1
|
Isler C, Cerci HM, Baghaki S, Aydin YS, Toklu S, Hanci MM. Expansion of the Subcutaneous Compartment by Umbilicus Resection for Intrathecal Pump Placement: The "Karagoz-Hacivat Technique". Oper Neurosurg (Hagerstown) 2024; 27:415-423. [PMID: 38531088 DOI: 10.1227/ons.0000000000001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/19/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intrathecal baclofen (ITB) for severe spasticity can encounter complications such as wound dehiscence and ulcers because of elevated intracompartmental pressure within the abdominal subcutaneous and subfascial pocket housing the pump. We propose an innovative technique to manage ITB wound ulcers. METHODS Resecting the umbilicus create a more spacious and less tension-prone pocket for the ITB pump. RESULTS Between 2015 and 2023, we implanted ITB pumps in 65 patients. Among them, 5 patients presented with skin ulcer or dehiscence underwent surgery using the novel technique. Postoperative follow-up revealed successful wound healing, with no further wound-related complications. CONCLUSION The proposed technique provides effective and practical solution to wound and skin complications related to ITB pump. Moreover, it may serve as a viable preemptive strategy during the initial implantation of the ITB pump in selected patients.
Collapse
Affiliation(s)
- Cihan Isler
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul , Turkey
| | - Huseyin Mert Cerci
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul , Turkey
| | - Semih Baghaki
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Koc University, Istanbul , Turkey
| | - Yekta Servet Aydin
- Department of Plastic and Reconstructive Surgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul , Turkey
| | - Süreyya Toklu
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul , Turkey
- Department of Neurosurgery, Erzurum City Hospital, Erzurum , Turkey
| | - Mehmet Murat Hanci
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul , Turkey
| |
Collapse
|
2
|
Themistoklis KM, Kossivas A, Korfias S, Papasilekas TI. Management of an intrathecal baclofen pump pocket empyema caused by a proximal vesicocutaneous fistula: A case report. Surg Neurol Int 2024; 15:185. [PMID: 38840604 PMCID: PMC11152545 DOI: 10.25259/sni_47_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/03/2024] [Indexed: 06/07/2024] Open
Abstract
Background Intrathecal baclofen infusing pumps are nowadays commonly implanted in patients suffering from severe, intractable spasticity with a background of multiple sclerosis. Although intrathecal baclofen therapy is considered a safe therapeutic modality, complications are unavoidable and broadly categorized as mechanical and infectious. In the instance of a pump pocket infection, a surgical explanation of the pump is often necessary to treat the infection. Case Description We present the rare case of a 60-year-old woman who was admitted emergently to our clinic with a subcutaneous pump pocket empyema caused by proximal vesicocutaneous fistulas. The patient underwent explantation of the pump and otherwise had an uncomplicated perioperative course. Conclusion The surgical explanation of the baclofen pump and antibiotic treatment were sufficient to treat the pump pocket empyema in this instance. To the best of our knowledge, this is the first report of a pump pocket empyema formed in the proximity of a vesicocutaneous fistula.
Collapse
Affiliation(s)
| | - Alexandros Kossivas
- Department of Neurosurgery, “Evaggelismos” General Hospital of Athens, Athens, Greece
| | - Stefanos Korfias
- Department of Neurosurgery, “Evaggelismos” General Hospital of Athens, Athens, Greece
| | | |
Collapse
|
3
|
Strader S, Mutchnick I. Brief pump externalization without ITB wean to treat a probable pocket infection. Childs Nerv Syst 2023; 39:3643-3645. [PMID: 37458770 DOI: 10.1007/s00381-023-06075-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/09/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND IMPORTANCE: Intrathecal baclofen (ITB) pumps are an effective management tool for spasticity and dystonia. In the pediatric population, ITB complications including infection are common, and strategies to minimize their impact are important. Current standard of care for pump infection involves a wean of the ITB therapy followed by explantation of the hardware, which can be a three to 6-month process. CLINICAL PRESENTATION: We present a 20-year-old female who developed an pump pocket infection after revision. The pump was removed from the body but left connected. The pocket was debrided, thoroughly washed, and packed with multiple microbicidal agents. Nine days later, a new pump and proximal catheter was re-implanted without complications or interruption of medication administered intrathecally. One year later, the patient is doing well without any infectious problems. CONCLUSION: To our knowledge, this is the first report of an externalized pump and expedited reimplantation without a break in ITB therapy. Further studies are required in order to best characterize this technique as a potential alternative for infected baclofen pump pockets.
