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A Novel Approach to Prevent Repeated Catheter Migration in a Patient With a Baclofen Pump: A Case Report
1060
CLINICAL NOTE
A Novel Approach to Prevent Repeated Catheter Migration in a Patient With a Baclofen Pump: A Case Report Donald A. Ross, MD, Cornelia Byers, MD, Timothy Hall, PA ABSTRACT. Ross DA, Byers C, Hall T. A novel approach to prevent repeated catheter migration in a patient with a baclofen pump: a case report. Arch Phys Med Rehabil 2005;86: 1060-1. We report a novel solution to a problem of repeated catheter migration that may aid others caring for patients with catheter migration problems. Catheter migration is a frequently reported complication of intrathecal drug delivery systems. We report on an ambulatory patient with a baclofen pump for control of spasticity due to cerebral palsy and dystonia; the patient suffered repeated episodes of catheter migration. The ultimate solution to the migrations was to place a pediatric pump in the lower thoracic, paraspinal region with the catheter entering the thoracic spine directly adjacent to the pump, thereby minimizing the differential motion between the pump and the spine, which was thought to be the cause of the repeated migration. This solution has not been previously described. Paraspinal pump placement may eliminate repeated catheter migration for patients with intrathecal drug pumps. Key Words: Baclofen; Case report; Catheters, indwelling; Cerebral palsy; Muscle spasticity; Rehabilitation. © 2005 by American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ATHETER MIGRATION is a described complication of intrathecal drug delivery pumps. Catheter migration ocC curs when the intrathecal portion of the catheter withdraws 1,2
from the spine until the tip is no longer intradural. Catheter migration is often discovered when the patient experiences a gradual or sudden loss of drug efficacy. Because baclofen withdrawal can be life-threatening, catheter migration can precipitate a crisis. We describe a patient with repeated catheter migration for whom a novel solution was necessary to keep the catheter functional. CASE DESCRIPTION At original presentation, the patient, in her mid twenties, had spastic cerebral palsy and dystonia that was poorly controlled by oral medications, but was responsive to a trial of intrathecal baclofen (ITB). She underwent baclofen pump implantation with an untrimmed, single-piece 89-cm catheter with the tip positioned at T6 and the mid-portion of the catheter secured to the paramedian lumbodorsal fascia with the standard butterfly
From the Medford Neurological and Spine Clinic, and Rehabilitation Medicine Physicians, Medford, OR. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated. Correspondence to Donald A. Ross, MD, Medford Neurological and Spine Clinic, 2900 State St, Medford, OR 97504, e-mail: [email protected]. Reprints are not available from the authors. 0003-9993/05/8605-9055$30.00/0 doi:10.1016/j.apmr.2004.10.009
Arch Phys Med Rehabil Vol 86, May 2005
tether supplied with the device. A purse string suture was placed in the fascia around the catheter to minimize cerebrospinal fluid leakage. She had an excellent response to ITB, but the response abruptly ceased 6 months later. Signs of withdrawal were prevented by reinstitution of oral baclofen. A radiograph showed that the tubing had backed out of the spine and was now coiled around the pump. Nine months after implantation, a revision was performed. The catheter length was increased to 119cm; large, loose coils were left in the back and the abdomen; and a purse string suture but no tether was used. Therapeutic effect was again observed, but within 3 weeks of surgery, efficacy was again lost. A radiograph showed that the catheter had broken at the level of the spinous processes. About 1 month later, a third procedure was performed to replace the catheter exactly as had been done at the second procedure. Postoperatively, the patient was maintained in a Jewett orthosis and was instructed to use a front-wheeled walker for ambulation. Postoperative radiographs showed the catheter migrating distally, and within 2 months, the catheter had again pulled out of the spine. Several months passed while consideration was given as to how to prevent another catheter pull-out. It was believed that the catheter migration was likely caused by differential motion between the patient’s abdomen and spine during ambulation. With this theory as a guide, the patient underwent her fourth operation, about 14 months after the original implantation. A pediatric pump was implanted in the paraspinal region at T10, with the catheter placed through the previous incision at L4-5. The pump functioned well for 6 weeks; however, radiographs taken about 1 month later showed that the catheter had pulled out again. After further consideration, the patient was offered a final procedure. About 20 months after the original implantation, the patient underwent a T11 hemilaminectomy directly adjacent to the pump and had the catheter placed under direct vision only a few centimeters from the pump. The catheter was secured to the fascia with the butterfly anchor (fig 1). The patient was then instructed to use a wheelchair as much as possible for the first month after surgery. As of 20 months postoperatively, the catheter is functional and, according to radiographs, the tip has not moved. The pump in the patient’s abdomen was removed. DISCUSSION Catheter-related complications are common in drug delivery pumps,1-4 but repeated catheter migration such as our patient experienced has not been reported. A large clinical survey covering 936 pump placements for ITB delivery noted only a 4% incidence of catheter kink or migration.4 However, 68 patients with baclofen pumps from a single center followed for an average of 70 months had a 31% incidence of catheterrelated problems, of which 4 (5.9%) were listed as catheter dislodgment.3 In a small series of 26 patients undergoing pump placement for benign back and leg pain, 9 (35%) underwent additional surgery for catheter-related complications.2 After the first catheter migration showed the tubing coiled around the pump, it was our theory that tension build-up at the
BACLOFEN PUMP CATHETER MIGRATION, Ross
1061
shorten the distance between the pump and the spine, but did not prevent migration from recurring. Because the thoracic and lumbar spines probably were still moving differentially, the final procedure placed the catheter directly into the thoracic spine immediately adjacent to the pump. The patient has tolerated the pump in this position and radiographs taken months after surgery show no change in the position of the catheter tip. The differential motion theory seems plausible in this patient, and is borne out by our empiric experience that patients with tetraplegia who are nonambulatory and do not transfer with their arms rarely experience catheter migration. The procedure that solved our patient’s problem may be useful in other ambulatory patients with spasticity who experience catheter migration. CONCLUSIONS Paraspinal pump placement seems to be well tolerated and may be useful in patients who have repeated catheter migration due to differential motion between the pump and the spine during ambulation. Fig 1. Anteroposterior radiograph showing the paraspinal pediatric pump location with the catheter inserted directly adjacent to the pump. The adult pump in the abdomen is also seen.
