Flipping the script: Conservative management of a flipped intrathecal baclofen pump

Intrathecal baclofen (ITB) pumps are used in the management of severe lower extremity spasticity.1, 2 They are surgically implanted in the abdomen and contain a finite amount of baclofen that is delivered to the intrathecal space via a catheter.1, 2 Clinicians can refill the pump by accessing a reservoir port through the skin. ITB pumps can flip in the surgical pocket from failure of the anchoring sutures, which is clinically relevant because a flip will cause the reservoir port to face toward the abdomen, making it inaccessible for percutaneous refills.1, 2 This is important to address in a timely manner, because if a pump is not refilled before medication is depleted, it can result in life-threatening withdrawal symptoms.1, 2 Once identified, pump flips are generally treated with surgical revision, which involves placing sutures through the pump anchor points to fix the device to adjacent mature scar tissue or fascia.2-4 This case is unique because it describes the successful reorientation of a flipped pump through surface manipulation. This case involves an individual with thoracic spinal cord injury, who was seen in the physiatry outpatient clinic for routine assessment approximately 10 weeks after receiving an ITB pump. Although the patient reported reduced bilateral leg tone with no signs or symptoms of acute baclofen withdrawal, we could not interrogate the pump despite trying different patient positions and programming devices. Given the challenges with device communication, we performed an ultrasound over the pump site using a high frequency (11 MHz) linear ultrasound probe and ordered an abdominal radiograph (Figure 1); both identified a flipped pump. The imaging findings were reviewed with the patient, and we expressed the need for timely surgical reorientation to facilitate impending pump refills. After the conversation, the patient inquired about reorienting the pump through the surface of the skin without the need for surgery. This was not thought to be appropriate in the outpatient clinic, given the concern for precipitating acute baclofen withdrawal by twisting and occluding the proximal catheter with surface manipulation. We reviewed the case with the neurosurgeon, who made an informed decision with the patient to proceed with an attempt at surface manipulation in the operating room, so that any complications could be surgically addressed if needed. A week later, the pump was successfully returned to the proper position by rotating the pump 180 degrees by applying a downward force on one side of the pump with one hand, and an upward force on the underside of the pump with the other hand. Immediately after manipulation, fluoroscopy was performed to confirm the correct orientation of the pump and a catheter access port aspiration was successfully completed to ensure catheter patency and intrathecal drug delivery. The patient was instructed to wear an abdominal binder for 2 months to reduce recurrent pump flips. The pump continued to be correctly oriented on ultrasonography at clinic follow-up 1 (Figure 2), 6, and 12 months later. There is limited research on surface manipulation for reorienting flipped ITB pumps. Surface manipulation has only been described once in the literature by Koo et al., where it failed to prevent recurrent flips.4 The authors did not describe their technique or clinical reasoning, as the purpose of their case was to discuss the impact of recurrent spontaneous flips on drug delivery. We were prompted to consider surface manipulation at the request of the patient. After discussion with the neurosurgeon and patient, it was thought to be technically feasible, as the patient had a thin body habitus that allowed examiners to get their hands under and around the pump. It was advantageous as it avoided the risks of anesthesia and infection from surgical revision. Despite the potential benefits and feasibility of surface manipulation, the entire team was concerned about the risks of recurrent spontaneous pump flips and impaired catheter flow with surface manipulation. To reduce the risk of recurrent pump flips, the neurosurgeon instructed the patient to wear an abdominal binder to keep the pump in place while the surgical pocket matured and scarred down around the device. As for the second risk, we felt that surface manipulation to reorient the pump could disrupt drug delivery by twisting the proximal catheter, which has been reported with spontaneous pump flips.2-4 To account for this possibility, the neurosurgeon completed catheter access port aspiration immediately after successful surface manipulation to ensure intrathecal drug delivery. Additionally, the neurosurgeon elected to perform surface manipulation in the operating room, as it offered the timely ability to convert to a surgical procedure if manipulation failed or was associated with disrupted catheter flow. This case highlights the role of the physiatrist in identifying flipped ITB pumps and the importance of communication between the physiatrist and neurosurgeon when managing these cases. If surface manipulation is considered for treatment, it should be performed with caution, with appropriate measures in place to promptly diagnose and manage catheter dysfunction after successful reorientation and with rescue plans established for surgical revision if manual manipulation is unsuccessful. Written patient consent was obtained for this case report. None.

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