Intrathecal baclofen for spasticity management: a comparative analysis of spasticity of spinal vs cortical origin

Position-Dependent Intrathecal Baclofen System Catheter Failure Resulting in Debilitating Spasticity: A Case Report

An intrathecal baclofen pump (ITB) can provide significant relief from excessive spasticity and pain that is difficult to control. However, it is not without its drawbacks. We present a case of a young quadriplegic male who underwent ITB pump placement, suffering four years of transient episodes of severe spasticity with withdrawal symptoms. Multiple adjustments were made to his ITB pump dosing without relief. Extensive workup including interrogation of the pump, serial abdominal radiographs, and fluoroscopic catheter dye study revealed no abnormalities. Intraoperatively, it was discovered that the initial catheter anchoring occurred directly adjacent to the vertebrae, leading to a position-dependent catheter occlusion. He underwent the replacement of his ITB pump and catheter. During surgical revision, emphasis was placed on reducing the length of the catheter outside the spine, anchoring to the supraspinous fascia with avoidance of bony prominences or post-laminectomy sites. After surgery, the patient's spasticity improved, and at the eight-month follow-up, he had no complications, resulting in a mean baclofen dose of 300.2 μg/day. This report highlights the potential risk of life-threatening intrathecal baclofen withdrawal secondary to postural changes, providing technical considerations to prevent recurrences. It also raises awareness regarding patients who are more susceptible to transient catheter occlusion after a spinal cord injury.

Dosing Patterns In Treatment of Disabling Spasticity With Intrathecal Baclofen

PURPOSE

The aim of this study was to describe and analyze dosing patterns for patients with ITB treatment over time and to identify possible subgroups demonstrating diversity in patterns.

DESIGN

A retrospective design.

METHODS

For 81 patients from six different hospitals, baclofen doses from the first 2 years of treatment were identified using medical records. Line graphs of each patient's doses were analyzed and grouped based on similarities in dosing pattern.

FINDINGS

The analyses of the dosing patterns resulted in four different subgroups classified as stable, slow increase, rapid increase, and fluctuating.

CONCLUSION

The results highlight the clinical challenge of predicting dose development over time.

CLINICAL RELEVANCE TO REHABILITATION NURSING

This study provides rehabilitation healthcare professionals with a better understanding of intrathecal baclofen dose development. Illustrations of the four subgroups can be used as an educational tool for patients, family, and caregivers.

Intravenous prostacyclin-analogue therapy in pulmonary arterial hypertension - A review of the past, present and future

Therapy with intravenous prostacyclin analogues in patients with pulmonary arterial hypertension (PAH) has been established for decades and is an integral component of the current guidelines for the treatment of pulmonary hypertension. Initially, these drugs were infused by external pump systems via tunnelled right atrial catheters with the need for cooling and frequent exchange of drug reservoirs. Associated complications included, among others, catheter-related infections. More recently, fully implantable pump systems have been developed with drug reservoirs that are filled transcutaneously, allowing intervals between refills of several weeks. This technique results in a low rate of infections. Epoprostenol, iloprost and treprostinil have all been used intravenously in PAH, but titration, dosing and dose escalation in long-term therapy are not standardized. Intravenous prostacyclin analogues are still under-used, despite available data suggesting that early and broad application of these therapies as part of risk-oriented, guideline-directed combination therapy for patients with PAH may lead to a survival benefit. This review provides a detailed overview of the drugs, infusion systems and dosing strategies used for intravenous therapy in patients with PAH.

[Long-term results of chronic intrathecal baclofen treatment in patients with spasticity and secondary dystonia]

AIM

To estimate the efficacy of intrathecal treatment with baclofen (ITB) in spasticity and dystonia.

MATERIAL AND METHODS

Two groups of patients have been operated: 19 patients with spinal spasticity and 33 patients with cerebral spasticity (cerebral palsy). After baclofen screening test, the Synchromed2 (Medtronic) was implanted. The level of muscle tone was assessed by the Ashworth scale. The locomotion was assessed by GMFM 88 and Arens scale. The dystonia was assessed by the BFM scale. Follow-up was performed 3, 6 and 12 months after the operation and yearly after that. The duration of the follow-up ranged from 2 to 9 years.

