369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/21/2020] [Accepted: 01/11/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Intrathecal baclofen pump associated central nervous system (CNS) infection and meningitis is a rare but serious complication and may have dire consequences. Due to bacterial biofilm formation, the optimal treatment strategy is usually for removal of the pump, followed by systemic antibiotics for treatment of local and CNS infection. We describe this case of a patient with recurrent Staphylococcus aureus pump site empyema and meningitis leading to status dystonicus, who was successfully managed with radical debridement and intrareservoir baclofen-vancomycin co-infusion. MATERIALS AND METHODS We retrospectively report a case of infected intrathecal baclofen pump with meningitis and provide a full review of literature. CONCLUSIONS To the best of our knowledge, this is the first reported case of intrathecal baclofen (ITB)-associated pump site empyema and meningitis successfully treated with this technique. In selected cases where surgical explantation is deemed not feasible, this method can provide clinicians with an additional option for pump salvage and retention, while eradicating CNS infection and maintaining optimal control of spasticity and dystonia.
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Affiliation(s)
- Paul A Koljonen
- Division Department of Orthopaedics & Traumatology, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Sophelia H S Chan
- Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Thomas Liu
- Division Department of Orthopaedics & Traumatology, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Alvin C C Ho
- Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Stella Chim
- Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Nai Shun Tsoi
- Department of Paediatrics & Adolescent Medicine, University of Hong Kong, Hong Kong
| | - Yat Wa Wong
- Division Department of Orthopaedics & Traumatology, Queen Mary Hospital, University of Hong Kong, Hong Kong
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Evaluation of Risk Factors for Cerebrospinal Leakage in Pediatric Patients With Cerebral Palsy Treated With Intrathecal Baclofen. J Pediatr Orthop 2020; 40:e522-e526. [PMID: 32501926 DOI: 10.1097/bpo.0000000000001472] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Insertion of an intrathecal baclofen (ITB) pump can provide significant benefits in patients with cerebral palsy (CP). However, there are little data describing the risk of complications. Specifically, there is a lack of data describing the incidence of cerebrospinal fluid (CSF) leakage and risk factors following ITB placement. The purpose of our study was to describe risk factors for developing CSF leak in pediatric patients with CP treated with ITB and to report the treatment and outcome of CSF leaks. METHODS Following institutional review board approval, 720 ITB procedures in 341 children with CP were identified retrospectively over a 15-year study period. Patients' demographic characteristics, medical comorbidities, muscle tone patterns, feeding tube status, seizure history, inpatient events, ITB-related CSF leak and headache complaints and their management, and other complications were evaluated. RESULTS Eighty-five (24.9%) patients experienced 90 CSF leak episodes over a follow-up time of 6.3±3.9 years. There were 72 episodes of headache as a result of CSF leakage in 61 (71.7%) of these 85 patients. There was a positive correlation between the risk of CSF leak and preoperative comorbidities such as epilepsy/seizure history, feeding tube, mixed type CP, and dystonic type CP. The risk of CSF leak after primary ITB administration was 5.8% (20/341), and the risk after secondary ITB procedures due to complications was 24.2% (32/132). There was no significant relationship between CSF leak and primary ITB (P=0.21), but the risk of CSF leak was positively correlated to the secondary ITB due to complications (P<0.05). CONCLUSIONS CSF leak was fairly common (25% incidence), and it correlated with epilepsy/seizure history, feeding tube, mixed type CP, and dystonic type CP. Recurrent ITB procedures were a risk factor for CSF leak. Half of these patients had self-limited symptoms that improved with conservative medical treatment, and the epidural blood patch was successful in resistant cases. Successful treatment of CSF leakage complications allows patients to continue ITB. LEVEL OF EVIDENCE Level III.
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Abraham M, Gold J, Dweck J, Ward M, Gendreau J, Panse N, Holani K, Gupta P, Mammis A. Classifying Device-Related Complications Associated With Intrathecal Baclofen Pumps: A MAUDE Study. World Neurosurg 2020; 139:e652-e657. [PMID: 32339729 DOI: 10.1016/j.wneu.2020.04.070] [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: 03/16/2020] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Intrathecal baclofen (ITB) is an effective treatment for spasticity, and therapeutic levels may be optimized using surgically implanted pumps. Though these devices are effective, complications can pose significant challenges to patients, decreasing the therapeutic effect and potentially requiring reoperation. As such, it is critical that complications associated with ITB be effectively characterized. METHODS We queried the Manufacturer and User Facility Device Experience (MAUDE) database for cases reported during the past 3 years documenting adverse events specifically related to ITB pumps. We identified 1935 adverse events that were individually analyzed and categorized by type of complication. RESULTS Out of the 1935 unique adverse events identified from the MAUDE database, 25.7% were device-related complications (n = 497). Of those, 50.3% were catheter-specific (n = 250), 21.3% (n = 106) were pump-specific, and 28.3% (n = 141) were included, more generally, in catheter or device erosion. CONCLUSIONS The MAUDE database may be a useful resource for evaluating ITB pump complications across a larger data set. By characterizing the complications and providing values for their total occurrences, patients and physicians may have more realistic expectations for the outcomes and morbidity of this device.
