512 - Subtle Clues, Hidden Failures: Catheter Complications in Intrathecal Baclofen Therapy

Intrathecal baclofen (ITB) pump complications due to catheter dysfunction.

Case Description:

 Case 1: 24-year-old woman with spastic tetraplegia required catheter revision after pump pocket swelling and withdrawal. X-ray and catheter access port (CAP) aspiration were normal, but intraoperatively fluid was found. Later, progressive reservoir discrepancies developed, initially without symptoms, followed by mild withdrawal. CAP aspiration was Beta-2 transferrin positive, confirming CSF leakage. Catheter replacement restored function.

Case 2: 51-year-old man with thoracic myelopathy had recurrent spasms. Sluggish CAP aspiration and dye study showing subdural spread prompted revision. Later, lumbar spine surgery damaged the catheter, causing severe withdrawal. Revision restored function, but infection later required pump explantation.

Case 3: 54-year-old woman with spastic paraplegia developed worsened tone without withdrawal from catheter malposition in paraspinal musculature. Later hospitalizations for altered mental status were attributed to paradoxical responses to oral baclofen, alcohol use, and polypharmacy. Symptoms stabilized after disabling patient therapy manager (PTM) and simplifying oral agents.

 

Discussions:

Case 1 highlights reservoir discrepancies as early clues to pump dysfunction; Beta-2 transferrin confirms CSF leak. Case 2 demonstrates that a dye study may reveal malpositioning and sluggish CAP aspiration may suggest catheter kinking. Surgery near the catheter tract risks direct damage, and multiple revisions increase infection risk. Case 3 illustrates that catheter migration may not present with withdrawal, and non-mechanical contributors such as paradoxical medication responses, substance use, or polypharmacy may mimic catheter dysfunction.

Conclusions:

Catheter-related ITB complications may present subtly with reservoir discrepancies, swelling, or sluggish aspiration. Beta-2 transferrin testing, dye studies, and radiographs assist with diagnosis but must be correlated with clinical findings. Surgical procedures near the catheter can increase the risk of direct injury, and repeated revisions heighten infection risk. Non-mechanical factors such as paradoxical medication responses or polypharmacy can mimic mechanical failure and complicate evaluation. Early recognition prevents severe withdrawal and limits complications.