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Deer TR, Hayek SM, Grider JS, Hagedorn JM, McDowell GC, Kim P, Dupoiron D, Goel V, Duarte R, Pilitsis JG, Leong MS, De Andrés J, Perruchoud C, Sukumaran H, Abd-Elsayed A, Saulino M, Patin D, Poree LR, Strand N, Gritsenko K, Osborn JA, Dones I, Bux A, Shah JM, Lindsey BL, Shaw E, Yaksh TL, Levy RM. The Polyanalgesic Consensus Conference (PACC)®: Intrathecal Drug Delivery Guidance on Safety and Therapy Optimization When Treating Chronic Noncancer Pain. Neuromodulation 2024; 27:1107-1139. [PMID: 38752946 DOI: 10.1016/j.neurom.2024.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 10/07/2024]
Abstract
INTRODUCTION The International Neuromodulation Society convened a multispecialty group of physicians and scientists based on expertise with international representation to establish evidence-based guidance on intrathecal drug delivery in treating chronic pain. This Polyanalgesic Consensus Conference (PACC)® project, created more than two decades ago, intends to provide evidence-based guidance for important safety and efficacy issues surrounding intrathecal drug delivery and its impact on the practice of neuromodulation. MATERIALS AND METHODS Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when PACC® last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence is scant. RESULTS The PACC® examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS The PACC® recommends best practices regarding intrathecal drug delivery to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA.
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Philip Kim
- Christiana Hospital, Newark, DE, USA; Bryn Mawr Hospital, Bryn Mawr, PA, USA
| | - Denis Dupoiron
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de L'Ouest, Angers, France
| | - Vasudha Goel
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Rui Duarte
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Julie G Pilitsis
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | | | - Jose De Andrés
- Anesthesia, Critical Care, and Multidisciplinary Pain Management Department, General University Hospital, València, Spain; Anesthesia Unit, Surgical Specialties Department, Valencia University Medical School, València, Spain
| | | | - Harry Sukumaran
- Department of Anesthesiology, Detroit Medical Center/Wayne State University, Detroit, MI, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Michael Saulino
- Department of Physical Medicine and Rehabilitation, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Dennis Patin
- University of Miami Health System, Miami, FL, USA
| | - Lawrence R Poree
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Karina Gritsenko
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, USA
| | - Jill A Osborn
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Ivano Dones
- Department of Neurosurgery, Istituto Nazionale Neurologico "C Besta" of Milan, Milan, Italy
| | - Anjum Bux
- Anesthesia and Chronic Pain Management, Ephraim McDowell Regional Medical Center, Danville, KY, USA
| | - Jay M Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Brad L Lindsey
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| | - Erik Shaw
- Shepherd Pain and Spine Institute, Atlanta, GA, USA
| | - Tony L Yaksh
- Anesthesiology and Pharmacology, University of California, San Diego, CA, USA
| | - Robert M Levy
- Neurosurgical Services, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Chan J, Singh H, Shem K. The presence of Candida parapsilosis with intrathecal baclofen pump in a person with high cervical spinal cord injury; infection or colonization? A Case Report. Spinal Cord Ser Cases 2023; 9:55. [PMID: 38036498 PMCID: PMC10689785 DOI: 10.1038/s41394-023-00610-5] [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: 12/20/2022] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
INTRODUCTION Intrathecal baclofen (ITB) therapy is an effective method of treating spasticity in persons with spasticity due to spinal cord injury (SCI), but complications are not rare and can include spinal fluid leaks, infection, and catheter/pump malfunction. CASE PRESENTATION This study presents information related to an adult male patient with traumatic SCI and a history of two prior ITB pump pocket infections that required removal due to pump infection. The patient then developed skin erosion over the third pump, and the fluid around the pump grew methicillin-sensitive Staphylococcus aureus, diphtheroids, and Candida parapsilosis. The patient was initially treated with antibiotics and anti-fungal medication without removal of the ITB pump. The ITB pump was eventually removed 27 months later, and the fourth pump was implanted 10 months later. DISCUSSION ITB pumps can be an effective treatment modality for spasticity in people with SCI; however, complications, including infection, can occur and require pump removal. This case illustrates a case of possible Candida colonization of the ITB pump, which was eventually removed.
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Affiliation(s)
- John Chan
- Division of Physical Medicine and Rehabilitation, Stanford University, Stanford, CA, USA.
| | - Harminder Singh
- Division of Neurosurgery, Santa Clara Valley Medical Center, San Jose, CA, USA
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Kazuko Shem
- Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA, USA
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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.
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