Management of Cerebrospinal Fluid Leak After Intrathecal Baclofen Pump Procedures in Adolescents With Cerebral Palsy: A Retrospective Study.

STUDY OBJECTIVE:  Epidural blood patches (EBPs) are frequently performed in children with cerebral palsy (CP) to manage post-dural puncture headache (PDPH) due to cerebrospinal fluid (CSF) leak after intrathecal baclofen pump (ITBP) placement or replacement procedures. The purpose of our study was to review the incidence and management of CSF leak following ITBP placement or replacement procedures in children with CP. The study was a retrospective review of 245 patients representing 310 surgical cases of baclofen pump insertion (n=141) or reinsertion (n=169) conducted at a 125-bed children's hospital with prominent specialty orthopedics surgical cases. MEASUREMENTS:  Demographic and clinical information was obtained from the anesthesia pain service database on all new ITBP placement and subsequent replacements over an eight-year period. MAIN RESULTS:  The overall incidence of CSF leak in our population was 16% (50 of 310) and 18% (25 of 141) with a new ITBP placement. Children with diplegia were associated with a threefold risk of developing CSF leak. Of patients who developed CSF leak (n=50), 68% (n=34) were successfully treated conservatively, while 32% (n=16) required EBPs. EBPs were successful in 87.5% (14 of 16) of patients at relieving PDPH on the first attempt.  Conclusions: CSF leak is a known problem after ITBP placement and replacement. Most patients were successfully treated with conservative management and EBPs were successful in patients failing conservative therapy. Diagnosing PDPH in non-verbal patients can be challenging.

Targeted Drug Delivery for the Treatment of Abdominal Pain in Chronic Pancreatitis: A Retrospective Case Series.

Abdominal pain secondary to chronic pancreatitis (CP) is difficult to manage and often requires chronic oral opioid therapy (OOT). Targeted drug delivery (TDD) allows for a diminished dose of opioid intake and improved pain levels. TDD has been used in different pain syndromes with only limited reports in CP. OBJECTIVE: The objective of this article is to perform a retrospective review of CP patients treated with TDD versus OOT to compare chronic pain control and consumed morphine-equivalent doses. METHODS: Patients receiving TDD between September 2011 and August 2018 were included. All patients were weaned off oral opioids one week before intrathecal trial and pump implantation. Patients with intrathecal trials providing at least 50% pain relief underwent pump implantation. Data were collected while on OOT and at two weeks, three months, and nine months post-implant. Data were analyzed with Microsoft Excel 365 MSO using means and standard deviations. P-values were calculated using a two-tailed student's t-test with paired two-sample means. RESULTS: Twenty-three patients were analyzed. Pre-trial average pain score was 6.5/10 with a mean improvement with trials greater than 71%. The mean chronic baseline oral morphine milligram equivalents (MME) was 188. The mean MME on TDD at two weeks (0.36), three months (1.39), and nine months (2.47) were significantly lower than OOT. Mean pain scores were 6, 4.9, and 5.6 at two weeks, three months, and nine months, respectively, compared to 6.5 on OOT. DISCUSSION: The results of this study indicate that TDD provides improved pain control with significantly lower opioid doses.

Intrathecal Baclofen Infusion Pump for the Treatment of Painful Spastic Hemiplegia: A Case Report.

Painful spastic hemiplegia is a common sequel to a stroke in which patients rarely achieve optimal levels of pain control. Herein, we report the case of a 62-year-old woman with painful spasticity secondary to an ischemic stroke of 15 years' evolution who received multiple pharmacological treatments without reaching motor or pain management goals. After an adequate analgesic response to the intrathecal baclofen test, the placement of an electromechanical pump was decided, reaching an effective maintenance dose of 150 µg per day. Despite achieving partial improvement in spasticity, optimal pain remission was achieved.

Intrathecal Medication From Pain Pump Caused Prolonged Alteration in Mental Status Following Decompression of Severe Spinal Stenosis.

Intrathecal drug delivery (IDD) has multiple indications, including chronic pain, spasticity, and spinal cord injury. Patients with an IDD device implanted who are undergoing decompressive spinal surgery may be at risk for intrathecal (IT) drug overdose in the perioperative setting. The present report describes a patient with an IDD device who underwent elective spinal surgery that was complicated by prolonged, severe alteration in mental status over several days, requiring discontinuation of his IT medications. The patient eventually returned to his neurological baseline by postoperative day 14. In the setting of severe spinal stenosis cranially in relation to an IDD device, consideration for weaning IT medications prior to elective surgery is recommended to avoid potential IT overdose. Patients undergoing weaning should be monitored for signs and symptoms of medication withdrawal.

Intrathecal Administration of Ziconotide as a Potential Treatment for Chronic Migraines.

Migraine is one of the most prevalent and debilitating illnesses globally. There are multitudes of treatment options available for migraines. One of the emerging treatment options for migraine, refractory to conventional treatment modalities, is the intrathecal Ziconotide. Ziconotide (Prialt, Jazz Pharmaceuticals, Dublin, Ireland) enforces selective block of N-type calcium channels, which control neurotransmission at many synapses. Ziconotide is proposed to have efficacy for chronic neuropathic pain, with a favorable lack of tolerance and chemical dependency. Few studies in the literature report the successful resolution of migraine headaches with Ziconotide. The authors report the successful use of intrathecal Ziconotide therapy for chronic refractory migraines.

A Patient with an Intradural Tumor: An Unexpected Finding.

Chronic back pain patients may require escalating doses of systemic opioids. In refractory cases, implantation of an intrathecal drug delivery system (IDDS) may provide effective relief of pain and improve overall function. This system infuses opioid directly into the cerebrospinal fluid via a catheter. While efficacious, it can be associated with complications, one of the most severe being the formation of a catheter-tip granuloma that can lead to permanent neurological deficits. We present a case of a 38-year-old male with an IDDS for pain related to retroperitoneal fibrosis, who began developing worsening back pain along with new-onset lower extremity weakness. A catheter-tip granuloma was suspected, and the patient was advised to obtain emergent spine imaging. He was non-compliant until the point of becoming wheelchair bound, whereupon imaging was finally obtained. Magnetic resonance imaging revealed an intradural mass causing spinal cord compression. After emergent surgical resection, pathology revealed a malignant tumor. Any patient with IDDS and escalating pain levels or new neurological deficits needs urgent neuroimaging to rule out catheter-tip granuloma. However, as this case demonstrates, the differential diagnosis should remain broad and always include neoplasm or abscess.

Intrathecal pump catheter-tip granuloma recurrence with associated myelomalacia - How safe is intrathecal analgesic infusion therapy? A case report.

BACKGROUND: A serious complication of intrathecal (IT) infusion therapy for pain management is catheter-tip-associated granuloma. Catheter-tip granulomas can lead to permanent severe neurological sequelae if not promptly detected. CASE DESCRIPTION: We report a patient with a recurrence of a catheter-tip granuloma causing a high-grade paresis of the lower extremities and we review briefly the literature. CONCLUSION: Patients with IT pump therapy presenting new neurological findings need prompt imaging of the spinal axis to rule out a catheter-tip granuloma. In case of catheter-tip granuloma, early surgical decompression is important.