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Pain and Spine Medicine

Back to Baclofen: An unusual presentation of fluid collection in the back of a patient with Stiff Person Syndrome

Back to Baclofen: An Unusual Presentation of Fluid Collection in the Back of a Patient with Stiff Person Syndrome

Thursday, November 16, 2023

    Primary Author(s)

  • Christian B. De Allie, MD, MBA

    Resident Physician
    Thomas Jefferson University Hospital, Department of Physical Medicine and Rehabilitation
    Blackwood, New Jersey

    • Co-Author(s)

  • RS

    Robert L. Selko, DO

    Resident Physician
    Sidney Kimmel Medical College At Thomas Jefferson University/TJUH PM&R Program
    Philadelphia, Pennsylvania

  • BS

    Benjamin R. Scoblionko, MD

    Fellow Physician
    Thomas Jefferson University Hospital, Department of Physical Medicine and Rehabilitation
    Philadelphia, Pennsylvania

  • GF

    Guy Fried, MD

    Attending Physician
    Magee Rehabilitation Hospital
    Philadelphia, Pennsylvania

  • Kimberly Heckert, MD

    Director, Spasticity Management Fellowship; Associate Professor
    Thomas Jefferson University
    Philadelphia, Pennsylvania

Case Diagnosis: Stiff Person Syndrome (SPS)

Case Description or Program Description: 35yF with PMH anxiety/depression and progressive spastic quadriparesis who underwent intrathecal baclofen pump implantation found to have fluid collection in abdomen and subcutaneous tissue along spine ultimately leading to pump removal.

Setting: Acute Rehab Hospital

Assessment/Results: Imaging demonstrated a 3.5cm x 2.1cm x 2cm fluid density collection in midline posterior subcutaneous tissue superficial to L2-L3 was found along with a small collection in RLQ close to 2 months after pump insertion. During surgical exploration, purulent material was discovered and the pump was removed. Fluid cultures (+) Propionibacterium Acnes and patient treated with doxycycline. After pump removal, patient began to experience baclofen withdrawal evident through agitation and autonomic instability including labile HR and BP. Withdrawal treated with oral clonidine 0.1mg every 8 hours as well as oral baclofen and tizanidine PRN.

Discussion (relevance): Although the exact cause of SPS is unknown, some characterize it as a neuro-immunological disorder. There have been certain genetic factors linked to this phenomenon. Muscle tone and spasticity can fluctuate and vary in severity.

Patients with SPS may benefit from a baclofen pump after a successful baclofen trial. 69% of infections occur within 1 month of procedure. In the event of withdrawal, symptoms such as pruritis, agitation, and increase in tone can occur; however, in patients with SPS, adrenergic symptoms such as HTN or tachycardia may be prominent.

Conclusions: This case illustrates a disease of unknown etiology leading to significant changes in motor strength, mobility, and ability to perform ADLs. If a surgical complication related to a baclofen pump arises in a patient with SPS, withdrawal symptoms can be monitored and managed with medications that would suppress the adrenergic response such as clonidine, tizanidine, or dexmedetomidine offered in conjunction with baclofen and benzodiazepines.