RESULTS

ITB led to a significant decrease in leg spasticity in both groups of patients (p<0.001). The dynamics of spasticity was more significant in the first group compared to the second group (2.77 and 2.07 points, respectively (p<0.0031)). The dynamics of muscle tone in arms was lesser then in legs (p<0.0022). The positive clinical dynamics in patients with secondary dystonia was minimal (BFM from 65±17 to 60±19). Increasing of ITB daily dose was required to maintenance the clinical effect in most patients. The loss of ITB effect was noted in 5% of patients.

CONCLUSION

ITB was more effective in patients with spinal spasticity. The influence of ITB on the secondary dystonia was lesser then on the spasticity. The dynamic of the muscle tone was more significant in legs than in arms. The loss of ITB effect can be observed in some cases after the operation despite the positive result of baclofen screening-test.

Title: Quantifying the change of spasticity after intrathecal baclofen administration: A descriptive retrospective analysis

OBJECTIVES

Exploratory research quantifying the change of spasticity among patients who underwent baclofen intrathecal drug delivery system (IDDS) implantation.

PATIENTS AND METHODS

88 patients with a baclofen IDDS were identified. Patient characteristics, spasticity scores pre/post intrathecal baclofen test dose, and IDDS perioperative implantation records were collected. The primary outcome was to quantify the extent to which there was a change in Modified Ashworth Scores (MAS) pre/post-intrathecal baclofen test dose administration. Secondary outcomes included the prevalence of perioperative IDDS implantation complications.

RESULTS

The mean age at IDDS implant was 44.2 years (range, 19-71), and 62.5% were male. 45.5% had spasticity of spinal cord origin, 9% of cerebral origin, and 45.5% of other upper motor neuron dysfunction. Reduction of MAS in the spinal cord origin group was 2.6 (mean, 3.5 to 0.9), cerebral origin group was 2.9 (mean, 3.3 to 0.4), and other origin group was 2.5 (mean, 3.6 to 1.1). In all patients, post dural puncture headache was the most commonly reported complication at 22.7%.

CONCLUSION

This report offers novel findings documenting a quantifiable change of at least two points on the MAS before and after intrathecal baclofen test dose as statistically significant and could prove to be useful information to enhance the decision making process to proceed with intrathecal baclofen beyond assessment of functional abilities.

Persons With Chronic Spinal Cord Injuries in the Emergency Department: a Review of a Unique Population

BACKGROUND

Persons with spinal cord injuries (SCIs) are frequent utilizers of emergency medical services but are a poorly understood and medically complex population. As the treatment of acute spinal cord injuries improves, there is a growing population of patients suffering from the chronic neurological deficits and altered homeostasis resulting from those injuries.

OBJECTIVES

We sought to highlight the unique diagnostic challenges of treating persons with SCIs and to review ailments uncommon in the general population but often encountered in this population.

DISCUSSION

Spinal cord anatomy is briefly reviewed and commonly used nomenclature and grading scales are defined. An organ by organ review is offered detailing unique clinical issues that pertain to those systems. Practice pearls and pitfall are elucidated when relevant. Psychiatric complications of this disease entity are also discussed.

CONCLUSION

A SCI is a devastating but increasingly survivable event. The long-term care of persons with SCIs is challenging because of the unique pathologies encountered in this population and the disruption of normal and expected physiological responses to common ailments. This review will facilitate a better understanding of the emergency care needs of this unique patient population.

Intrathecal baclofen pump infection treated by adjunct intrareservoir teicoplanin instillation

Background:

The delivery of intrathecal baclofen via pumps is gaining increasing use in the management of intractable spasticity. One of the rare but devastating complications of this method is infection. In the majority of cases, removal of the device is required, despite appropriate intravenous antibiotic therapy. We report a case that highlights the use of intrareservoir teicoplanin to achieve sterilization of the infected pump system in a patient in whom removal of the pump was not an easy option.

Case Description:

We describe our experience on a patient with cerebral palsy in whom Staphylococcus epidermidis pump infection developed due to contamination of the infusion reservoir during refilling procedure, which was successfully sterilized in situ by the combined use of systemic antibiotics and intrareservoir coadministration of baclofen with teicoplanin. The infection was eradicated and baclofen therapy was continued uninterrupted.

Conclusions:

Removal of intrathecal baclofen pump is not necessary as the first measure in cases with mild clinical symptomatology. In view of the fact that pumps for intrathecal drug delivery are very costly, salvage of the device may be attempted in selected cases, although it is not generally recommended. Combined infusion of baclofen and an antibiotic through the pump makes it possible to maintain treatment for spasticity, sterilize the pump reservoir and flow tubes, and effectively treat infections that develop during the use of these systems.

