Submuscular Placement of Intrathecal Baclofen Pumps Safer Placement to Avoid Extrusion
Jarrod T. Bogue, MD, Gal Wald, BS, Jeffrey Greenfield, MD, PhD, David M. Otterburn, MD.
New York Presbyterian Hospital, New York, NY, USA.
Background
Baclofen pumps provide treatment of symptoms of spasticity for disease processes such as Cerebral Palsy and Traumatic Brain Injury. These devices provide continuous infusion or periodic dosing of intrathecal baclofen. Traditionally, these pumps have been placed subcutaneously. However, subcutaneous placement has been reported to be associated with infection and extrusion of baclofen pumps. Of note baclofen pumps are large and range from eight to ten centimeters in diameter and four to eight centimeters in width. Patients requiring device placement typically have a paucity of subcutaneous tissue. Cachexia coupled with the size and bulk of these devices leads to increased protrusion and friction. Submuscular placement provides a well vascularized pocket that directs the device inward eliminating protrusion and decreasing the potential for soft tissue breakdown.
Methods
A retrospective chart review was performed of intrathecal baclofen (ITB) pump placement in a submuscular plane by a single plastic surgeon at a major academic center in conjunction with a neurosurgeon. Inclusion criteria were cases of primary placement or replacement of ITB pumps and spasticity requiring intrathecal baclofen. Devices were placed in a submuscular pocket involving the abdominal wall musculature and fascia. Major complications included infection, extrusion and reoperation.
Results
Five patients over a 5-month period were treated with submuscular placement of intrathecal baclofen pumps. Average age of patients included was 18.4 years. Average preoperative BMI was 18.8 kg/m2 with values ranging from 15.8 to 20.1 kg/m2. Medical histories of patients included diagnoses of cerebral palsy and traumatic brain injury (TBI) causing spasticity. The most frequently cited reason for plastic surgical consultation preoperatively was cachexia. Two patients had previous baclofen pumps placed subcutaneously. Average follow up was 6 months and ranged from 0.3 to 13 months. There were no major complications. One patient had a small seroma that spontaneously resolved. No patient had wound healing problems and there were no extrusions or reoperations.
Conclusion
Submuscular placement of baclofen pumps provides a well vascularized and stable environment for device placement that minimizes the dangers of pump extrusion and infection. Patients who require treatment with intrathecal baclofen commonly have severe cachexia which makes subcutaneous device placement high risk. Submuscular placement should be performed in all patients with BMI less than 20. Obesity is a relative contraindication due to technical difficulties in reservoir refills.
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