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Intrathecal Baclofen Pump

Intrathecal Baclofen Pump

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Intrathecal Baclofen Pump

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  1. IntrathecalBaclofen Pump Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS

  2. What is Spasticity • Tightness or stiffness in the muscles that impairs normal smooth motion. • May be beneficial: • Improved “strength” for transfers/mobility • Improved blood flow • Decreased swelling • Treat Spasticity when it begins to interfere with function, care-giving or causes discomfort

  3. Treatment options for Spasticity • Stretching and other modalities • Oral medications • Baclofen • Tizanidine • Clonazepam • Dantrolene • Valium • Gabapentin • Injections • Botulinum toxin • Phenol • IntrathecalBaclofen

  4. Goal of ITB Therapy • Reduce spasticity that interferes with activity, care and comfort • Facilitate rehabilitation therapies • Improve function • Improve ADLs • Prevent spasticity related complications • Pressure ulcers, contractures, pain • Reduce caregiver burden • Improve hygiene, transfers, catheterization

  5. ITB Pump System • Small Titanium Disk (3cm diameter x 1cm thick) • Refillable Reservoir for liquid Medication • Computer chip regulates battery-operated pump • Flexible silicone catheter directs medication to intrathecal space. • Pump refilled every 1-3 months • Pump replaced every 5-7 years

  6. Pump Exterior View

  7. Pump and Catheter Placement

  8. Who is eligeble for ITB Pump Therapy? Person with MS who has significant spasticity that interferes with function, care-taking or causes discomfort. Other therapy options are ineffective Other therapy options have too many side-effects Person is able to comply with refill and maintenance schedules Person lives in an area that has quick access to care in case of pump system difficulties. Person has sufficient body size to implant pump system Person does NOT have an active infection Person does NOT have hypersensitivity to baclofen Person has trialed test dose and had effective response

  9. Test Dosing for ITB Pump • Try before you buy theory • Given test dose of intrathecal baclofen inserted through a needle. • Works in 1-2 hrs • Look for improved ROM • Look for reduction in spasticity • Wears off in 4-8 hrs • May not be perfect dose • OK because pump is fully titratible and programmable • May repeat test trial at different dose

  10. Surgical Procedure • Requires General Anesthesia • 1st incision – Lower Abdomen • Create a pocket for pump beneath skin (above muscle layer) • 2nd incision – Lower Back • Insertion site for catheter to enter Intrathecal Space • Catheter is tunneled from back to lower abdomen to connect to pump. • Incisions heal in about 2 weeks

  11. Pump and Catheter Placement

  12. Complications of Procedure Anesthesia risks Bleeding Infection Spinal Fluid leak Initial alteration in bladder control Initial alteration in spasticity control requiring titration of intrathecal medication

  13. Complications of Pump System • Pump Malfunction • Delivery of too much medication • Baclofen Overdose • Delivery of too little medication • Baclofen Withdrawal • Catheter Malfunction • Kinked catheter

  14. Baclofen overdose • Symptoms • Drowsiness, lightheadedness, dizziness, somnolence, respiratory depression, seizures, loss of consciousness or comma. • Treatment • Be evaluated by a physician immediately • Maintain proper airway and breathing precautions • Empty pump reservoir • May be given physostigmine • May have Lumbar puncture to reduce baclofen in CSF

  15. BaclofenUnderdose/Withdrawal • Symptoms of Underdose • Itching, low blood pressure, new sensory symptoms, fever, change in mental status • Symptoms of Withdrawal • High fever, change in mental status, severe increase in spasticity or muscle stiffness. • In severe cases can lead to muscle breakdown, multiple organ failure or death.

  16. Treatment for Baclofen Withdrawal • Immediately contact a physician (or ER) that is experienced with ITB therapy. • Even if symptoms seem mild • Have person and pump evaluated • Restore intrathecal baclofen infusion • If ITB therapy is unavailable • Start high-dose oral baclofen • Use IV benzodiazepines as needed

  17. BaclofenUnderdose/ Withdrawal • Your physician will • Interrogate the pump status • Check x-rays of the pump and catheter system • Perform a pump refill procedure • System troubleshooting procedures • If needed, surgical repair, revision or replacement of system components.

  18. Refilling Pump • Clinic Procedure taking about 20 minutes • Uses a handheld device placed on skin to program the pump • Sterile technique to access port • Needle inserted through skin to access port reservoir • Remove any Medication left • Refill reservoir fully with liquid Baclofen. • Reprogram pump to desired dosing schedule

  19. Programming Device

  20. Baclofen Refill Container

  21. Common Concerns • OK to go through metal detectors • May set off alarm – have ID card with you • OT to have CT scan • OK to have MRI (must interrogate pump afterwards) • OK to continue stretching and activities • OK to be near household appliances • OK to scuba-dive (up to 10 meters)

  22. Website Resources www. Va.gov/MS www.nationalmssociety.org www.msworld.org http://professional.medtronic.com/therapies/intrathecal-baclofen-therapy-for-severe-spasticity/ www.webmd.com www.medicinenet.com