tether had caused the catheter to snap back. Lengthening the catheter and omitting the tether did not prevent catheter migration and breakage. Our second theory was that differential motion between the abdominal pump and the spine during spastic ambulation was responsible for gradual withdrawal of the catheter. Placement of a paraspinous pediatric pump at T10 with the catheter entering the spine at L4-5 was an attempt to
References 1. Teddy P, Jamous A, Gardner B, Wang D, Silver J. Complications of intrathecal baclofen delivery. Br J Neurosurg 1992;6:115-8. 2. Tutak U, Doleys DM. Intrathecal infusion systems for treatment of chronic low back and leg pain of noncancer origin. South Med J 1996;89:295-300. 3. Albright AL, Gilmartin R, Swift D, Krach LE, Ivanhoe CB, McLaughlin JF. Long-term intrathecal baclofen therapy for severe spasticity of cerebral origin. J Neurosurg 2003;98:291-5. 4. Stempien L, Tsai T. Intrathecal baclofen pump use for spasticity: a clinical survey. Am J Phys Med Rehabil 2000;79:536-41.
Arch Phys Med Rehabil Vol 86, May 2005
CLINICAL NOTE
A Novel Approach to Prevent Repeated Catheter Migration in a Patient With a Baclofen Pump: A Case Report Donald A. Ross, MD, Cornelia Byers, MD, Timothy Hall, PA ABSTRACT. Ross DA, Byers C, Hall T. A novel approach to prevent repeated catheter migration in a patient with a baclofen pump: a case report. Arch Phys Med Rehabil 2005;86: 1060-1. We report a novel solution to a problem of repeated catheter migration that may aid others caring for patients with catheter migration problems. Catheter migration is a frequently reported complication of intrathecal drug delivery systems. We report on an ambulatory patient with a baclofen pump for control of spasticity due to cerebral palsy and dystonia; the patient suffered repeated episodes of catheter migration. The ultimate solution to the migrations was to place a pediatric pump in the lower thoracic, paraspinal region with the catheter entering the thoracic spine directly adjacent to the pump, thereby minimizing the differential motion between the pump and the spine, which was thought to be the cause of the repeated migration. This solution has not been previously described. Paraspinal pump placement may eliminate repeated catheter migration for patients with intrathecal drug pumps. Key Words: Baclofen; Case report; Catheters, indwelling; Cerebral palsy; Muscle spasticity; Rehabilitation. © 2005 by American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ATHETER MIGRATION is a described complication of intrathecal drug delivery pumps. Catheter migration ocC curs when the intrathecal portion of the catheter withdraws 1,2
from the spine until the tip is no longer intradural. Catheter migration is often discovered when the patient experiences a gradual or sudden loss of drug efficacy. Because baclofen withdrawal can be life-threatening, catheter migration can precipitate a crisis. We describe a patient with repeated catheter migration for whom a novel solution was necessary to keep the catheter functional. CASE DESCRIPTION At original presentation, the patient, in her mid twenties, had spastic cerebral palsy and dystonia that was poorly controlled by oral medications, but was responsive to a trial of intrathecal baclofen (ITB). She underwent baclofen pump implantation with an untrimmed, single-piece 89-cm catheter with the tip positioned at T6 and the mid-portion of the catheter secured to the paramedian lumbodorsal fascia with the standard butterfly
From the Medford Neurological and Spine Clinic, and Rehabilitation Medicine Physicians, Medford, OR. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated. Correspondence to Donald A. Ross, MD, Medford Neurological and Spine Clinic, 2900 State St, Medford, OR 97504, e-mail: [email protected]. Reprints are not available from the authors. 0003-9993/05/8605-9055$30.00/0 doi:10.1016/j.apmr.2004.10.009
Arch Phys Med Rehabil Vol 86, May 2005
tether supplied with the device. A purse string suture was placed in the fascia around the catheter to minimize cerebrospinal fluid leakage. She had an excellent response to ITB, but the response abruptly ceased 6 months later. Signs of withdrawal were prevented by reinstitution of oral baclofen. A radiograph showed that the tubing had backed out of the spine and was now coiled around the pump. Nine months after implantation, a revision was performed. The catheter length was increased to 119cm; large, loose coils were left in the back and the abdomen; and a purse string suture but no tether was used. Therapeutic effect was again observed, but within 3 weeks of surgery, efficacy was again lost. A radiograph showed that the catheter had broken at the level of the spinous