Collapse
Affiliation(s)
- Shannon Strader
- Department of Physical Medicine and Rehabilitation, University of Louisville, Louisville, KY, 40202, USA.
| | - Ian Mutchnick
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, KY, USA
- Division of Pediatric Neurosurgery, Norton Neuroscience Institute and Children's Hospital, Louisville, KY, USA
| |
Collapse
|
4
|
Unlu Akyuz E, Cankurtaran D, Tezel N. The patients with intrathecal baclofen pump in the age of COVID-19: a single center study. Int J Neurosci 2023:1-7. [PMID: 37855598 DOI: 10.1080/00207454.2023.2273769] [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: 04/15/2022] [Accepted: 10/17/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE Intrathecal baclofen pump treatment is employed in the treatment of various diseases. Despite the benefits of intrathecal baclofen pump, patients may occasionally encounter severe complications. These complications may necessitate urgent assessment or intervention for patients with intrathecal baclofen pumps. This study aimed to evaluate the intrathecal baclofen pump-related problems, the utilization of health services, physical-psychosocial status, and the quality of life of patients with intrathecal baclofen pumps during the coronavirus disease 2019 pandemic. MATERIALS AND METHODS We conducted a cross-sectional, phone-based survey study between 1 June 2021 and 15 July 2021 with a sample of 23 patients with intrathecal baclofen pumps. The patients' quality of life before the implantation of the pump, after one year of implantation, and during the pandemic was evaluated with the 3-level version of EQ-5D. RESULTS Catheter migration developed in one of the patients, after which the pump was changed. While the dose of baclofen was altered in eight (38.1%) patients during the pandemic period, the filling period was modified in three (14.3%) patients. While 61.9% of the patients reported that their general health, mobility, spasticity and joint mobility were worse than before the pandemic, 90.5% of the patients stated that their communication and mood were worse than before the pandemic. The 3-level version of EQ-5D and EQ-Visual Analogue Scale scores of the patients were significantly decreased during pandemic (p < .05). CONCLUSIONS Due to the complications of the intrathecal baclofen pump, its management should continue uninterruptedly during the pandemic period.
Collapse
Affiliation(s)
- Ece Unlu Akyuz
- Department of Physical Medicine and Rehabilitation, University of Health Sciences Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey
| | - Damla Cankurtaran
- Department of Physical Medicine and Rehabilitation, University of Health Sciences Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey
| | - Nihal Tezel
- Department of Physical Medicine and Rehabilitation, University of Health Sciences Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey
| |
Collapse
|
5
|
Qin ES, Patel H, Montagnino J, Pham K, Lam NY. Behavioral dysregulation exacerbated by intrathecal baclofen in an adolescent with severe traumatic brain injury. J Pediatr Rehabil Med 2022; 15:383-387. [PMID: 35466913 DOI: 10.3233/prm-210018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This is a case of a 19-year-old male with a history of remote severe traumatic brain injury (TBI) with an intrathecal baclofen (ITB) pump for dystonia management. Given concern for lack of efficacy despite increasing doses of ITB, his catheter was evaluated and found to be epidural rather than intrathecal. The baclofen dose was down-titrated and he underwent catheter revision. Post-op, his baclofen dose was up-titrated and complicated by significant behavioral changes including aggressive physical and verbal behaviors resulting in hospitalization. Work-up was negative for infection, new neurologic pathology, and epileptic activity. Psychiatric medications were adjusted but the behaviors persisted. Due to concern that the increased baclofen dose was causing his mood instability, his pump was down-titrated. As the dosage decreased, the frequency of outbursts also decreased. Throughout these dose adjustments, his dystonia remained stable and overall functional status improved. This is one of the first cases demonstrating that ITB may exacerbate mood instability in patients with TBI.