Cost-effectiveness of Intrathecal Baclofen Therapy in severe refractory non-focal disabling spasticity: a Spanish hospital perspective

BACKGROUND

Current knowledge about long-term economic consequences of Intrathecal Baclofen Therapy (ITB Therapy®) is incomplete.

METHODS

A markov model was developed to estimate long-term clinical and economic outcomes with ITB Therapy® and conventional medical management of severe refractory non-focal disabling spasticity. Clinical and cost inputs were obtained through a non-interventional, prospective, observational study in a Spanish neurorehabilitation hospital.

RESULTS

ITB Therapy® increased remaining lifetime costs by €35,605 and resulted in a gain of 1.06 quality-adjusted life-years (QALYs), thus showing an incremental cost-effectiveness ratio (ICER) of €33,619/QALY gained. In alternative scenarios, reflecting other clinical settings and management options, considerably lower ICER values were obtained. In particular, opportunities were identified to improve efficiency by setting clinically and economically sound targets for post-operation length of stay.

CONCLUSION

In the Spanish setting, ITB Therapy® resulted in an ICER close to €30,000/QALY gained; potential ways to reduce costs and further enhance efficiency can be identified.

Intrathecal Baclofen Pump Migration Into the Peritoneal Cavity: A Case Report

INTRODUCTION

Intrathecal baclofen pumps are valuable treatment options for those with cerebral palsy. Although subfascial baclofen pump placement is generally preferred over a subcutaneous pump placement due to lower infection rates, rare complications can occur with the subfascial approach such as pump migration.

CASE PRESENTATION

The authors here describe a case of baclofen pump migration into the peritoneal cavity of a 26-year-old male patient with cerebral palsy, shunted hydrocephalus, and epilepsy. Because the patient's pump could not be palpated on exam and hence refilled, imaging was undertaken, but did not reveal clear evidence of pump migration. Surgery afterward confirmed that the pump had migrated into the peritoneal cavity through a fascial defect. Baclofen pump had to be replaced instead subcutaneously as well as the patient later had to be readmitted for 2 ventriculoperitoneal shunt revisions due to progression of his hydrocephalus.

CONCLUSIONS

Intraperitoneal migration of a subfascially placed baclofen pump is a rare, yet serious complication, which has been reported only once in the literature. We advise neurosurgeons to have a low level of threshold in confirming the location of a baclofen pump with imaging and surgical exploration if necessary in order to avoid detrimental outcomes such as bowel perforation.

Resolution of Enantiomers of (RS)-Baclofen by Ligand-Exchange Thin-Layer Chromatography

A new chromatographic method has been developed for direct enantioresolution of (RS)-baclofen by ligand-exchange thin-layer chromatography (TLC) adopting two different approaches; (A) TLC plates were prepared by mixing the ligand exchange reagents (LER) with silica gel slurry and the chromatograms were developed with different achiral solvents or solvents having no chiral additive, and (B) the LER consisting of Cu(II)-L-amino acid complex was used as chiral mobile phase additive and the plain plates of silica gel having no chiral selector were used. Cu(II) acetate and four L-amino acids (namely, L-tryptophan, L-histidine, L-proline and L-phenylalanine) were used for the preparation of LERs. Spots were located by the use of iodine vapor. Effect of temperature and the mole ratio of Cu(II)-to-amino acid on enantioresolution were also studied. The results for the two methods have been compared, and the issue of involvement of the Cu(II) cation for the best performance of the two methods has been discussed with respect to the same mobile phase. L-Trp proved to be a good ligand using a common mobile phase in each case.

Long-term effects of intrathecal baclofen in multiple sclerosis

OBJECTIVES

Spasticity is associated with various neurological conditions. In this study the authors analyzed the long term effects of intrathecal baclofen therapy in multiple sclerosis and evalued the benefits of the treatment on spasticity, disability, pain, spasm frequency and rated the incidence of side effects.

PATIENTS AND METHODS

A records of 123 patients, with a severe, progressive and refractory to medical therapy spasticity from different causes, underwent baclofen pump placement, after a bolus test, from 2000 to 2012,under Department of Neurosurgery at the Second University of Naples/Italy. We present our experience in treating 28 subjects that was affected by multiple sclerosis. For all patients we reviewed long-term response to therapy, surgical technique, surgery- and pump-related complications. Every patients were evaluated by means of the Modified Ashworth Scale (MAS), Penn Spasm Frequency Scale (SFS), Visual analogue Scale For Pain (VAS), Barthel index (BI) and Self Rating Depression Scale (SDS) RESULTS: During follow up the mean MAS score for upper and lower extremities decrease significantly. Also SFS's decrease was statistically significant. This resulted in a dramatic improvement of BI. Furthermore, we observed a marked improvement in VAS and SDS.