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Affiliation(s)
- Mickey Abraham
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Justin Gold
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
| | - Jack Dweck
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Max Ward
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Julian Gendreau
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Neal Panse
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Keshav Holani
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Priya Gupta
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Antonios Mammis
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Imerci A, Rogers KJ, Pargas C, Sees JP, Miller F. Identification of complications in paediatric cerebral palsy treated with intrathecal baclofen pump: a descriptive analysis of 15 years at one institution. J Child Orthop 2019; 13:529-535. [PMID: 31695821 PMCID: PMC6808077 DOI: 10.1302/1863-2548.13.190112] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Intrathecal baclofen (ITB) treatment is used with increasing frequency in the cerebral palsy population. We describe the complications of ITB treatment, the incidence of complications, and our experience with their treatment. METHODS In a period of 15 years, 341 paediatric patients with cerebral palsy treated with ITB were evaluated. Device problems associated with the catheter or pump, or infection and complications such as cerebrospinal fluid (CSF) leak and postdural spinal headache, were reviewed. Infection was classified as early (≤ 90 days) or late (> 90 days) according to the time of onset. RESULTS The infection rate was 6.9% per procedure (50/720) and 14.6% per patient (50/341) over a mean 6.3 ± 3.9 years. There was a positive correlation between the risk of infection and preoperative comorbidities including epilepsy/seizure history, feeding tube, and mixed type cerebral palsy (p < 0.05, p = 0.03, p = 0.01, respectively). Eighty-five (24.9%) patients experienced 90 CSF leak episodes; 61 of these 85 patients had headache complaints as a result of CSF leak. There was a positive correlation between the risk of early infection and CSF leak (p < 0.05). CONCLUSIONS The most common complication related to ITB was associated with pump and catheter problems. The rate of complications with the use of ITB is relatively high; however, based on the literature reports, it is the most effective treatment for severe spasticity and dystonia in patients with severe cerebral palsy. LEVEL OF EVIDENCE III.
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Affiliation(s)
- A. Imerci
- Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children Wilmington, Delaware, USA
| | - K. J. Rogers
- Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children Wilmington, Delaware, USA
| | - C. Pargas
- Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children Wilmington, Delaware, USA
| | - J. P. Sees
- Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children Wilmington, Delaware, USA
| | - F. Miller
- Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children Wilmington, Delaware, USA,Correspondence should be sent to F. Miller, Alfred I. duPont Hospital for Children, Department of Orthopaedics, 1600 Rockland Road, Wilmington, DE 19803, USA. E-mail:
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Buxton K. Balancing the benefits of intrathecal baclofen pump surgery with potential postoperative complications. Dev Med Child Neurol 2018; 60:972-973. [PMID: 29574822 DOI: 10.1111/dmcn.13756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW The review provides an update on the treatment of hypertonia in cerebral palsy, including physical management, pharmacotherapy, neurosurgical, and orthopedic procedures. RECENT FINDINGS Serial casting potentiates the effect of Botulinum neurotoxin A injections for spasticity. Deep brain stimulation, intraventricular baclofen, and ventral and dorsal rhizotomy are emerging tools for the treatment of dystonia and/or mixed tone. The long-term results of selective dorsal rhizotomy and the timing of orthopedic surgery represent recent advances in the surgical management of hypertonia. SUMMARY Management of hypertonia in cerebral palsy targets the functional goals of the patient and caregiver. Treatment options are conceptualized as surgical or nonsurgical, focal or generalized, and reversible or irreversible. The role of pharmacologic therapies is to improve function and mitigate adverse effects. Further investigation, including clinical trials, is required to determine the role of deep brain stimulation, intraventricular baclofen, orthopedic procedures for dystonia, and rhizotomy.