Collapse
Affiliation(s)
- Evelyn S Qin
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Hetal Patel
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Jami Montagnino
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Kelly Pham
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Ny-Ying Lam
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
6
|
Bareli T, Ahdoot HL, Ben Moshe H, Barnea R, Warhaftig G, Gispan I, Maayan R, Rosca P, Weizman A, Yadid G. Novel Opipramol-Baclofen Combination Alleviates Depression and Craving and Facilitates Recovery From Substance Use Disorder-An Animal Model and a Human Study. Front Behav Neurosci 2021; 15:788708. [PMID: 35002647 PMCID: PMC8733380 DOI: 10.3389/fnbeh.2021.788708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Substance use disorders (SUDs) are associated with depression and anxiety, with the latter being one of the major factors in substance-seeking and relapse. Due to dose-dependent sedative side effects there is limited efficacy of baclofen treatment for SUDs. Here we suggest the use of a novel combination of opipramol and baclofen (O/B) which is known to attenuate anxiety and depression, for the facilitation of recovery from SUDs. Since both opipramol and baclofen have a common downstream signal transduction, their individual doses could be reduced while still maintaining the benefits of the combination. We tested the O/B combination in both animals and patients. Rats treated with O/B showed significant attenuation in craving behavior and in relapse rate during withdrawal from cocaine. In a double-blind, placebo-controlled pilot study, conducted in a residential detoxification center, 14 males and 3 females, aged 28-60 years were assigned to a study (n = 6) and a placebo (n = 11) group (placebo group: 40 ± 10.5 years; O/B group 40 ± 10.8 years). The participants completed scales measuring depression, anxiety and craving symptoms and provided saliva samples for stress hormone examination [cortisol and dehydroepiandrosterone-sulfate (DHEA-S)]. Participants with polysubstance use disorder (PsUD) treated with O/B showed a reduction in cravings and depression and an increase in DHEA-S and in the DHEA-S/cortisol ratio. Our findings indicate a beneficial effect of O/B treatment. This study suggests a novel candidate for pharmacological treatment of patients with SUD and comorbid mood/anxiety disorders that may facilitate their rehabilitation.
Collapse
Affiliation(s)
- Tzofnat Bareli
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Hadas Levi Ahdoot
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Hila Ben Moshe
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Royi Barnea
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Gal Warhaftig
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Iris Gispan
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Rachel Maayan
- The Laboratory of Molecular Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Paola Rosca
- Department for the Treatment of Substance Abuse and Mental Health Services, Israeli Ministry of Health, Jerusalem, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Abraham Weizman
- The Laboratory of Molecular Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Research Unit, Geha Mental Health Center, Petah Tikva, Israel
| | - Gal Yadid
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| |
Collapse
|
7
|
Tenney-Soeiro R, Sieplinga K. Teaching about children with medical complexity: A blueprint for curriculum design. Curr Probl Pediatr Adolesc Health Care 2021; 51:101129. [PMID: 35086780 DOI: 10.1016/j.cppeds.2021.101129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Children with medical complexity make up a small portion of the pediatric population but utilize a large percentage of health care time and spending. The medical needs of children with medical complexity are highly variable and the education of healthcare providers in the care of these children has taken on more significance. Designing curricula and educational innovations related to the care of children with medical complexity can be challenging. Familiarity with the sociocultural theory, the zone of proximal development, Kolb's experiential learning model, and the educational resources that already exist allow for more ease in developing a curriculum that fits the needs of learners who may have a wide range of exposure to children with medical complexity. Flipped classroom models, simulations, asynchronous modules, and home and community experiences are all useful learning modalities to provide a varied and important curriculum. Taking advantage of the knowledge and skills of the many different members of the multi-disciplinary team caring for children with medical complexity is an important educational strategy that provides benefits to the learners and can enhance interprofessional education.