CONCLUSIONS

Intrathecal baclofen provides effective long-term treatment of spasticity multiple sclerosis related. ITB therapy increases the quality of lifestyle and functional independence in appropriately selected cases.

Intrathecal Versus Oral Baclofen: A Matched Cohort Study of Spasticity, Pain, Sleep, Fatigue, and Quality of Life

BACKGROUND

Baclofen commonly is used to manage spasticity caused by central nervous system lesions or dysfunction. Although both intrathecal and oral delivery routes are possible, no study has directly compared clinical outcomes associated with these 2 routes of treatment.

OBJECTIVE

To compare spasticity levels, pain, sleep, fatigue, and quality of life between individuals receiving treatment with intrathecal versus oral baclofen.

DESIGN

Cross-sectional matched cohort survey study.

SETTING

Urban academic rehabilitation outpatient clinics.

PARTICIPANTS

Adult patients with spasticity, treated with intrathecal or oral baclofen for at least 1 year, matched 1:1 for age, gender, and diagnosis.

METHODS

Standardized surveys were administered during clinic appointments or by telephone.

MAIN OUTCOME MEASURES

Surveys included the Penn Spasm Frequency Scale, Brief Pain Inventory, Epworth Sleepiness Scale, Fatigue Severity Scale, Life Satisfaction Questionnaire, and Diener Satisfaction with Life Scale.

RESULTS

A total of 62 matched subjects were enrolled. The mean (standard deviation [SD]) age was 46 (11) years with a mean duration of intrathecal baclofen or oral baclofen treatment of 11 (6) and 13 (11) years, respectively. There were 40 (64%) male and 22 (36%) female subjects. Primary diagnoses included spinal cord injury (n = 38), cerebral palsy (n = 10), stroke (n = 10), and multiple sclerosis (n = 4). The mean (SD) dose of intrathecal and oral baclofen at the time of survey were 577 (1429) μg/day and 86 (50) mg/day, respectively. Patients receiving intrathecal compared with oral baclofen experienced significantly fewer (1.44 [0.92] versus 2.37 [1.12]) and less severe (1.44 [0.92] versus 2.16 [0.83]) spasms, respectively as measured by the Penn Spasm Frequency Scale (P < .01; P < .01). There were no significant differences in pain, sleep, fatigue, and quality of life between groups. Subanalysis of patients with SCI mirrored results of the entire study sample, with significant decreases in spasm frequency and severity associated with intrathecal compared to oral baclofen (P < .01; P < .01), but no other between group differences. The mean (SD) percent change in dose of oral (21% [33%]) compared with intrathecal (3% [28%]) baclofen was significantly larger two years prior to the date of survey (P = .02).

CONCLUSIONS

Long-term treatment with intrathecal compared with oral baclofen is associated with reduced spasm frequency and severity as well as greater dose stability. These benefits must be weighed against the risks of internal pump and catheter placement in patients considering intrathecal baclofen therapy.

Intrathecal baclofen bolus dosing and catheter tip placement in pediatric tone management

Intrathecal baclofen (ITB), administered by an implanted pump, has emerged as an efficacious therapy for the treatment of hypertonicity in pediatrics. Although ITB has been used for more than 20 years clinically, much is still unknown about the most optimal dosing regimens and intrathecal catheter tip placement. Clinician experience, animal research, and advanced imaging is guiding the use of ITB. The rationale for high cervical catheter tip placement and pulsating flex dosing is described.

Toll-like receptors in central nervous system injury and disease: a focus on the spinal cord

