1. ANALYSIS OF SURGICAL INTRATHECAL [i. t
ANALYSIS OF SURGICAL INTRATHECAL [i.t.] BACLOFEN [ITB] IMPLANT RESULTS EMPHASIZING REVISION SURGERY IN A MIXED PEDIATRIC/ADULT POPULATION
Authors
Yasser AWAAD MD, Msc, FAAN, FAAP 1&2, Tamer RIZK MD MRCPCH 2 Norbert ROOSEN MD 3, Kelly A. MCINTOSH , P.A.-C. 3 and G. Michael WAINES, C.S.A 4..
1 Department of Pediatrics, Service of Pediatric Neurology and Movement Disorders, Oakwood Health System, Dearborn, MI, 2 Department of Pediatric Neurology, Neuroscience centre, King Fahad Medical City, Riyadh, Saudi Arabia 3 Department of Neurosurgery, Henry Ford Health System, Detroit, MI , 4 Operating Room Services, Oakwood Hospital, Dearborn, MI
Introduction
Results
Figure 1. Baclofen Pump in Situ
Figure 2. Tear at metal connector to pump within protective silicone covering.
Spasticity is a frequent condition with variable etiology which reflects on patients' wellbeing (functioning, ADL, care, etc.)
Intrathecal administration of baclofen is increasingly becoming popular for management of severe spasticity
ITB administration has been introduced therefore to maximize baclofen’s effects and minimize its side effects16,17. ITB has been shown to be useful in the majority of patients to treat otherwise severe or intractable spasticity leading to a decrease in muscle spasms, pain, and an increase in functional motor activity and control. 16,17
ITB revision surgery complications:
infection (4 cases)
Post pump exchange 2° manufacturer- related mechanical pump failure
Post abdominal wound dehiscence → catheter exposure
P. aeruginosa in catheter left in situ during previous pump removal ( >1 yr) at outside institution
Following abdominal wound dehiscence → catheter exposure.
Increasing ITB needs & withdrawal symptomatology
Tear at metal connector to pump within protective silicone covering.
perforating tear at metal Connector to pump with protrusion of connector.
Retrieval of old intrathecal catheter Fragment Through limited hemilaminotomy with durotomy
3.CSF Leakage
catheter tear at pump connector site (fig 2)
Purpose
Emphasizing the issue that Implantable spasticity therapy becomes a valid alternative for these patients with proper handling of evolving complications.
We set to identify and observe complications of ITB pump, and to report avoidance and cure of complications. Sharing our knowledge regarding patients with ITB is important because of the increasing use of this device, familiarity with the workup of possible implant malfunction is important. There may be diagnostic and technical difficulties. The consequences of the pump malfunction can be detrimental to the patient.
Methods
Review of Our Series of 44 patients,
Study period: 2002 – 2006.
Single operative (NR & GMW) and clinical (NR, KAMcI & YA) team series retrospective, observational in one institution
All surgical patients: N = 44 (23 ♀ vs. 21 ♂) , 24 children (16 ♀ vs. 8 ♂), 20 adults (7 ♀ vs. 13 ♂)
All programmable pumps from one single manufacturer.
Primary-implant-patients»: N = 30 (16 children and 14 adults)
«Revision-only-patients»: N = 14 (8 children and 6 adults)
ITB – Implant Surgery Patient Population (N = 44)
CP: N = 29 (20 children and 9 adults)
CHI: N = 3 (2 children and 1 adult)
MS: N = 3 adults
Dystonia: N = 2 (1 child and 1 adult)
SCM: N = 4 adults
ICH-HTN: N = 1 adult
Spasticity: N = 2 adults
ITB – Revision Surgery «Primary-Implant-Patient» Population (N = 30)
Patients requiring revision: N = 8 (5 children and 3 adults)
17 revision operative procedures performed in 8 of 30 patients
5 patients had only 1 revision procedure
3 patients had multiple revision procedures
ITB – Revision Surgery «Revision-Only-Patient» Population (N = 14)
Patients with previous surgery of any kind at outside institution: N = 14 (7 children and 7 adults)
16 additional revision procedures performed on 14 patients
Conclusions
ITB is an implant surgery with significant morbidity, with extended care and hospitalization requirements.
Strive to reduce problems by:
Meticulous attention to details of surgery.
Thorough work-up to rule out implant system dysfunction if clinical evolution is atypical
Consistently obtaining pre-operative imaging (at least plain X-rays!, but low threshold to perform pump injection studies with contrast)
We recommend a standardised implantation technique that can be used as a guide for a safer ITB implants and may help reduce the complications.
Table 1. List of common post implantation complications
Dehiscence.
Disturbed wound healing.
Mechanical implant dysfunction.
Infection
Decreasing therapeutic effect.