Collapse
Affiliation(s)
- Rebecca Tenney-Soeiro
- Associate Professor of Pediatrics, Perelman School of Medicine at University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Kira Sieplinga
- Assistant Professor Pediatrics, Program Director Pediatric Residency Spectrum Health, Helen DeVos Children's Hospital, Michigan State University College of Human Medicine, Grand Rapids, MI, United States
| |
Collapse
|
8
|
Characterization of standard work tools for intrathecal baclofen therapy. Childs Nerv Syst 2021; 37:3073-3081. [PMID: 34263339 DOI: 10.1007/s00381-021-05290-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intrathecal baclofen (ITB) has been an effective therapy since the 1980s, with widely reported revision, infection, and complication rates. Publications targeting surgical workflow have resulted in decreased infection and revision rates, but a standard workflow for the entire pathway has not been described. To present, define, and test standard work tools for patients receiving ITB to promote uniformity and standard of care in the field. METHODS A multidisciplinary approach from the movement disorder program of a tertiary care center defined all steps comprising the ITB pathway, and then developed standard work tools to decrease variability with respect to preoperative workup, day of surgery protocol, post-operative care, and also evaluation and treatment with respect to pump infection or malfunction. RESULTS Defined steps used at specific points of ITB pathway are presented with a single institution's outcome using the protocol from July 2017 to November 2020. A total of 60 procedures were performed. The overall complication rate was 14.5% at 6 months. Complications included an infection rate of 3.6% at 6 months, wound revision rate of 1.8% at 6 months, CSF leak rate of 1.7% at 6 months, and a 30-day readmission rate related to initial surgery of 6.7%. CONCLUSIONS Workflow efficiency and optimization for ITB patients can be used to obtain lower complication rates compared to historical cohorts in literature. A single-center, retrospective review highlights this.
Collapse
|
9
|
Danzig JA, Katz EB. Musculoskeletal and skin considerations in children with medical complexity: Common themes and approaches to management. Curr Probl Pediatr Adolesc Health Care 2021; 51:101074. [PMID: 34656455 DOI: 10.1016/j.cppeds.2021.101074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The term "children with medical complexity" (CMC) describes a population of heterogeneous genetic and metabolic disorders with multi-system involvement, with shared common abnormalities within the musculoskeletal system. Disorders that affect the central nervous system (CNS) result in abnormal muscular tone, ranging from dystonia and spasticity, to hypotonia, to combinations of both (axial hypotonia with appendicular hypertonia). Abnormal tone can impair movement and function and contribute to development of contractures, progressive scoliosis and hip dislocation. Impaired mobility, chronic illness and polypharmacy can result in fragile bones and increased risk of fracture, which can be difficult to diagnose and associated with pain. Additionally, CMC with impaired ability to communicate, total dependence on caregivers and frequent use of support devices can develop unintended skin injuries. There are a variety of treatments available for CMC with musculoskeletal disorders ranging from physical supports to pharmacologic treatments to surgeries. Medical and surgical treatments can promote changes in tone and support bone health to improve comfort, hygiene and proper positioning. These therapies may also carry significant risk in medically fragile patients. It is important for CMC to have a care team with a good understanding of the patient's overall health and goals of care and that can advocate for the patient to balance optimization of function and reduction of pain while also minimizing risk.
Collapse
Affiliation(s)
- Jennifer A Danzig
- Division of General Pediatrics, The Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Elana B Katz
- Center for Rehabilitation, The Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| |
Collapse
|
10
|
Gburek-Augustat J, Krause M, Bernhard M, Sorge I, Gräfe D, Siekmeyer M, Nestler U, Merkenschlager A. Unusual mechanical failures of intrathecal baclofen pump systems: symptoms, signs, and trouble shooting. Childs Nerv Syst 2021; 37:2597-2604. [PMID: 33834279 PMCID: PMC8342333 DOI: 10.1007/s00381-021-05154-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/29/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Although intrathecal baclofen (ITB) therapy is an effective treatment for spasticity, it has several disadvantages and a risk of complications. METHODS We present six pediatric patients who suffered from unusual mechanical failures of intrathecal baclofen pump systems. RESULTS With these case-vignettes, we provide a systematic approach on how to interpret the symptoms of ITB complications and an advice which further diagnostic and therapeutic steps to follow. We underline the seriousness of baclofen overdose, underdosing or withdrawal.
Collapse
Affiliation(s)
- Janina Gburek-Augustat
- Division of Neuropediatrics, Hospital for Children and Adolescents, University Hospital Leipzig, Leipzig, Germany.
