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Assumpcao de Monaco B, Fruett da Costa PR, Franceschini PR. Intracerebroventricular baclofen therapy improves function and quality of life in a child with severe cerebral palsy. Childs Nerv Syst 2023; 39:3639-3642. [PMID: 37515719 DOI: 10.1007/s00381-023-06084-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/15/2023] [Indexed: 07/31/2023]
Abstract
Limited therapies are available for severe cerebral palsy children (CP) with complex movement disorders, especially when both dystonia and spasticity are present. In this publication, we present the improvement of a child with severe CP after intracerebroventricular baclofen therapy. The treatment can impact not just the movement disorders but also on the quality of life of the child and caregivers. Global functional improvements can be observed on the 6-month follow-up.
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Affiliation(s)
- Bernardo Assumpcao de Monaco
- Department of Neurosurgery, Clinica de Dor E Funcional (CDF), Sao Paulo, SP, Brazil.
- Division of Neurosurgery, Clinics Hospital, University of Sao Paulo, Sao Paulo, SP, Brazil.
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Hurth H, Morgalla M, Heinzel J, Daigeler A, Kolbenschlag J, Schuhmann M. [Surgical procedures for treatment of spasticity]. Nervenarzt 2023; 94:1116-1122. [PMID: 37955654 DOI: 10.1007/s00115-023-01568-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND The causes of spasticity are various and include cerebral palsy, spinal cord injury, stroke, multiple sclerosis or other congenital or acquired lesions of the central nervous system (CNS). While there is often a partial functional component, spasticity also results in varying degrees of impairment of the quality of life. OBJECTIVE A review of surgical treatment options for spasticity. MATERIAL AND METHODS A systematic PubMed review of the literature on epidemiology and treatment options with a focus on neurosurgical interventions for spasticity and developments in the last 20 years as well as inclusion of still valid older landmark papers was carried out. Illustration of indications, technique, follow-up, and possible pitfalls of the different methods for the surgical treatment of spasticity. RESULTS Depending on the affected region, the number of muscle groups, and the extent of spasticity, focal (selective peripheral neurotomy, nerve transfer), regional (selective dorsal rhizotomy), or generalized (baclofen pump) procedures can be performed. The indications are usually established by an interdisciplinary team. Conservative (physiotherapy, oral medications) and focally invasive (botulinum toxin injections) methods should be performed in advance. In cases of insufficient response to treatment or only short-term relief, surgical methods can be evaluated. These are usually preceded by test phases with, for example, trial injections. CONCLUSION Surgical methods are a useful adjunct in cases of insufficient response to conservative treatment in children and adults with spasticity.
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Affiliation(s)
- Helene Hurth
- Universitätsklinik für Neurochirurgie, Department für Neurochirurgie und Neurotechnologie, Eberhard Karls Universität Tübingen, Tübingen, Deutschland.
| | - Matthias Morgalla
- Universitätsklinik für Neurochirurgie, Department für Neurochirurgie und Neurotechnologie, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - Johannes Heinzel
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Unfallklinik Tübingen, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - Adrien Daigeler
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Unfallklinik Tübingen, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - Jonas Kolbenschlag
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Unfallklinik Tübingen, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - Martin Schuhmann
- Universitätsklinik für Neurochirurgie, Department für Neurochirurgie und Neurotechnologie, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Gianaris T, Holland RM, Villelli NW, Lee AE. Prepontine placement of an intrathecal baclofen pump catheter for treatment of dystonia. Surg Neurol Int 2021; 12:477. [PMID: 34754527 PMCID: PMC8571247 DOI: 10.25259/sni_146_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 12/13/2019] [Indexed: 11/24/2022] Open
Abstract
Background: Cerebral palsy with medically refractory spasticity and dystonia is a condition that often benefits from intrathecal baclofen pump therapy to treat these symptoms. In this case report, an intracranial baclofen catheter was placed in the prepontine space to improve withdrawal symptoms in a patient unable to undergo new lumbar catheter placement due to infection. Case Description: A 22-year-old female with past medical history of cerebral palsy presented with baclofen pump failure and was unable to undergo placement of a new lumbar baclofen catheter due to an infection in her lower back precluding safe and efficacious catheter placement. It was decided the patient would benefit from intrathecal baclofen administered in the prepontine space as a means to avoid a lumbar catheter and thus bypass this prior infection site. An endoscopic third ventriculostomy (ETV) was performed with the endoscope and the distal end of the baclofen pump catheter was fed through this ETV into the prepontine space. Placement in the prepontine space was confirmed by a follow-up head computed tomography. There was a significant improvement in autonomic symptoms and spasticity. By postoperative day 5, the patient was surgically and medically cleared for discharge. Conclusion: In cases of severe baclofen withdrawal due to dysfunctional pumps, immediate reversal is preferred but may not be feasible due to factors such as infection. This case report has demonstrated that prepontine catheter placement can be effective for the administration of baclofen to reverse withdrawal symptoms in these types of patients.