Toll-like receptors (TLRs) are best known for recognizing pathogens and initiating an innate immune response to protect the host. However, they also detect tissue damage and induce sterile inflammation upon the binding of endogenous ligands released by stressed or injured cells. In addition to immune system-related cells, TLRs have been identified in central nervous system (CNS) neurons and glial subtypes including microglia, astrocytes and oligodendrocytes. Direct and indirect effects of TLR ligands on neurons and glial subtypes have been documented in vitro. Likewise, the effects of TLR ligands have been demonstrated in vivo using animal models of CNS trauma and disease including spinal cord injury (SCI), amyotrophic lateral sclerosis (ALS) and neuropathic pain. The indirect effects are most likely mediated via microglia or immune system cells that infiltrate the diseased or injured CNS. Despite considerable progress over the past decade, the role of TLRs in the physiological and pathological function of the spinal cord remains inadequately defined. Published reports collectively highlight TLRs as promising targets for therapeutic interventions in spinal cord pathology. The findings also underscore the complexity of TLR-mediated mechanisms and the necessity for further research in this field. The goals of the current review are to recapitulate the studies that investigated the role of TLRs in the spinal cord, to discuss potential future research directions, and to examine some of the challenges associated with pre-clinical studies pertinent to TLRs in the injured or diseased spinal cord.

Occurrence of adverse events in long-term intrathecal baclofen infusion: a 1-year follow-up study of 158 adults

OBJECTIVE

To assess the frequency and types of adverse events (AEs) related to intrathecal baclofen (ITB) therapy in adults, and associated risk factors.

DESIGN

A prospective, observational cohort study of adults followed up from January 1 to December 31, 2010.

SETTING

A neurologic rehabilitation department in a university hospital.

PARTICIPANTS

All consecutive adult subjects (N=158) receiving ITB via a pump, either implanted or followed up during the study period.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Frequency and type of AEs.

RESULTS

In 2010, 158 subjects were followed up for ITB therapy, of whom 128 were implanted before 2010 (nonsurgical subjects), and 30 underwent implantation in 2010 (surgical subjects). Of these 30 subjects, 20 were "newly implanted" and 10 were "replacements." The most frequent pathologic disorders were spinal cord injury (42%) and multiple sclerosis (28%). Twenty-eight subjects (18%) experienced a total of 38 AEs. The rate of AEs was .023 per month of ITB treatment. AEs were related to the surgical procedure in 53% of cases, to the device in 29% (predominantly catheter dysfunctions), and to adverse effects of baclofen in 18%. AEs related to the surgical incision (scar complications and collections) were more frequent in replacement than newly implanted subjects (P=.009). No significant association between occurrence of an AE and subject characteristics (age, gait capacity, spinal vs cerebral spasticity, duration of ITB therapy follow-up) was found. Nearly half of the AEs were serious, extending admission time by a mean of 16 days. No AE induced long-term morbidity or death.

CONCLUSIONS

The AE rate was relatively low in this cohort. This has to be balanced against the clinical, functional, and quality-of-life improvements, which are expected from ITB therapy.

A Review of Spasticity Treatments: Pharmacological and Interventional Approaches

Spasticity is a velocity-dependent increase in muscle tone and uncontrolled, repetitive, involuntary contractions of skeletal muscles. Spasticity presents as upper motor neuron symptoms in patients with central nervous system pathology such as stroke, spinal cord injury, brain injury, or multiple sclerosis. As a result, a patient can have significant pain and limited mobility, which can lead to decreased quality of life and difficulty maintaining personal care. In this article we discuss mechanisms, indications, efficacy, and side effects of the most accepted current treatments. Currently available treatment options include oral medications and interventional procedures. Oral medications comprise centrally acting agents, such as baclofen, clonidine, and tizanidine, as well as anticonvulsants such as benzodiazepines and gabapentin and peripherally acting dantrolene. Interventional procedures include focal injections of botulinum toxin, phenol or alcohol, and an intrathecal baclofen pump. Surgical treatments include selective dorsal rhizotomy and neurectomy. We found that there are several treatments available with data to support their use, but many still need further research to prove their efficacy and develop optimal utilization.

Spasticity following spinal cord injury

BACKGROUND

Up to 70% of patients with spinal cord injuries develop spasticity. The main aim of the paper is to provide an overview of spasticity management, primarily in patients with spinal cord injuries.

METHOD

The article is based on literature searches in PubMed using the keyphrases «spasticity» and «spasticity AND spinal cord injury», and own clinical experience and research.

RESULTS

Spasticity may be general, regional or localised. Factors such as an over-filled bladder, obstipation, acute infections, syringomyelia or bone fractures may substantially influence the degree of spasticity and must be determined. An assessment of the clinical and functional consequences for the patient is decisive before management. Active exercise, physiotherapy and peroral drugs are the simplest and cheapest options. Baclofen is the only centrally acting spasmolytic registered in Norway and is the first choice for peroral treatment. Benzodiazepines can also be used. The effect of the tablets is generally limited and there are often pronounced side effects. Local spasticity can be treated with botulinum toxin injections. The effect is time-limited and the treatment must be repeated. International guidelines recommend a combination of botulinum toxin injections and physiotherapy. In cases of regional spasticity, particularly in the lower limbs, intrathecal baclofen administered via a programmable pump may provide a continuous spasm-reducing effect. Orthopaedic surgery or neurosurgery may be an option for selected patients with intractable spasticity.