| | - Matthias Krause
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Matthias Bernhard
- Division of Neuropediatrics, Hospital for Children and Adolescents, University Hospital Leipzig, Leipzig, Germany
| | - Ina Sorge
- Pediatric Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Daniel Gräfe
- Pediatric Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Manuela Siekmeyer
- Pediatric Intensive Care Unit, Hospital for Children and Adolescents, University Hospital Leipzig, Leipzig, Germany
| | - Ulf Nestler
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Andreas Merkenschlager
- Division of Neuropediatrics, Hospital for Children and Adolescents, University Hospital Leipzig, Leipzig, Germany
| |
Collapse
|
11
|
Scerrati A, De Bonis P, Norri N, Cavallo MA. Surgical treatment of spasticity: intrathecal baclofen pump implantation under subarachnoid block. NEUROSURGICAL FOCUS: VIDEO 2020; 3:V9. [PMID: 36285267 PMCID: PMC9542496 DOI: 10.3171/2020.7.focvid2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/02/2020] [Indexed: 11/06/2022]
Abstract
Most patients with spasticity, rigidity, and other symptoms of the upper motor neuron syndrome respond effectively to surgical treatment with an intrathecal baclofen pump when their symptoms become intractable to nonsurgical measures. Baclofen administered into the lumbar subarachnoid space produces a locally high concentration at the spinal level and a low concentration supraspinally, avoiding most of the central side effects associated with a high oral dose, such as drowsiness and confusion.The aim of surgical treatment is to provide the appropriate volume and concentration of the drug in the subarachnoid space, avoiding the main surgical complications, that is, infections, skin erosion, and catheter displacement.The video can be found here: https://youtu.be/HetelPwwwak
Collapse
|
12
|
Stepien KM, Gevorkyan AK, Hendriksz CJ, Lobzhanidze TV, Pérez-López J, Tol G, Del Toro Riera M, Vashakmadze ND, Lampe C. Critical clinical situations in adult patients with Mucopolysaccharidoses (MPS). Orphanet J Rare Dis 2020; 15:114. [PMID: 32410642 PMCID: PMC7227065 DOI: 10.1186/s13023-020-01382-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/13/2020] [Indexed: 01/16/2023] Open
Abstract
Background Mucopolysaccharidoses (MPS) are rare, inherited disorders associated with enzyme deficiencies that result in glycosaminoglycan (GAG) accumulation in multiple organ systems. Management of MPS is evolving as patients increasingly survive to adulthood and undergo multiple surgeries throughout their lives. As surgeries in these patients are considered to be high risk, this can result in a range of critical clinical situations in adult patients. Results We discuss strategies to prepare for and manage critical clinical situations in adult patients with MPS, including supporting the multidisciplinary team, preoperative and airway assessments, surgical preparations, and postoperative care. We also present eight critical clinical cases (age range: 21–38 years) from four leading inherited metabolic disease centres in Europe to highlight challenges and practical solutions to optimise the care of adult patients with MPS. Critical clinical situations included surgical procedures, pregnancy and a thrombus in a port-a-cath. Conclusions Individualised strategies to manage critical clinical situations need to be developed for each patient to compensate for the heterogeneous symptoms that may be present and the potential complications that may occur. These strategies should include input from the wider MDT, and be coordinated by metabolic specialists with expertise in the management of MPS disorders and surgery in adult patients with MPS.
Collapse
Affiliation(s)
- Karolina M Stepien
- The Mark Holland Metabolic Unit, Adult Inherited Metabolic Diseases, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
| | | | | | | | | | - Govind Tol
- Anaesthetics Department, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | | | | | - Christina Lampe
- HELIOS Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
| |
Collapse
|
13
|
Steensland I, Koskinen LD, Lindvall P. Treatment of restless legs syndrome with a pump; efficacy and complications. Acta Neurol Scand 2020; 141:368-373. [PMID: 31883387 DOI: 10.1111/ane.13213] [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: 10/13/2019] [Revised: 12/15/2019] [Accepted: 12/26/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Restless legs syndrome (RLS) has a prevalence of 2.5%-15% in the general population. For those who suffer from a medically refractory RLS, intrathecal morphine treatment has been shown to be effective. The aim of this retrospective study was to investigate efficacy, complications and side effects in patients treated over several years with an implantable pump. A comparison was done to a group of patients treated with a similar pump system due to spasticity. MATERIALS AND METHODS The charts of ten patients with severe or very severe RLS have been reviewed. These patients have received an intrathecal drug delivery system during 2000-2016. To compare the rate of complications, a control group of 20 patients treated with intrathecal baclofen due to spasticity was included in the study. Their time of treatment corresponded to the RLS patients. RESULTS The severity of symptoms related to RLS decreased significantly after treatment. Doses required ranged from 68 to 140 µg/d. Two cases of side effects were detected; one case with nausea and dizziness and one case with headache and fatigue. The rate of mechanical, infectious and other complications was similar between the two groups. CONCLUSIONS In light of the decrease in symptom severity and the low rate of side effects, intrathecal morphine can be considered an adequate treatment for those suffering from medically refractory RLS. The occurrence of complications did not differ between subjects with RLS and spasticity.
