Intrathecal baclofen Troubleshooting and Management Michael Saulino, MD PhD MossRehab Assistant...
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Transcript of Intrathecal baclofen Troubleshooting and Management Michael Saulino, MD PhD MossRehab Assistant...
![Page 1: Intrathecal baclofen Troubleshooting and Management Michael Saulino, MD PhD MossRehab Assistant Professor Thomas Jefferson University Adjuvant Assistant.](https://reader036.fdocuments.us/reader036/viewer/2022062407/56649e7d5503460f94b7f512/html5/thumbnails/1.jpg)
Intrathecal baclofen Troubleshooting and Management
Michael Saulino, MD PhDMossRehab
Assistant Professor Thomas Jefferson University
Adjuvant Assistant ProfessorTemple University
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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
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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
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Intrathecal baclofen therapy
Consider all factors to optimize therapy
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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.
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Patient factors
• Might be a problem with language
• “Spasms” and “Stiffness” can have multiple meanings
• Pain ≠ spasticity
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Disease factorsVarieties of increased resistance to PROM
• Spasticity ITB approved• Dystonia ITB sensitive• Contracture not ITB sensitive• Heterotopic ossification• Ankylosis • Rigidity • Gegenhalten / paratonia
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Diseases (approved indications)
• Spinal cord injury
• Multiple sclerosis
• Cerebral palsy
• Stroke
• Traumatic brain injury
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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
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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
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Potential Noxious Stimuli
• Urinary: infection, stones, distention
• Dermatological: decubuti, surgical incisions
• Neurological: hydrocephalus, syringomyelia
• Pulmonary: pneumonia, coughing
• Medications: SSRIs
• Unusual: sunburn, bee stings, cancer
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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.
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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
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Catheter Micro-fractures
Dawes WJ, Drake JM, Fehlings D. Pediatr Neurosurg. 2003 Sep;39(3):144-8.
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Agents
• Intrathecal Lioresal – FDA approved – Medtronic / Novartis
• Intrathecal Gablofen – FDA approved – CNS therapeutics
• Compounded baclofen – not FDA approved – state regulated, compounding pharmacies
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Investigation Techniques for Catheter Problems
Plain radiography
Catheter dye study
CT myelogram
Nuclear medicine cisternogram
Magnetic resonance imaging
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Device factors
• PumpPotential problems: pocket fill, battery failure, empty reservoir, programming errors, motor stall
• Catheter Potential problems: kinks, holes, blockages
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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.
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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
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Normal study
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Contrast loculated in the spinal canal
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Contrast ventral to CSF suggesting subdural migration
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Contrast extravasating into the subcutaneous tissues suggesting catheter breakage
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Contrast filing of an
intrathecal granuloma
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Clinicians
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Intrathecal baclofen therapy
Consider all factors to optimize therapy