Intrathecal baclofen pumps: what the neurologist needs to know.

Increasing numbers of patients have an intrathecal baclofen pump implanted as part of spasticity management. Neurologists may be asked about the management of these devices when patients attend emergency departments for unrelated illnesses. Occasionally, the intrathecal baclofen system itself will directly lead to an acute presentation. Furthermore, the presence of an intrathecal baclofen pump needs consideration when requesting investigations, particularly MR imaging. This review aims to increase understanding of intrathecal baclofen treatment, highlighting serious complications and outlining considerations for routine investigations. Neurologists may still need advice from the intrathecal baclofen specialist team.

Reducing Intrathecal Baclofen Related Infections: Service Evaluation and Best Practice Guidelines.

OBJECTIVES: Intrathecal baclofen (ITB) pumps are an effective treatment for spasticity; however infection rates have been reported in 3-26% of patients in the literature. The multidisciplinary ITB service has been established at The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square, London for over 20 years. Our study was designed to clarify the rate of infection in our ITB patient cohort and secondly, to formulate and implement best practice guidelines and to determine prospectively, whether they effectively reduced infection rates. METHODS: Clinical record review of all patients receiving ITB pre-intervention; January 2013-May 2015, and following practice changes; June 2016-June 2018. RESULTS: Four of 118 patients receiving ITB during the first time period (3.4%, annual incidence rate of infection 1.4%) developed an ITB-related infection (three following ITB pump replacement surgery, one after initial implant). Infections were associated with 4.2% of ITB-related surgical procedures. Three of four pumps required explantation. Following change in practice (pre-operative chlorhexidine skin wash and intraoperative vancomycin wash of the fibrous pocket of the replacement site), only one of 160 ITB patients developed infection (pump not explanted) in the second time period (0.6%, annual incidence rate 0.3%). The infection rate related to ITB surgical procedures was 1.1%. In cases of ITB pump replacement, the infection rate was reduced to 3.3% from 17.6%. CONCLUSIONS: This study suggests that a straightforward change in clinical practice may lower infection rates in patients undergoing ITB therapy.

Canomad presenting without ophthalmoplegia and responding to intravenous immunoglobulin.

The acronym CANOMAD encompasses chronic ataxic neuropathy combined with ophthalmoplegia, M protein, cold agglutinins, and anti-disialosyl antibodies.Herein we describe 2 patients presenting with progressive ataxic neuropathy who only developed ophthalmoplegia after a significant delay post-presentation, which in 1 case had features indicative of brainstem dysfunction. Both patients were found to have an IgM paraprotein and anti-disialosyl antibodies. They responded to treatment with intravenous immunoglobulin, thus illustrating the importance of diagnosing this condition.

Amyotrophic lateral sclerosis and ocular flutter.

A previously unreported association of amyotrophic lateral sclerosis and ocular flutter is presented. It is hypothesized that initial loss of brainstem inhibitory interneurons resulted in disinhibition of burst interneurons and that the ocular flutter subsequently disappeared as burst interneurons also became affected by the disease process. The association adds clinical evidence of involvement of brainstem interneurons to other evidence of involvement of neurons other than motor neurons in the disease process.