Collapse
Affiliation(s)
- Ingrid Steensland
- Department of Clinical Science, Neurosciences Umeå University Umeå Sweden
| | | | - Peter Lindvall
- Department of Clinical Science, Neurosciences Umeå University Umeå Sweden
| |
Collapse
|
14
|
Hagemann C, Schmitt I, Lischetzki G, Kunkel P. Intrathecal baclofen therapy for treatment of spasticity in infants and small children under 6 years of age. Childs Nerv Syst 2020; 36:767-773. [PMID: 31399764 DOI: 10.1007/s00381-019-04341-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/05/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study is to prove the efficacy and safety of intrathecal baclofen therapy in infants and children below 6 years of age by retrospective analysis of our pediatric cohort of 135 primary pump implantations. METHODS Between 2007 and 2018, 17 patients with pump implantations were below 6 years of age. Data were acquired retrospectively with a follow-up of 12 months to 11 years regarding complications. RESULTS The youngest infant was 11 months at implantation with a bodyweight of 6, 4 kg, and 63 cm length. Surgical complications were comparable to published literature and mainly involved the catheter (2 catheter dislocations and 1 catheter transection) and one pump infection resulting in 4 revision surgeries in 3 patients. One baclofen-related apnea during titration and an overdose after refill were treated conservatively. Using a subfascial implantation technique, we observed neither skin ulceration nor pump infection since 2007. In a growing child, catheter slides are common and related to growth, scoliosis, spine surgery, and surgical failure. CONCLUSION Intrathecal baclofen therapy in infants and small children is as safe and effective as published for older pediatric patients; therefore, intrathecal baclofen can be considered in all infants as long as an 8-cm incision fits into the triangle of the anterior superior iliac spine, costal margin of the 10th rib, and navel. We suggest the utilization of subfascial surgical technique for implantation pump and catheter. Titration of intrathecal baclofen should be performed slowly to avoid bradycardia in infants. This is a retrospective study (level of evidence 4).
Collapse
Affiliation(s)
- Christian Hagemann
- Department of Pediatric Neurosurgery, Altona Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany.
| | - Ilka Schmitt
- Department of Pediatric Neurosurgery, Altona Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany
| | - Grischa Lischetzki
- Department of Pediatric Neurology, Altona Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany
| | - Philip Kunkel
- Department of Pediatric Neurosurgery, Altona Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany
| |
Collapse
|
15
|
Abstract
BACKGROUND Baclofen pumps provide treatment of symptoms of spasticity for disease processes such as cerebral palsy and traumatic brain injury. These devices provide continuous infusion or periodic dosing of intrathecal baclofen (ITB). Traditionally, these pumps have been placed subcutaneously. Subcutaneous device placement has been associated with infection and extrusion. Baclofen pumps are large and range from 8 to 10 cm in diameter and 4 to 8 cm in width. Patients requiring device placement typically have a paucity of subcutaneous tissue. Cachexia coupled with the size and bulk of these devices leads to increased protusion and friction. Submuscular placement provides a well-vascularized pocket that directs the device inward eliminating protrusion and decreasing the potential for soft tissue breakdown. METHODS A retrospective chart review of ITB pump placement in a submuscular plane by a single plastic surgeon at a major academic center in conjunction with a neurosurgeon was performed. Inclusion criteria were cases of primary placement or replacement of ITB pumps and spasticity requiring ITB. Major complications included infection, extrusion, and reoperation. RESULTS Five patients during a 5-month period were treated with submuscular placement of ITB pumps. Average age of patients included was 18.4 years. Average preoperative body mass index was 18.8 kg/m, with values ranging from 15.8 to 20.1 kg/m. Medical histories of patients included diagnoses of cerebral palsy and traumatic brain injury causing spasticity. The most frequently cited reason for plastic surgical consultation preoperatively was cachexia. Two patients had previous baclofen pumps placed subcutaneously. Average follow-up was 6 months and ranged from 3 to 13 months. There were no major complications. One patient had a small seroma that spontaneously resolved. No patient had wound healing problems, and there were no extrusions of implanted devices or reoperations. CONCLUSION Submuscular placement of baclofen pumps provides a well-vascularized and stable environment for device placement that minimizes the dangers of pump extrusion and infection. Patients who require treatment with ITB commonly have severe cachexia, which makes subcutaneous device placement high risk. Submuscular placement should be performed in all patients with body mass index less than 20 kg/m.