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Affiliation(s)
- Thomas Gianaris
- Department of Neurological Surgery, Indiana University, IN United States
| | - Ryan M Holland
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN United States
| | - Nicolas W Villelli
- Department of Neurological Surgery, Indiana University, IN United States
| | - Albert E Lee
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Carmel, IN United States
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Saenz A, Grijalba M, Mengide JP, Argañaraz R, Ford F, Mantese B. Baclofen pump with pre-brainstem catheter tip placement: technical note and case series. Childs Nerv Syst 2021; 37:203-210. [PMID: 32504173 DOI: 10.1007/s00381-020-04679-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/13/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aims to describe a new baclofen pump implantation technique with pre-brainstem catheter placement and to demonstrate the benefits that this procedure has in treating spasticity and dystonia. METHODS We described a new technique to place a baclofen pump catheter anterior to the brainstem. To illustrate the technique, we presented five patients with both spasticity and dystonia in whom conventional treatment was not effective. They each received a baclofen pump with a pre-brainstem catheter. We evaluated the results using the Ashworth scale for spasticity, the Barry-Albright scale for dystonia, and the PedsQL for quality of life assessment. Each patient was evaluated before a surgery and after 6 months of follow-up. RESULTS There were statistically significant differences in all the physical examination evaluated areas using the Barry-Albright and modified Ashworth scales between the preoperative and the postoperative period. The same applies to the results of the PedsQL quality of life scale. CONCLUSION We presented an innovative baclofen pump implantation technique with pre-brainstem catheter placement that could be a therapeutic alternative in patients with dystonia and spastic quadriparesis for whom conventional therapy is not effective.
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Affiliation(s)
- Amparo Saenz
- Division of Pediatric Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Combate de los Pozos 1881, 1245, Buenos Aires, ZC, Argentina.
