Ultrasound Guidance for Technically Challenging Intrathecal Baclofen Pump Refill

Abstract

Intrathecal baclofen (ITB) therapy is a common treatment used to reduce spasticity due to neurologic disorders and injuries. A variety of factors can increase the difficulty of ITB pump refill. Excess subcutaneous fat overlying the pump, spasticity, suboptimal positioning, pump rotation or inversion, and scar formation over the reservoir fill port can create challenges during pump refill. As a result, multiple unsuccessful attempts at accessing the reservoir fill port can be painful and increase the risk of infection, particularly when repeat skin puncture is required. Blind attempts to refill a pump in challenging cases may also result in subcutaneous injection or pocket fill, resulting in a potentially fatal baclofen withdrawal syndrome. We describe 3 successful ITB pump refills in technically challenging cases when using ultrasound guidance. This represents an innovative approach to using ultrasound guidance to facilitate ITB refill in adults with intractable spasticity. We present these new clinical data with a literature review of potential complications related to inaccurate pump refill procedures and discuss the utility of ultrasound guidance for preventing such adverse events.

A Comparison of Refill Procedures and Patient Outcomes Following Ultrasound-Guided and Template-Guided Intrathecal Drug Delivery Systems With Recessed Ports

“…Several methods of ultrasonography guidance of IDDP refill have been described. The first consists of marking the reservoir port site and then performing a scan after refill to assess for any subcutaneous tissue or pocket-fill (17). A second technique uses dynamic color Doppler throughout the refill procedure to monitor direct injection into the pump reservoir (18).…”

Ease of Fill Port Access During the Ultrasound-Guided vs. the Blind Refill Technique of Intrathecal Drug Delivery Systems With a Raised Septum, a Prospective Comparison Study

“…As the safety of US gel and skin marker dye into the reservoir or intrathecally has not been established , US gel or skin marker dye was not used during this study. We furthermore did not use color Doppler for visualization of the drug injection, described by Gofeld et al , as the US probe needs to be positioned very close to the needle to visualize drug injection, with the risk of needle displacement.…”

Refill Procedures of Intrathecal Drug Delivery Systems With a Recessed Fill Port on the Pump Surface: A Prospective Comparison Study of Ultrasound-Guided vs. Blind Refill Technique

“…The skin was palpated to localize the subcutaneous position of the pump and the skin was wet with 5–10 mL of sterile NaCl 0.9%. As the safety of US gel and skin marker dye into the reservoir or intrathecally has not been established , US gel or skin marker dye was not used. The US transducer was placed on the skin over the center of the pump and the transducer was swept across the pump surface until an anechoic depression and a break in the bright echogenic line of the pump surface appeared, indicating the RFP (Fig.…”