Collapse
|
16
|
Imerci A, Rogers K, Dixit D, McManus M, Miller F, Sees JP. The effectiveness of epidural blood patch in patients with cerebral palsy treated with intrathecal baclofen implantation. Paediatr Anaesth 2020; 30:153-160. [PMID: 31837185 DOI: 10.1111/pan.13791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/27/2019] [Accepted: 12/10/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cerebrospinal fluid leak and postdural puncture spinal headache following intrathecal baclofen therapy are known complications. Although primary treatments are conservative, epidural blood patch is an alternative in patients with persistent and severe symptoms. AIM The purpose of this article is to review the effectiveness of epidural blood patch for the treatment of spinal headache and cerebrospinal fluid leak associated with intrathecal baclofen treatment in children with cerebral palsy. METHODS Our database was reviewed for epidural blood patch in 341 pediatric patients with cerebral palsy who underwent primary intrathecal baclofen treatment from 2004 to 2018 at one institution. The number of patches, time frame of treatment, and effectiveness of the epidural blood patch were collected. All patients treated with epidural blood patch were evaluated for primary and secondary intrathecal baclofen-related procedures, and subsequent treatment of intrathecal baclofen associated with cerebrospinal fluid leak and spinal headache. RESULTS Twenty-nine epidural blood patch procedures were performed on 26 patients who had received intrathecal baclofen procedures. Of these 26 patients, four had a secondary epidural blood patch. The incidence of spinal headache/cerebrospinal fluid leak was 31% (107/341), and 81/107 (76%) patients with spinal headache/cerebrospinal fluid leak responded to conservative treatments. Success rate for initial epidural blood patch was 79.3% (23/29). The second epidural blood patch was performed in four patients after failure of initial epidural blood patch. Second epidural blood patch success rate was 75% (3/4). CONCLUSION Spinal headache and cerebrospinal fluid leak are known complications after intrathecal baclofen treatment in children with cerebral palsy. When conservative treatments are unsuccessful, epidural blood patch can be used with confidence for these patients. In patients with ongoing symptoms, it is possible to obtain success by repeating the epidural blood patch to continue intrathecal baclofen treatment and avoid aggressive surgery.
Collapse
Affiliation(s)
- Ahmet Imerci
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Kenneth Rogers
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Divya Dixit
- Department of Anesthesiology and Perioperative Medicine, Nemours/Alfred I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, DE, USA
| | - Maura McManus
- Division of Rehabilitation, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Freeman Miller
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Julieanne P Sees
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| |
Collapse
|
17
|
Zhu X, Kohan LR, Goldstein RB. Low-Dose Intrathecal Ziconotide for Spasticity From Primary Lateral Sclerosis: A Case Report. A A Pract 2019; 13:31-33. [DOI: 10.1213/xaa.0000000000000978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
18
|
Ryan S, Dudley N, Green M, Pruitt C, Jackman G. Altered Mental Status at High Altitude. Pediatrics 2018; 142:peds.2017-3973. [PMID: 29976571 DOI: 10.1542/peds.2017-3973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 11/24/2022] Open
Abstract
Intrathecal baclofen pumps are commonly used in pediatric patients with spastic cerebral palsy. Baclofen binds to γ-aminobutyric acid receptors to inhibit both monosynaptic and polysynaptic reflexes at the spinal cord level. The blockade stops the release of excitatory transmitters and thereby decreases muscle contraction. It is commonly used for lower limb spasticity and has been shown to improve postural ability and functional status. The US Food and Drug Administration has approved baclofen for the treatment of spasticity of cerebral or spinal origin in adult and pediatric patients 4 years or older. Various complications of baclofen pumps are described in the literature. Immediately after surgery, problems from infection can arise and range from superficial skin infections to meningitis and bacteremia. Another early complication includes cerebrospinal fluid leak that can be observed by notable swelling beneath the lumbar incision. Additional problems that arise later are usually from the mechanics of the pump and catheter. Pump-related complications include failure, migration, and flipping. Catheter-related complications include disconnection, occlusion, fracture, or kink. Most of these complications typically lead to baclofen withdrawal, although there are a few case reports of overdose due to mechanical causes. Here we describe 2 cases of individuals experiencing complications of excessive baclofen exposure after significant changes in the atmospheric pressure due to travel involving ambient altitude change. These cases reflect the need to discuss this potential complication with families and patients with baclofen pumps before travel to high elevations.