| | - Miguel Grijalba
- Division of Pediatric Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Combate de los Pozos 1881, 1245, Buenos Aires, ZC, Argentina
| | - Juan Pablo Mengide
- Division of Pediatric Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Combate de los Pozos 1881, 1245, Buenos Aires, ZC, Argentina
| | - Romina Argañaraz
- Division of Pediatric Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Combate de los Pozos 1881, 1245, Buenos Aires, ZC, Argentina
| | - Fernando Ford
- Division of Kinesiology, Hospital de Pediatría Juan P. Garrahan, Buenos Aires, Argentina
| | - Beatriz Mantese
- Division of Pediatric Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Combate de los Pozos 1881, 1245, Buenos Aires, ZC, Argentina
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Dallas J, Naftel RP, Shannon CN. Pediatric Intrathecal Baclofen Pumps: A Descriptive Analysis of Hospital Course and Associated Costs. Pediatr Neurosurg 2021; 56:334-344. [PMID: 33965955 DOI: 10.1159/000515988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The purpose of this study was to identify predictors of increased cost and postoperative length-of-stay (LOS) following intrathecal baclofen pump (ITBP) placement. METHODS Patients were derived from the 2009/2012 kids' inpatient database. Inclusion criteria were selected for patients with ICD-9 codes 343.X (infantile cerebral palsy), 86.06 (infusion pump insertion), 03.90 (spinal catheter insertion), and elective hospitalizations. Nonparametric univariate analysis and subsequent gamma log-link general linear modeling were used to identify significant predictors of cost/LOS (p < 0.05). RESULTS 529 unweighted patients (787 with survey weights applied) met criteria. Median LOS was 3.00 days, and median cost was USD 23,284. Following multivariate modeling, predictors of increased LOS (in days) included increased hospital ITBP volume (p = 0.027), small hospital size (+0.55, p = 0.004), device complications (+0.95, p < 0.001), procedural complications (+1.40, p < 0.001), additional procedures (+0.86, p < 0.001), electrolyte abnormalities (+3.74, p < 0.001), and neurological comorbidities (+1.60, p < 0.001). Factors associated with decreased LOS were paralysis (-0.53, p < 0.001), Northeastern hospital region (-0.55, p = 0.018), and investor-owned hospital status (-0.75, p = 0.001). Similarly, predictors of increased cost included race of Hispanic (+USD 1,156, p = 0.033) or "other" (+USD 2,158, p = 0.001), Northeast hospital region (+USD 4,120, p < 0.001), small (+USD 4,139, p < 0.001) or medium (+USD 3,368, p < 0.001) hospital sizes, additional procedures (+USD 1,649, p < 0.001), neurological comorbidities (+USD 3,222, p = 0.003), and increased LOS (p < 0.001). Factors associated with decreased cost included Western hospital region (-USD 1,594, p = 0.001), government hospitals (-USD 1,391, p = 0.019), and investor-owned hospitals (-USD 2,057, p = 0.021). CONCLUSION This study found multiple variables associated with increased cost/LOS following ITBP placement. Broadly, this analysis demonstrates national trends associated with increased cost following ITBP placement.
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Affiliation(s)
- Jonathan Dallas
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Robert P Naftel
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA.,Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA.,Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Zubair AS, Raymond M, Patwa HS. Utility of intrathecal baclofen pump in primary lateral sclerosis. J Neurol Sci 2021; 420:117227. [PMID: 33239209 DOI: 10.1016/j.jns.2020.117227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 11/23/2022]
Abstract
Primary lateral sclerosis is a disorder categorized by insidious onset of progressive upper motor neuron dysfunction without lower motor neuron involvement. PLS often presents with gradual-onset, progressive lower extremity stiffness and pain due to muscle spasticity. Intrathecal Baclofen pumps (ITB) have been used to effectively treat spasticity in several neurologic conditions including MS and spinal cord injury. This study aimed at reviewing a cohort of PLS patients with spasticity requiring ITB to assess the clinical course, benefits, and complications in these patients. A series of 5 patients were identified who were diagnosed with PLS and received ITB as treatment for spasticity. The average age of the patients at the time of ITB insertion was 56.4 years. The average length of treatment was 10.4 years with a range of 4-15 years. All patients reported improvement in spasticity as measured by clinical examinations and Ashworth scores; 1/5 had complications with the pump related to migration of catheter. No patients required permanent removal of the ITB. ITB is a safe and effective treatment for spasticity in PLS and should be considered in other patients.
