Introduction: Intrathecal baclofen (ITB) pump placement for refractory spasticity and dystonia is complicated in patients with prior thoracolumbar spinal fusion for neuromuscular scoliosis. We report the first case series of ITB catheter placement using cone beam computer-tomography (CBCT) image-guidance.
Methods: Data 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. Subcutaneous puncture was performed with CBCT-guided placement of a sheathed needle. Navigation provided real-time two-dimensional projections and three-dimensional reconstructions for detailed volumetric imaging. A bone biopsy drill needle was passed through the sheath, providing a canal through the fusion mass. A Touhy needle was advanced into the thecal sac. Once the catheter was threaded cephalad under fluoroscopy and CSF flow was confirmed, the stylet was replaced, the external catheter tubing was sterilely wrapped, and patients were transported to the operating room. The external portion of the spinal catheter was removed, and a connector was used to connect the pump to the abdominal catheter.
Results: Fifteen consecutive patients with cerebral palsy (mean age 20.1 years) were included. Fourteen experienced refractory painful muscle spasm and 7 had dystonia. Nine patients underwent initial catheter placement, while 6 underwent catheter replacement due to catheter failure. The procedure was technically successful in all patients, with 100% accuracy of proximal catheter placement. Mean length of stay was 7.1 (median 4) days for all patients, and 3.5 (median 3) days for those undergoing initial placement. With a mean follow-up of 16.8 (range 9-28) months, no CSF leakage or catheter disconnection, dislodgment, or failure occurred. One late infection presented at 4 months, attributed to a urinary tract infection.
Conclusions: Image-guided navigation resulted in accurate placement of the proximal catheters for intrathecal baclofen pumps in patients who have previously undergone thoracolumbar spinal fusion.
Patient Care: Implantation of an intrathecal baclofen pump catheter using Cone Beam commuted-tomography image-guidance is safe and is another approach in the armamentarium of neurosurgeons when approaching patients with spasticity and concomitant thoracolumbar spinal fusion.
Learning Objectives: 1. Real-time 2D images and 3D image reconstructions with Cone Beam commuted tomography allowed for navigation into the intrathecal space in the setting of complex patient anatomy.
2. Image-guidance resulted in accurate placement of the proximal catheters for intrathecal baclofen pumps in patients who have previously undergone thoracolumbar spinal fusions.
3. Implantation of an ITB catheter via this multi-modality approach is safe and another approach in the armamentarium of neurosurgeons when approaching patients with spasticity and concomitant thoracolumbar spinal fusion.