Understanding the reasons for delayed referral for intrathecal baclofen therapy in pediatric patients with severe spasticity

Berman, Casey Melissa; Eppinger, Melissa Ann; Mazzola, Catherine A.

doi:10.1007/s00381-014-2591-4

Cited by 10 publications

(8 citation statements)

References 21 publications

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“…Larger studies on ITB treatment in children with CP may lead to further development of treatment standards and recommendations, based on sound evidence, 14 and serve as a basis for informed decisions about ITB, and as an argument for ITB in countries and regions that do not yet offer this treatment to children with CP. Such studies may also reduce perceived delay in treatment, discussed recently by Berman et al 25 We conclude that there are significant differences in access to ITB treatment for children with CP across Europe, which illustrate the inequalities in health care that these children face. Furthermore, the frequency of ITB treatment differs between boys and girls.…”

Section: Discussionsupporting

confidence: 55%

Access to Intrathecal Baclofen Treatment for Children with Cerebral Palsy in European Countries: An SCPE Survey Reveals Important Differences

et al. 2020

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Aim The aim is to study access to intrathecal baclofen (ITB) for children with cerebral palsy (CP) in Europe, as an indicator of access to advanced care. Methods Surveys were sent to CP registers, clinical networks, and pump manufacturers. Enquiries were made about ITB treatment in children born in 1990 to 2005 by sex, CP type, level of gross motor function classification system (GMFCS) and age at the start of treatment. Access to ITB was related to the country's gross domestic product (GDP) and % GDP spent on health. Results In 2011 population-based data from Sweden, Norway, England, Portugal, Slovenia, and Denmark showed that 114 (3.4%) of 3,398 children with CP were treated with ITB, varying from 0.4 to 4.7% between centers. The majority of the children were at GMFCS levels IV-V and had bilateral spastic CP. In Sweden, dyskinetic CP was the most commonly treated subtype. Boys were more often treated with ITB than girls (p = 0.014). ITB was reported to be available for children with CP in 25 of 43 countries. Access to ITB was associated with a higher GDP and %GDP spent on health (p < 0.01). Updated information from 2019 showed remaining differences between countries in ITB treatment and sex difference in treated children was maintained. Conclusion There is a significant difference in access to ITB for children with CP across Europe. More boys than girls are treated. Access to ITB for children with CP is associated with GDP and percent of GDP spent on health in the country.

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Section: Discussionsupporting

confidence: 55%

Access to Intrathecal Baclofen Treatment for Children with Cerebral Palsy in European Countries: An SCPE Survey Reveals Important Differences

et al. 2020

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“…There are musculoskeletal consequences in delayed or nonintervention, including contracture, ankylosis, and skin breakdown . These detrimental processes could potentially overwhelm any potential benefits of ITB therapy.…”

Section: Timing Of Interventionmentioning

confidence: 99%

Best Practices for Intrathecal Baclofen Therapy: Patient Selection

Saulino

Ivanhoe

McGuire

et al. 2016

Neuromodulation: Technology at the Neural Interface

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“…Intrathecal baclofen for patients with CP safely and effectively reduces spasticity, pain, and dystonia; in addition, it confers superior functional abilities and results in improved management by caregivers. 1,2,[9][10][11][12]21,25,33,36,43,48 However, many patients who require baclofen present with concomitant scoliosis; their spinal torsion, or fusion mass and instrumentation, further increases the challenge of device implantation. 4,6,20,24,27,34,35,41,42 Moreover, procedural complications decrease the cost-benefit ratio of intervention.…”

Section: Discussionmentioning

confidence: 99%

“…11,27,28,43 Significant potential postoperative complications include CSF leakage, wound dehiscence, catheter disconnection or dislodgment, and surgical site infection-the latter of which may lead to meningitis and necessitate explantation. 2,9,11,17,20,22,24,27,34,36 Difficulty entering the spinal canal has been reported in patients with scoliosis who have had surgical correction and lumbar fusions, specifically iatrogenic damage to the catheter, incidental durotomies, CSF leakage, and failure of access. 29,32,44 Several strategies have been described to facilitate IT catheterization in this setting.…”