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Lins LAB, Nechyporenko AV, Halanski MA, Hetzel SJ, Noonan KJ. Does an intrathecal baclofen pump impact scoliosis progression and complicate posterior spine fusion in patients with cerebral palsy? Spine Deform 2020; 8:115-121. [PMID: 31981152 DOI: 10.1007/s43390-020-00034-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 07/11/2019] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVES In patients with cerebral palsy (CP), we determine the impact of intrathecal baclofen pumps (ITBPs) on scoliosis curve progression before posterior spine fusion (PSF) and its effects on surgical outcome. BACKGROUND Children with CP can have rapid scoliosis progression, and high rates of surgical complications can be encountered. It is unknown whether the presence of pre-existing ITBP results in more difficult surgery and higher complication rates in similarly affected children. METHODS This is a single-center retrospective study of CP patients undergoing PSF over a 15-year period. Demographics, comorbidities, curve magnitudes, and surgical methods were compared between patients with ITBP and those without. Postoperative complications, length of intensive care unit/hospital stay, drain use and output volume, and need for further surgery were also compared. Curve progression analysis after ITBP placement was performed on a subgroup of patients with high-quality consistent radiographs. RESULTS Nineteen patients with ITBP and 49 patients without ITBP met inclusion criteria. Age, comorbidities, number of levels fused, and fixation techniques during PSF were not significantly different between cohorts. ITBP patients were more likely to have PSF with osteotomy (p = 0.022). Increased intraoperative neurosurgical consultations were found for patients with ITBP (42.1% vs. 4.0%; p < 0.001). Median surgical time was 1.2 h greater in patients with ITBP (6.7 vs. 5.5 h, p = 0.039). There was no difference in hospital course and complications in patients with ITBP and those without ITBP. Thirty-one patients without ITB were compared with 15 ITBP patients for curve progression before PSF, demonstrating a mean rate of scoliosis progression of 9.6° ± 6.7°/year and 14.8° ± 9.1°/year (p = 0.0346), respectively. CONCLUSION The presence of an ITBP appears to be associated with the increase in scoliosis progression; and these patients will likely have a more challenging spine fusion. Fortunately, the final outcome is not affected by ITBP. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Laura A B Lins
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, 750 Highland Ave, Madison, WI, 53726, USA.
| | - Anatoliy V Nechyporenko
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, 750 Highland Ave, Madison, WI, 53726, USA
| | - Matthew A Halanski
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, 750 Highland Ave, Madison, WI, 53726, USA
| | - Scott J Hetzel
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, 750 Highland Ave, Madison, WI, 53726, USA
| | - Kenneth J Noonan
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, 750 Highland Ave, Madison, WI, 53726, USA
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Fiaschi P, Cama A, Piatelli G, Moretti P, Pavanello M. A Novel Skin and Fascia Opening for Subfascial Inserting of Intrathecal Baclofen Pump. World Neurosurg 2017; 110:244-248. [PMID: 29174241 DOI: 10.1016/j.wneu.2017.11.086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/12/2017] [Accepted: 11/15/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this article is to introduce a new skin and fascia opening for intrathecal baclofen pump implantation in the abdomen, with the purpose of reducing complications related to wound breakdown. METHODS We introduce a novel way of cutaneous and fascial opening that leads two opposed "L shaped" incisions. RESULTS This method entails numerous advantages. The first advantage is avoiding the direct alignment of overlapped sutures, which creates a locus minoris resistentiae that can weaken and break under the push of the pump. Another advantage consists of an increased obstruction against deep extension of infective processes from cutaneous origin. The wide opening of the subfascial pocket permits the implantation of any type of pump available, and it reduces complexities in reopening the pouch for pump replacement. It also permits the fastening of all anchoring systems usually present in pumps. Another advantage is the improved possibility of careful muscle cauterization thanks to the wide fascia opening, with reduced risk of postsurgical hematoma. Our results showed a reduction of wound complications with this method. CONCLUSIONS This method could contribute to reducing the rate of wound complications and patient discomfort.
