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Pediatric Rehabilitation

Withdrawal After Baclofen Pump Placement: A Case Report

Thursday, November 16, 2023

    Primary Author(s)

  • Jake P. Gooing, DO

    Resident Physician, PGY-3
    University of California (Irvine) PM&R Program
    Irvine, California

    • Co-Author(s)

  • SL

    Sujin Lee, MD

    Attending Physician
    MemorialCare Long Beach Hospital
    Long Beach, California

  • RB

    Riya Bansal, Other

    Medical Student
    UCI School of Medicine
    Orange, California

Case Diagnosis: Spastic Quadriplegia

Case Description: A 20 year old male with spastic quadriplegia secondary to ruptured right frontal arteriovenous malformation develops increased spasticity and tachycardia seven days after placement of an intrathecal baclofen pump and oral anti-spasticity medication discontinuation. Prior to pump placement, the patient was on tizanidine, baclofen and clonazepam. The patient was advised to continue tizanidine and baclofen during transition, however, the patient developed withdrawal symptoms.

Discussion: Intrathecal baclofen is a spasticity treatment option which has a lower rate of side effects as well as fewer and less severe spasms experienced compared to oral therapy. A challenge with intrathecal baclofen is the lack of standardized weaning protocols from either oral to intrathecal or intrathecal to oral medications which may result in life threatening withdrawal if conversion is not performed appropriately. Clonazepam has a reported half-life of 20 to 80 hours with peak withdrawal symptoms occurring around one to two weeks after discontinuation of the medication. Withdrawal from oral anti-spasticity medications should be included in the differential for patients with acute tachycardia and increase in spasticity with recent intrathecal baclofen pump placement.

Setting: Outpatient Pediatric Spasticity Clinic

Assessment/Results: The parents were instructed to resume oral clonazepam. Once clonazepam was resumed, the patient’s symptoms resolved. At the next follow-up visit, the patient’s baclofen pump rate was increased by 24% with a taper of clonazepam prescribed. After completion of the clonazepam taper, the patient did not experience subsequent withdrawal symptoms.

Conclusion: Intrathecal baclofen allows for a lower side effect profile with potentially fewer and less severe spasms compared to oral therapy. Clonazepam discontinuation after intrathecal pump placement may lead to delayed withdrawal symptoms. When multiple anti-spasticity medications are being utilized prior to intrathecal pump placement, optimal withdrawal rescue medication selection is unclear.