Prevention of Baclofen Withdrawal Using External Intrathecal Baclofen Taper Following Abrupt Explant of Infected Intrathecal Baclofen Pump: A Case Report

Case Diagnosis: 17-year-old male with spastic quadriplegic cerebral palsy (CP) chronically managed with intrathecal baclofen pump.

Case Description or Program Description: Patient developed a granulomatous blister overlying lateral aspect of intrathecal baclofen (ITB) pump incision one year following placement. Skin was thinning and actively draining with concerns of infection. Antibiotics and pressure dressings failed. Culture revealed Staphylococcus epidermidis and decision was made to remove the pump. Current settings were ITB 4000 mcg/mL with daily dose of 700 mcg delivered in flexible dosing mode. Pump refills required ultrasound guidance and were difficult due to overlying calcium deposition. Intraoperative culture was negative, however the distal portion of the catheter in the pocket was calcified, requiring portion of orphaned catheter to remain in flank. A lumbar drain was placed following a 100-mcg bolus of ITB intraoperatively. Then, a 36-hour taper was initiated with compounded baclofen of 20mcg/cc starting with 400mcg/day equating to 0.8cc/hr with subsequent reductions every 6 hours using a patient-controlled analgesia pump in continuous infusion mode. Patient was monitored in the PICU, and drain was removed upon completion. Patient tolerated taper comfortably with serial creatinine kinase levels stable around 100, requiring only minimal up-titration of oral antispasmodics.

Setting: Pediatric Intensive Care Unit (PICU).

Assessment/Results: Patient discharged to home on oral baclofen 30mg four times daily with plans to undergo pump reimplantation following adequate wound healing.

Discussion (relevance): Patients with ITB pumps are at risk of potential life-threatening withdrawal syndrome that can be difficult to manage effectively without an external catheter or invasive interventions.

Conclusions: ITB pumps offer benefit to those with significant spasticity, yet are commonly complicated by infection, leading to need for surgical revision or explant which may require management of withdrawal. This can be successfully prevented with a multidisciplinary approach by placement of a lumbar drain and ITB taper.