Introduction: It has long been observed but seldom reported that children with cerebral palsy and resultant spasticity tend to have increased intracranial pressure (ICP) even in the absence of radiographic ventriculomegaly. Though mostly clinically silent, increased ICP becomes evident when such patients undergo lumbar puncture (LP) as they have increased opening pressures (OP) and proclivity for cerebrospinal fluid (CSF) leak.
Methods: We retrospectively reviewed our database of pediatric patients with cerebral palsy undergoing LP for intrathecal baclofen trial between 2009 and 2012. We analyzed age, opening pressure, anesthetic agent, and post-procedure complications. We also considered whether the patients ultimately elected for placement of baclofen pump and, if a CT scan of the head was ordered, whether it demonstrated ventriculomegaly. Patients up to the age of 20 were included.
Results: Twenty-eight patients met inclusion criteria. Nineteen (67.9%) had OP greater than 20 cm H20 and 5 (17.9%) developed CSF leaks post-procedure. The mean OP was 23.25 cm H20. Univariate analysis revealed no correlation with increased OP or CSF leak and type of anesthetic agent used or radiographic evidence of ventriculomegaly.
Conclusions: Though mostly clinically silent, increased ICP may be responsible for a higher rate of post-LP and post-baclofen pump placement CSF leaks. These data confirm the findings of one previously reported series by Albright et al. that children with cerebral palsy have increased OP. More work ought to be done to elucidate the etiology of increased pressure in this population to optimize management of these patients.
Patient Care: By increasing awareness of increased opening pressure in children with cerebral palsy and resulting spasticity, we hope that clinicians will take measures to minimize the common complications of LP and baclofen pump placement by considering more agressive post-procedure management
Learning Objectives: By the conclusion of the session, participants should be able to:
1) Describe the common complications of LP and baclofen pump placement in children with cerebral palsy
2) Discuss how to minimize such complications, bearing in mind that these patients have increased OP
3) Consider whether more agressive management of ICP in these patients may provide any cognitive or functional benefit
References: Albright AL, Ferson S, Carlos S. Occult hydrocephalus in children with cerebral palsy. Neurosurgery 2005;56(1):93-97.