1321 - Improvement in hypertonicity with suprasellar intrathecal baclofen (ITB) catheter placement as compared to high cervical placement: a case report

Case Diagnosis: Dystonia and Spasticity Exacerbation Secondary to Intrathecal Baclofen Pump Catheter Tip Repositioning

Case Description: An 18-year-old female with mixed (spastic/dystonic) quadriplegic cerebral palsy managed by intrathecal baclofen (ITB) presented with worsening spasticity, diaphoresis, tremulousness, and writhing movements. The patient’s ITB pump was replaced five months prior secondary to end battery life during which a leak was found at the pump segment of the intrathecal catheter. During repair, the faulty catheter segment was excised, resulting in repositioning of catheter tip. The pump rate was initially decreased to address possible discrepancy in dosage secondary to leak and eventually increased to her prior regimen. After excluding common noxious stimuli as inciting factors for increasing hypertonicity, cervical spine x-ray was obtained which revealed catheter tip repositioning from the original suprasellar position to C3-C4 level. The patient required a new catheter above the foramen magnum. Within 24 hours post-op, the patient demonstrated continued improvement in hypertonicity during subsequent follow-up visits, even with lowered ITB dose.

Discussions: ITB pump is widely used for severe spasticity, but not as common for dystonia. Management of worsening hypertonicity in patients with ITB is guided by a stepwise approach of ruling out pump or catheter malfunction and obtaining work-up for noxious stimuli not limited to urinary tract infection, increased stool burden, and skin ulceration. In this case, repositioning of the catheter tip below foramen magnum was the primary generator of worsening hypertonicity, ultimately demonstrating the importance of suprasellar tip placement when treating patients with ITB for dystonia.

Conclusions: Although many patients with mixed spastic/dystonic cerebral palsy are managed with ITB catheter tip placed in the high cervical region, we demonstrate here a case-specific benefit of continuing to push the catheter to achieve suprasellar placement. Further studies should be aimed at comparing the efficacy between locations.