Identification and management of intrathecal baclofen pump complications: a comparison of pediatric and adult patients.

OBJECT: Intrathecal baclofen therapy is an effective means of treating intractable spasticity and dystonia in the pediatric and adult population. The authors present a review of complications encountered in a series of 314 pump and catheter-related procedures. The identification and management of these complications will be reviewed. The authors will also identify populations that may be at increased risk for complications. METHODS: A retrospective review was performed of all procedures undertaken during the last 5 years by two surgeons at the authors' institution. Postoperative complications were reviewed. A total of 314 surgical procedures (226 pediatric and 88 adult) were performed in 195 pediatric and adult patients. This included 171 new pump and catheter implants (116 pediatric and 55 adult), 26 elective pump replacements due to end of battery life (15 pediatric and 11 adult), five elective pump repositionings per physiatrist request (three pediatric and two adult), 14 elective catheter repositionings (10 pediatric and four adult), and two normal pediatric catheter explorations. Surgical procedures for complication management included seven pump revisions (five pediatric and two adult), 48 catheter revisions (38 pediatric and 10 adult), and 41 wound revisions (37 pediatric and four adult). The majority of adult pumps were implanted subdermally, whereas in pediatric patients they were placed subfascially. In general, intrathecal catheters were placed under fluoroscopic guidance with the catheter tip placed at T-1 to T-2 for spastic quadriplegia, T-6 to T-10 for spastic diplegia, and midcervical for dystonia. No significant intraoperative complications were encountered. Overall, there was a statistically significantly higher percentage of procedures for overall complication management and wound complication management in pediatric patients compared with adult patients. CONCLUSIONS: Intrathecal baclofen therapy is a highly effective treatment option for patients with medically refractory spasticity. The catheter, pump, and wound are subject to numerous complications both at the time of implantation and throughout the life of the implanted system. Careful technique, close observation, and aggressive evaluation and correction of problems can reduce the incidence and severity of the complications when they occur.

Intrathecal baclofen therapy and multiple sclerosis: outcomes and patient satisfaction.

OBJECT: In this study the authors provide an assessment of intrathecal baclofen (ITB) therapy and evaluate patient outcomes and satisfaction. METHODS: Records for patients with multiple sclerosis who were selected as candidates for ITB therapy were reviewed for their response to test dose, surgical technique, surgery- and pump-related complications, and short- and long-term response to therapy. Family and caregiver assessments of the value of ITB therapy were also reviewed. CONCLUSIONS: Intrathecal baclofen therapy is safe and effective. Most patients and caregivers express satisfaction with the therapy and would recommend it to other patients. Spasm frequency appears to be the single most common variable positively affected by therapy.

The use of closed-suction irrigation systems to manage spinal infections.

OBJECT: Management of infection in the hardware system-fixated spine has proven to be problematic. In many cases, instrumentation is required to provide stability or to maintain correction of deformity, and removal could be hazardous. The authors describe the use of closed continuous irrigation to treat spinal wound infections in patients with fixation systems; irrigation can be used in all parts of the spine with excellent results. METHODS: The authors conducted a retrospective chart-based review of cases in which spinal instrumentation procedures were performed consecutively during a 10-year period. Infection developed in 36 patients. The infections involved the cervical, thoracic or thoracolumbar, and lumbar regions. Anterior and posterior drains were placed in one patient. In one patient refractory infections responded to replacement of the dual-inflow port drainage system. In all cases the wound infection completely resolved. There were no cases that required the removal of the fusion mass or instrumentation. In all cases progression to solid fusion was achieved. CONCLUSIONS: Closed irrigation systems can be used effectively to manage anterior or posterior cervical, thoracic, and lumbar wound infections. These systems preclude the explantation of the instrumentation and allow spinal stability to be preserved. The authors noted no evidence of recurrent infection or failed fusion.

Histoplasmosis in Patients With Cell-Mediated Immunodeficiency: Human Immunodeficiency Virus Infection, Organ Transplantation, and Tumor Necrosis Factor-α Inhibition.

Background. Histoplasmosis causes severe disease in patients with defects of cell-mediated immunity. It is not known whether outcomes vary related to the type of immunodeficiency or class of antifungal treatment. Methods. We reviewed cases of active histoplasmosis that occurred at Vanderbilt University Medical Center from July 1999 to June 2012 in patients with human immunodeficiency virus (HIV) infection, a history of transplantation, or tumor necrosis factor (TNF)-α inhibitor use. These groups were compared for differences in clinical presentation and outcomes. In addition, outcomes were related to the initial choice of treatment. Results. Ninety cases were identified (56 HIV, 23 transplant, 11 TNF-α inhibitor). Tumor necrosis factor-α patients had milder disease, shorter courses of therapy, and fewer relapses than HIV patients. Histoplasma antigenuria was highly prevalent in all groups (HIV 88%, transplant 95%, TNF-α 91%). Organ transplant recipients received amphotericin B formulation as initial therapy less often than other groups (22% vs 57% HIV vs 55% TNF-α; P = .006). Treatment failures only occurred in patients with severe disease. The failure rate was similar whether patients received initial amphotericin or triazole therapy. Ninety-day histoplasmosis-related mortality was 9% for all groups and did not vary significantly with choice of initial treatment. Conclusions. Histoplasmosis caused milder disease in patients receiving TNF-α inhibitors than patients with HIV or solid organ transplantation. Treatment failures and mortality only occurred in patients with severe disease and did not vary based on type of immunosuppression or choice of initial therapy.

Evaluation of salvage techniques for infected baclofen pumps in pediatric patients with cerebral palsy.

OBJECT: Intrathecal baclofen therapy has been used successfully for intractable spasticity in children with cerebral palsy. Infections are rare, but they are potentially life threatening if complicated by bacteremia or meningitis. Treatment without removal of the system is desirable if it can be done safely and effectively. METHODS: The Authors reviewed the records of 207 patients ranging from 3 to 18 years of age with cerebral palsy who underwent placement or revision of a baclofen pump. They identified 38 patients with suspected or documented infectious complications. Initial attempts were made to eradicate infection with the devices in situ in all patients. Methods and effectiveness of pump salvage were evaluated. RESULTS: Of the 38 patients identified, 13 (34.2%) had documented infections; 11 had deep wound/pocket empyemas and 2 had meningitis. Eight patients with deep wound infections received intravenous antibiotics alone. All required pump explantation. The remaining 3 patients underwent a washout procedure as well; the infection was cured in 1 patient. Both patients with meningitis received intravenous and intrathecal antibiotics, and both required device explantation. In addition, 25 patients (65.8%) had excessive or increasing wound erythema. No objective criteria to document a superficial infection were present. The wounds were considered suspicious and were managed with serial examinations and oral antibiotics. The erythema resolved in 24 of the 25 patients. CONCLUSIONS: In general, observation, wound care, and oral antibiotics are sufficient for wounds that are suspicious for superficial infection. For deep-seated infection, antibiotic therapy alone is generally insufficient and explantation is required. Washout procedures can be considered, but failures are common.