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Affiliation(s)
- Pietro Fiaschi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa, Genova, Italy.
| | - Armando Cama
- Department of Neurosurgery, Istituto Giannina Gaslini, Genova, Italy
| | - Gianluca Piatelli
- Department of Neurosurgery, Istituto Giannina Gaslini, Genova, Italy
| | - Paolo Moretti
- Physical Medicine and Rehabilitation Unit, Istituto Giannina Gaslini, Genova, Italy
| | - Marco Pavanello
- Department of Neurosurgery, Istituto Giannina Gaslini, Genova, Italy
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Ghobrial GM, Thakkar V, Singhal S, Oppenlander ME, Maulucci CM, Harrop JS, Jallo J, Prasad S, Saulino M, Sharan AD. Efficacy of intraoperative vancomycin powder use in intrathecal baclofen pump implantation procedures: single institutional series in a high risk population. J Clin Neurosci 2014; 21:1786-9. [PMID: 24938386 DOI: 10.1016/j.jocn.2014.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 04/05/2014] [Indexed: 10/25/2022]
Abstract
We aimed to assess the efficacy of intraoperative vancomycin powder in intrathecal baclofen pump placement patients, a high risk population. A retrospective review was conducted using prospectively collected data at an academic tertiary care unit. The neurosurgical adult patient population was queried for all intrathecal baclofen pump implantation procedures. Patients were then reviewed for the use of intraoperative crystalline vancomycin powder. Those with a history of prior surgical site infection, chronic systemic infections or osteomyelitis were excluded. Anhydrous, crystalline vancomycin was utilized in the wound bed after completion of implantation, distributed evenly in the case of multiple incisions. Patients received 500 mg or 1,000 mg of crystallized vancomycin, evenly distributed through the wound layers based on a 70 kg weight cutoff. Intraoperative institutional standards of infection prophylaxis were unchanged throughout the study period. Infection rate of baclofen pump placement prior to the use of vancomycin powder from 2001-2009 at the same institution was monitored. Wound infection rate was tracked for a 12 month postoperative period. Six patients out of 26 baclofen pump implantations (23%) in this cohort were identified to have seven infections despite vancomycin powder placement in the lumbar and catheter wounds. Prior infection rates have been investigated for intrathecal drug delivery systems from 2001 to 2009 at the same institution with an overall infection rate of 3% (8/274). The use of vancomycin powder in patients with implants in this series did not reduce infection rates compared to published historical controls, and was elevated compared to institutional controls. Further prospective study of this high risk patient population is warranted.
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Affiliation(s)
- George M Ghobrial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, 3rd floor, Philadelphia, PA 19107, USA
| | - Vismay Thakkar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, 3rd floor, Philadelphia, PA 19107, USA
| | - Saurabh Singhal
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, 3rd floor, Philadelphia, PA 19107, USA
| | - Mark E Oppenlander
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, 3rd floor, Philadelphia, PA 19107, USA; Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Christopher M Maulucci
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, 3rd floor, Philadelphia, PA 19107, USA
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, 3rd floor, Philadelphia, PA 19107, USA
| | - Jack Jallo
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, 3rd floor, Philadelphia, PA 19107, USA
| | - Srinivas Prasad
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, 3rd floor, Philadelphia, PA 19107, USA
| | - Michael Saulino
- Department of Rehabilitation Medicine, Jefferson Medical College, Moss Rehab, Elkins Park, PA, USA
| | - Ashwini D Sharan
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, 3rd floor, Philadelphia, PA 19107, USA.
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Abstract
There are 3 surgical procedures that patients with cerebral palsy (CP) undergo that may be considered major procedures: femoral osteotomies combined with pelvic osteotomies, spine fusion, and intrathecal baclofen pump implant for the treatment of spasticity. Many complications are known to occur at a higher rate in this population, and some may be avoided with prior awareness of the preoperative pathophysiology of the patient with CP.
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Affiliation(s)
- Mary C Theroux
- Department of Anesthesiology and Critical Care Medicine, Nemours/Alfred I. duPont Hospital for Children, Post Office Box 269, Wilmington, DE 19899, USA; Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, 111 S 11th Street, PA 19107, USA.
| | - Sabina DiCindio
- Department of Anesthesiology and Critical Care Medicine, Nemours/Alfred I. duPont Hospital for Children, Post Office Box 269, Wilmington, DE 19899, USA; Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, 111 S 11th Street, PA 19107, USA
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