LETTER RE: Managing loss of intrathecal baclofen efficacy: Review of the literature and proposed troubleshooting algorithm
JoeOrdia, Peabody, MA, jordia@bu.edu
Julien Vaisman, Pain and Wellness Center, Peabody, MA
Submitted July 11, 2014
We congratulate Boster et al. for proposing a troubleshooting algorithm for loss of intrathecal baclofen (ITB) efficacy.1
The catheter accounts for most of the problems with ITB. We are concerned that the algorithm excludes contrast study, and indium scan, for assessing catheter function. They recommend catheter replacement if catheter access port (CAP) aspiration is negative or inconclusive. The result is likely to be some unnecessary surgeries. Vender et al. cautioned, "often, a functional catheter will not aspirate CSF. This does not prove that a catheter occlusion exists."2
CAP aspiration is not a standalone test. Aspiration empties the catheter of baclofen before injecting Omnipaque (GE Healthcare). Flow is visualized by fluoroscopy or spiral computed tomography (CT). Contrast is not injected if fluid cannot be aspirated. If the patient is stable, radionuclide study should be considered. Indium 111 is injected into the pump reservoir. Scans are acquired 3 days later. The study can provide accurate information about catheter patency, occlusion, leak, and even mechanical pump failure.3
In conclusion, if fluid cannot be aspirated from the CAP for catheter contrast study, indium scan through the reservoir should be considered to confirm that a catheter problem actually exists.
Disclosures: J. Ordia serves on a data safety monitoring board for Intrinsic Therapeutics; is author on a patent re: Removable hub tunneling needle; receives publishing royalties for Dafidi and Abdul: Beyond Friends (Trafford Publishing, 2009); serves as a consultant for Codman, a Johnson & Johnson company; and receives research support from Codman, a Johnson & Johnson Company and Intrinsic Therapeutics. J. Vaisman is author on a patent re: Removable hub tunneling needle.
References
1. Boster A, Nicholas J, Bartoszek M, O'Connell C, Oluigbo C. Managing loss of intrathecal baclofen efficacy: Review of the literature and proposed troubleshooting algorithm. Neurol Clin Pract 2014;4:123-130.
2. Vender JR, Hester S, Waller JL, Rekito A, Lee MR. Identification and management of intrathecal baclofen pump complications: a comparison of pediatric and adult patients. J Neurosurg 2006;104:9-15.
3. Stinchon JF, Shah NP, Ordia J, Oates E. Scintigraphic evaluation of intrathecal infusion systems: selection of patients for surgical or medical management. Clin Nucl Med 2006;31:1-4.
The catheter accounts for most of the problems with ITB. We are concerned that the algorithm excludes contrast study, and indium scan, for assessing catheter function. They recommend catheter replacement if catheter access port (CAP) aspiration is negative or inconclusive. The result is likely to be some unnecessary surgeries. Vender et al. cautioned, "often, a functional catheter will not aspirate CSF. This does not prove that a catheter occlusion exists."2
CAP aspiration is not a standalone test. Aspiration empties the catheter of baclofen before injecting Omnipaque (GE Healthcare). Flow is visualized by fluoroscopy or spiral computed tomography (CT). Contrast is not injected if fluid cannot be aspirated. If the patient is stable, radionuclide study should be considered. Indium 111 is injected into the pump reservoir. Scans are acquired 3 days later. The study can provide accurate information about catheter patency, occlusion, leak, and even mechanical pump failure.3
In conclusion, if fluid cannot be aspirated from the CAP for catheter contrast study, indium scan through the reservoir should be considered to confirm that a catheter problem actually exists.
Disclosures: J. Ordia serves on a data safety monitoring board for Intrinsic Therapeutics; is author on a patent re: Removable hub tunneling needle; receives publishing royalties for Dafidi and Abdul: Beyond Friends (Trafford Publishing, 2009); serves as a consultant for Codman, a Johnson & Johnson company; and receives research support from Codman, a Johnson & Johnson Company and Intrinsic Therapeutics. J. Vaisman is author on a patent re: Removable hub tunneling needle.
References
1. Boster A, Nicholas J, Bartoszek M, O'Connell C, Oluigbo C. Managing loss of intrathecal baclofen efficacy: Review of the literature and proposed troubleshooting algorithm. Neurol Clin Pract 2014;4:123-130.
2. Vender JR, Hester S, Waller JL, Rekito A, Lee MR. Identification and management of intrathecal baclofen pump complications: a comparison of pediatric and adult patients. J Neurosurg 2006;104:9-15.
3. Stinchon JF, Shah NP, Ordia J, Oates E. Scintigraphic evaluation of intrathecal infusion systems: selection of patients for surgical or medical management. Clin Nucl Med 2006;31:1-4.