intrathecal baclofen troubleshooting and management michael saulino, md phd mossrehab assistant...
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Intrathecal baclofen Troubleshooting and Management
Michael Saulino, MD PhDMossRehab
Assistant Professor Thomas Jefferson University
Adjuvant Assistant ProfessorTemple University
CME Disclosures 1
• Speaker’s bureau for Jazz Pharmaceuticals
• Speaker’s bureau and clinical investigator for Medtronic, Inc
• Speaker’s bureau for Ipsen
• Consultant for SPR therapeutics and Myoscience
CME Disclosures 2
• Will discuss off label and investigational indications for medications and devices
• All activities are reviewed by Albert Einstein Healthcare Network’s conflict of interest committee
• Honoraria are paid directly to PMR department
Intrathecal baclofen therapy
Consider all factors to optimize therapy
Patients
• Given the divergence of disease conditions and presentations that be affected by ITB, it is crucial that clinicians counsel patients carefully regarding their expectations for this therapy
• Patients should be queried about their individual goals for treatment.
• They may indentify a wide variety of aspirations, anything from reduced caregiver burden to improved ambulatory capacity.
Patient factors
• Might be a problem with language
• “Spasms” and “Stiffness” can have multiple meanings
• Pain ≠ spasticity
Disease factorsVarieties of increased resistance to PROM
• Spasticity ITB approved• Dystonia ITB sensitive• Contracture not ITB sensitive• Heterotopic ossification• Ankylosis • Rigidity • Gegenhalten / paratonia
Diseases (approved indications)
• Spinal cord injury
• Multiple sclerosis
• Cerebral palsy
• Stroke
• Traumatic brain injury
Other illnesses potentially sensitive to ITB
• Non-traumatic spinal diseases: hereditary spastic paraparesis, transverse myelitis, ALS
• Dystonias
• Metabolic disorders: adrenoleukodystrophy
• Primary muscle diseases: tetanus, stiff person syndrome
Noxious stimuli
• Can increase or drive increase tone
• In a previously stable patient, increased tone can be the harbinger of a secondary influence
• Searching for this driving force can be a daunting task
Potential Noxious Stimuli
• Urinary: infection, stones, distention
• Dermatological: decubuti, surgical incisions
• Neurological: hydrocephalus, syringomyelia
• Pulmonary: pneumonia, coughing
• Medications: SSRIs
• Unusual: sunburn, bee stings, cancer
Agent
• Traditionally, effects of ITB have been related to two factors:– Catheter tip location
– Dosage administered
• Emerging data suggests that drug concentration / volume administered / flow rate can play a role in therapeutic effects.
Agent
• Does tolerance to ITB exist ?
• Reported as high as 30 % in the literature, although thorough investigation into other potential causes can be lacking
• Potentially addressed by bolus delivery or variable / complex dosing regimens
Catheter Micro-fractures
Dawes WJ, Drake JM, Fehlings D. Pediatr Neurosurg. 2003 Sep;39(3):144-8.
Agents
• Intrathecal Lioresal – FDA approved – Medtronic / Novartis
• Intrathecal Gablofen – FDA approved – CNS therapeutics
• Compounded baclofen – not FDA approved – state regulated, compounding pharmacies
Investigation Techniques for Catheter Problems
Plain radiography
Catheter dye study
CT myelogram
Nuclear medicine cisternogram
Magnetic resonance imaging
Device factors
• PumpPotential problems: pocket fill, battery failure, empty reservoir, programming errors, motor stall
• Catheter Potential problems: kinks, holes, blockages
CT myelogram after side port injection
• Remove 2-3 mls of fluid
• Inject 2-3 mls of isotonic contrast
• Patient is then immediately spiral scanned from 2 vertebral segments above the tip of the catheter, down through the pump in the abdomen.
CT myelogram dye study• Advantages: – Improved sensitivity compared to plain films
and fluoroscopy
– “Free” CT of abdomen, thorax, lumbar and thoracic spine
• Disadvantages: – Technical expertise
– Coordination with radiology
– Cannot undertake if fluid cannot be aspirated from side port
Normal study
Contrast loculated in the spinal canal
Contrast ventral to CSF suggesting subdural migration
Contrast extravasating into the subcutaneous tissues suggesting catheter breakage
Contrast filing of an
intrathecal granuloma
Clinicians
Intrathecal baclofen therapy
Consider all factors to optimize therapy