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Nagel SJ, Reddy CG, Frizon LA, Holland MT, Machado AG, Gillies GT, Howard MA. Intrathecal Therapeutics: Device Design, Access Methods, and Complication Mitigation. Neuromodulation 2017; 21:625-640. [DOI: 10.1111/ner.12693] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/26/2017] [Accepted: 07/29/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Sean J. Nagel
- Center for Neurological Restoration; Cleveland Clinic; Cleveland OH USA
| | - Chandan G. Reddy
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | | | - Marshall T. Holland
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | - Andre G. Machado
- Center for Neurological Restoration; Cleveland Clinic; Cleveland OH USA
| | - George T. Gillies
- Department of Mechanical and Aerospace Engineering; University of Virginia; Charlottesville VA USA
| | - Matthew A. Howard
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
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Robinson S, Robertson FC, Dasenbrock HH, O'Brien CP, Berde C, Padua H. Image-guided intrathecal baclofen pump catheter implantation: a technical note and case series. J Neurosurg Spine 2017; 26:621-627. [DOI: 10.3171/2016.8.spine16263] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEMedically refractory spasticity and dystonia are often alleviated with intrathecal baclofen (ITB) administration through an indwelling catheter inserted in the lumbar spine. In patients with cerebral palsy, however, there is a high incidence of concomitant neuromuscular scoliosis. ITB placement may be technically challenging in those who have severe spinal deformity or who have undergone prior instrumented thoracolumbar fusion. Although prior reports have described drilling through the lumbar fusion mass with a high-speed bur, as well as IT catheter implantation at the foramen magnum or cervical spine, these approaches have notable limitations. To the authors' knowledge, this is the first report of ITB placement using cone beam CT (CBCT) image guidance to facilitate percutaneous IT catheterization.METHODSData were prospectively collected on patients treated between November 2012 and June 2014. In the interventional radiology suite, general anesthesia was induced and the patient was positioned prone. Imaging was performed to identify the optimal trajectory. Percutaneous puncture was performed at an entry site with image-guided placement of a sheathed needle. CBCT provided real-time 2D projections and 3D reconstructions for detailed volumetric imaging. A biopsy drill was passed through the sheath, and subsequently a Tuohy needle was advanced intrathecally. The catheter was threaded cephalad under fluoroscopic visualization. After tip localization and CSF flow were confirmed, the stylet was replaced, the external catheter tubing was wrapped sterilely in a dressing, and the patient was transported to the operating room. After lateral decubitus positioning of the patient, the IT catheter was exposed and connected to the distal abdominal tubing with typical pump placement.RESULTSOf 15 patients with Gross Motor Function Classification System Levels IV and V cerebral palsy and instrumented thoracolumbar fusion, 8 had predominantly spasticity, and 7 had mixed spasticity and dystonia. The mean age of patients was 20.1 years (range 13–27 years). Nine patients underwent initial catheter and pump placement, and 6 underwent catheter replacement. The procedure was technically successful, with accurate spinal catheter placement in all patients. The median hospital stay was 4 days (IQR 3–5 days). One patient had an early postoperative urinary tract infection. With a mean follow-up of 25.8 months (median 26, range 18–38 months), no CSF leakage or catheter failure occurred. One late infection due to Pseudomonas aeruginosa (requiring pump explantation) occurred at 4 months, probably secondary to recurrent urinary tract infections.CONCLUSIONSImage-guided CBCT navigation resulted in accurate percutaneous placement of the IT catheter for ITB pumps in patients with prior instrumented thoracolumbar fusion. The multimodality approach is an alternate technique that may be used for IT catheter insertion in patients with complex lumbar spine anatomy, extending the potential to provide safe, durable ITB therapy in this population.
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Affiliation(s)
| | | | - Hormuzdiyar H. Dasenbrock
- 2Harvard Medical School
- 3Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
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Saulino M, Anderson DJ, Doble J, Farid R, Gul F, Konrad P, Boster AL. Best Practices for Intrathecal Baclofen Therapy: Troubleshooting. Neuromodulation 2016; 19:632-41. [DOI: 10.1111/ner.12467] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 05/02/2016] [Accepted: 05/11/2016] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Jennifer Doble
- Associates in Physical Medicine and Rehabilitation; Ypsilanti MI USA
- St. Joseph Mercy Hospital; Ann Arbor MI USA
| | - Reza Farid
- University of Missouri Health Care; Columbia MO USA
| | - Fatma Gul
- University of Texas Southwestern Medical Center; Dallas TX USA
| | - Peter Konrad
- Vanderbilt University Medical Center; Nashville TN USA
| | - Aaron L. Boster
- Neurology MS Program; OhioHealth Neurological Physicians; Columbus OH USA
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