processes. About 1 month later, a third procedure was performed to replace the catheter exactly as had been done at the second procedure. Postoperatively, the patient was maintained in a Jewett orthosis and was instructed to use a front-wheeled walker for ambulation. Postoperative radiographs showed the catheter migrating distally, and within 2 months, the catheter had again pulled out of the spine. Several months passed while consideration was given as to how to prevent another catheter pull-out. It was believed that the catheter migration was likely caused by differential motion between the patient’s abdomen and spine during ambulation. With this theory as a guide, the patient underwent her fourth operation, about 14 months after the original implantation. A pediatric pump was implanted in the paraspinal region at T10, with the catheter placed through the previous incision at L4-5. The pump functioned well for 6 weeks; however, radiographs taken about 1 month later showed that the catheter had pulled out again. After further consideration, the patient was offered a final procedure. About 20 months after the original implantation, the patient underwent a T11 hemilaminectomy directly adjacent to the pump and had the catheter placed under direct vision only a few centimeters from the pump. The catheter was secured to the fascia with the butterfly anchor (fig 1). The patient was then instructed to use a wheelchair as much as possible for the first month after surgery. As of 20 months postoperatively, the catheter is functional and, according to radiographs, the tip has not moved. The pump in the patient’s abdomen was removed. DISCUSSION Catheter-related complications are common in drug delivery pumps,1-4 but repeated catheter migration such as our patient experienced has not been reported. A large clinical survey covering 936 pump placements for ITB delivery noted only a 4% incidence of catheter kink or migration.4 However, 68 patients with baclofen pumps from a single center followed for an average of 70 months had a 31% incidence of catheterrelated problems, of which 4 (5.9%) were listed as catheter dislodgment.3 In a small series of 26 patients undergoing pump placement for benign back and leg pain, 9 (35%) underwent additional surgery for catheter-related complications.2 After the first catheter migration showed the tubing coiled around the pump, it was our theory that tension build-up at the
BACLOFEN PUMP CATHETER MIGRATION, Ross
1061
shorten the distance between the pump and the spine, but did not prevent migration from recurring. Because the thoracic and lumbar spines probably were still moving differentially, the final procedure placed the catheter directly into the thoracic spine immediately adjacent to the pump. The patient has tolerated the pump in this position and radiographs taken months after surgery show no change in the position of the catheter tip. The differential motion theory seems plausible in this patient, and is borne out by our empiric experience that patients with tetraplegia who are nonambulatory and do not transfer with their arms rarely experience catheter migration. The procedure that solved our patient’s problem may be useful in other ambulatory patients with spasticity who experience catheter migration. CONCLUSIONS Paraspinal pump placement seems to be well tolerated and may be useful in patients who have repeated catheter migration due to differential motion between the pump and the spine during ambulation. Fig 1. Anteroposterior radiograph showing the paraspinal pediatric pump location with the catheter inserted directly adjacent to the pump. The adult pump in the abdomen is also seen.
tether had caused the catheter to snap back. Lengthening the catheter and omitting the tether did not prevent catheter migration and breakage. Our second theory was that differential motion between the abdominal pump and the spine during spastic ambulation was responsible for gradual withdrawal of the catheter. Placement of a paraspinous pediatric pump at T10 with the catheter entering the spine at L4-5 was an attempt to
References 1. Teddy P, Jamous A, Gardner B, Wang D, Silver J. Complications of intrathecal baclofen delivery. Br J Neurosurg 1992;6:115-8. 2. Tutak U, Doleys DM. Intrathecal infusion systems for treatment of chronic low back and leg pain of noncancer origin. South Med J 1996;89:295-300. 3. Albright AL, Gilmartin R, Swift D, Krach LE, Ivanhoe CB, McLaughlin JF. Long-term intrathecal baclofen therapy for severe spasticity of cerebral origin. J Neurosurg 2003;98:291-5. 4. Stempien L, Tsai T. Intrathecal baclofen pump use for spasticity: a clinical survey. Am J Phys Med Rehabil 2000;79:536-41.
Arch Phys Med Rehabil Vol 86, May 2005