Section: Discussionmentioning

confidence: 99%

Image-guided intrathecal baclofen pump catheter implantation: a technical note and case series

Robinson

Robertson

Dasenbrock

et al. 2017

Journal of Neurosurgery: Spine

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OBJECTIVEMedically refractory spasticity and dystonia are often alleviated with intrathecal baclofen (ITB) administration through an indwelling catheter inserted in the lumbar spine. In patients with cerebral palsy, however, there is a high incidence of concomitant neuromuscular scoliosis. ITB placement may be technically challenging in those who have severe spinal deformity or who have undergone prior instrumented thoracolumbar fusion. Although prior reports have described drilling through the lumbar fusion mass with a high-speed bur, as well as IT catheter implantation at the foramen magnum or cervical spine, these approaches have notable limitations. To the authors' knowledge, this is the first report of ITB placement using cone beam CT (CBCT) image guidance to facilitate percutaneous IT catheterization.METHODSData were prospectively collected on patients treated between November 2012 and June 2014. In the interventional radiology suite, general anesthesia was induced and the patient was positioned prone. Imaging was performed to identify the optimal trajectory. Percutaneous puncture was performed at an entry site with image-guided placement of a sheathed needle. CBCT provided real-time 2D projections and 3D reconstructions for detailed volumetric imaging. A biopsy drill was passed through the sheath, and subsequently a Tuohy needle was advanced intrathecally. The catheter was threaded cephalad under fluoroscopic visualization. After tip localization and CSF flow were confirmed, the stylet was replaced, the external catheter tubing was wrapped sterilely in a dressing, and the patient was transported to the operating room. After lateral decubitus positioning of the patient, the IT catheter was exposed and connected to the distal abdominal tubing with typical pump placement.RESULTSOf 15 patients with Gross Motor Function Classification System Levels IV and V cerebral palsy and instrumented thoracolumbar fusion, 8 had predominantly spasticity, and 7 had mixed spasticity and dystonia. The mean age of patients was 20.1 years (range 13–27 years). Nine patients underwent initial catheter and pump placement, and 6 underwent catheter replacement. The procedure was technically successful, with accurate spinal catheter placement in all patients. The median hospital stay was 4 days (IQR 3–5 days). One patient had an early postoperative urinary tract infection. With a mean follow-up of 25.8 months (median 26, range 18–38 months), no CSF leakage or catheter failure occurred. One late infection due to Pseudomonas aeruginosa (requiring pump explantation) occurred at 4 months, probably secondary to recurrent urinary tract infections.CONCLUSIONSImage-guided CBCT navigation resulted in accurate percutaneous placement of the IT catheter for ITB pumps in patients with prior instrumented thoracolumbar fusion. The multimodality approach is an alternate technique that may be used for IT catheter insertion in patients with complex lumbar spine anatomy, extending the potential to provide safe, durable ITB therapy in this population.

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Understanding the reasons for delayed referral for intrathecal baclofen therapy in pediatric patients with severe spasticity

Abstract: Despite the limitations of this subjective retrospective analysis of outcomes and delay in referral, the opinions of the parents and caregivers should be considered. Earlier referral for ITB therapy may better treat severe spasticity in pediatric patients.

Cited by 10 publications

References 21 publications

Access to Intrathecal Baclofen Treatment for Children with Cerebral Palsy in European Countries: An SCPE Survey Reveals Important Differences

Access to Intrathecal Baclofen Treatment for Children with Cerebral Palsy in European Countries: An SCPE Survey Reveals Important Differences

Best Practices for Intrathecal Baclofen Therapy: Patient Selection

Image-guided intrathecal baclofen pump catheter implantation: a technical note and case series

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