Collapse
Affiliation(s)
- Sydney Ryan
- Division of Pediatric Emergency Medicine, .,Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah; and
| | - Nanette Dudley
- Division of Pediatric Emergency Medicine.,Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah; and
| | - Michael Green
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah; and
| | - Charles Pruitt
- Division of Pediatric Emergency Medicine.,Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah; and
| | - Geoffrey Jackman
- Department of Pediatric Emergency Medicine, Rady Children's Hospital, San Diego, California
| |
Collapse
|
19
|
Kupfer M, Kucer BT, Kupfer H, Formal CS. Persons With Chronic Spinal Cord Injuries in the Emergency Department: a Review of a Unique Population. J Emerg Med 2018; 55:206-212. [PMID: 29807681 DOI: 10.1016/j.jemermed.2018.04.029] [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: 10/03/2017] [Revised: 02/04/2018] [Accepted: 04/12/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Persons with spinal cord injuries (SCIs) are frequent utilizers of emergency medical services but are a poorly understood and medically complex population. As the treatment of acute spinal cord injuries improves, there is a growing population of patients suffering from the chronic neurological deficits and altered homeostasis resulting from those injuries. OBJECTIVES We sought to highlight the unique diagnostic challenges of treating persons with SCIs and to review ailments uncommon in the general population but often encountered in this population. DISCUSSION Spinal cord anatomy is briefly reviewed and commonly used nomenclature and grading scales are defined. An organ by organ review is offered detailing unique clinical issues that pertain to those systems. Practice pearls and pitfall are elucidated when relevant. Psychiatric complications of this disease entity are also discussed. CONCLUSION A SCI is a devastating but increasingly survivable event. The long-term care of persons with SCIs is challenging because of the unique pathologies encountered in this population and the disruption of normal and expected physiological responses to common ailments. This review will facilitate a better understanding of the emergency care needs of this unique patient population.
Collapse
Affiliation(s)
- Mendel Kupfer
- Department of Rehabilitation Medicine, Magee Rehabilitation Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania; Spinal Cord Injury Medical Home at Magee Rehabilitation Hospital, Philadelphia, Pennsylvania
| | - Brian T Kucer
- Department of Rehabilitation Medicine, Magee Rehabilitation Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania; Brain Injury Program, Magee Rehabilitation Hospital, Philadelphia, Pennsylvania
| | - Herschel Kupfer
- Department of Emergency Medicine, Lower Bucks Hospital, Bristol, Pennsylvania
| | - Christopher S Formal
- Department of Rehabilitation Medicine, Magee Rehabilitation Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| |
Collapse
|
20
|
Obst B, Roesler M. Hidden Medical Devices in the School Setting: What the School Nurse Needs to Know About the Safe Use of Baclofen Pumps. NASN Sch Nurse 2018; 33:78-83. [PMID: 29351050 DOI: 10.1177/1942602x17750452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
One of the "hidden" medical devices in the school setting is the baclofen pump, which is used for the treatment of spasticity. The goals of spasticity treatment are to decrease muscle tone, deformity, and pain in order to maximize function and ease of care for both child and caregiver. The use of an intrathecal baclofen pump, often for children with cerebral palsy, spinal cord injury, brain injury, or stroke, has been effective in spasticity treatment. It is important for school nurses to be aware of the safety implications associated with this type of device. The Specialized Health Needs Interagency Collaboration (SHNIC) program at the Kennedy Krieger Institute has complied education and materials that explain the use of baclofen pumps in children with spasticity and the role of the school nurse in providing staff training, developing emergency care plans, and creating a safe school environment for children with special health needs.
Collapse
Affiliation(s)
- Barbara Obst
- Co- Coordinator of SHNIC, Kennedy Krieger Institute, Baltimore, MD
| | - Megan Roesler
- SHNIC Nurse, Kennedy Krieger Institute, Baltimore, MD
| |
Collapse
|