INTERPRETATION

Spasticity following a spinal cord injury must be assessed regularly. The treatment strategy depends on the degree of functional failure caused by the spasticity and its location.

Polyanalgesic Consensus Conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel

INTRODUCTION

The use of intrathecal (IT) infusion of analgesic medications to treat patients with chronic refractory pain has increased since its inception in the 1980s, and the need for clinical research in IT therapy is ongoing. The Polyanalgesic Consensus Conference (PACC) panel of experts convened in 2000, 2003, and 2007 to make recommendations on the rational use of IT analgesics based on preclinical and clinical literature and clinical experiences.

METHODS

The PACC panel convened again in 2011 to update the standard of care for IT therapies to reflect current knowledge gleaned from literature and clinical experience. A thorough literature search was performed, and information from this search was provided to panel members. Analysis of published literature was coupled with the clinical experience of panel members to form recommendations regarding the use of IT analgesics to treat chronic pain.

RESULTS

After a review of literature published from 2007 to 2011 and discussions of clinical experience, the panel created updated algorithms for the rational use of IT medications for the treatment of neuropathic pain and nociceptive pain.

CONCLUSIONS

The advent of new algorithmic tracks for neuropathic and nociceptive pain is an important step in improving patient care. The panel encourages continued research and development, including the development of new drugs, devices, and safety recommendations to improve the care of patients with chronic pain.

Intrathecal baclofen therapy in severe head injury, first time in Nepal, a technique suitable for underdeveloped countries

Intrathecal baclofen (ITB) has been found to be helpful not only for spasticity but also for unconsciousness in a vegetative patient. This is the first case of ITB in Nepal, and here we discuss the effectiveness of ITB for spasticity in a patient in vegetative state. We also discuss about a simple technique for ITB used in Nepal where baclofen pump is not available. Here, we present a case of a 40-year-old male patient who had severe head injury with diffuse axonal injury treated conservatively. He went on to a vegetative state and subsequently developed severe spasticity of all the limbs. ITB was started under the guidance of one of the authors , Prof. Taira. Baclofen was injected to the spinal intrathecal space through a catheter which is used for spinal anesthesia. Spasticity improved significantly and his higher mental function also showed signs of improvement. He finally became fully conscious and well oriented. ITB is very useful in cases of severe spasticity and vegetative condition, a state of unconsciousness lasting longer than a few weeks. Even with a simple technique in the absence of baclofen pump, ITB can be used with its optimum effect.

Combined C-arm fluoroscopy and C-arm cone beam computed tomography for the evaluation of patients with possible intrathecal baclofen delivery system malfunctions

BACKGROUND

Evaluating intrathecal baclofen (ITB) delivery systems for potential malfunction can be challenging. The catheter systems are prone to myriad complications that are frequently difficult to ascertain by conventional imaging techniques. Newer imaging technologies and their combinations can be used to identify such problems, define surgical indications, and focus operative planning. C-arm fluoroscopy and C-arm cone beam CT performed in one imaging session represents one such combination that has great utility.

OBJECTIVE

We present a case series of ITB catheter evaluations using combined C-arm fluoroscopy (CF) and C-arm cone beam CT (CCBCT).

METHODS

We retrospectively analyzed 7 pediatric patients who underwent ITB catheter systems evaluations by the use of combined CF and CCBCT. Study variables included indications for evaluation, imaging results, interventions, correlation of surgical findings with imaging, and clinical outcome.

RESULTS

Three patients had intact and patent catheter systems. Four patients demonstrated various problems of the catheter systems, including disconnection, microfracture, fracture with segment migration, and subdural migration. Dosage adjustments improved all patients with normal studies. Surgery was guided by the imaging, and all operative patients improved after targeted interventions. Intraoperative findings correlated perfectly with imaging.

CONCLUSION

Combined CF and CCBCT proved highly effective in the evaluation of our patients with potential ITB system malfunctions. This technique is advocated for such evaluations because it accurately defines problems with connectivity, integrity, and position of catheter systems. When surgical intervention is required, this information aids in operative planning.