SCI
Edith B. Martinez Lozano, MD
PM&R resident
Cleveland Clinic
Cleveland, Ohio, United States
Haris Arshad, DO
Fellow
Case Western Reserve University/The MetroHealth System
Cleveland, Ohio, United States
Edith B. Martinez Lozano, MD
Cleveland Clinic
Cleveland, Ohio, United States
A 61-year-old man with a chronic C2 incomplete spinal cord injury from a cervical abscess and a 13-year history of ITB therapy presented with increasing spasticity and falls. Imaging showed a catheter fracture at the L5 entry point, with the distal tip migrating upward into the foramen magnum, while the proximal catheter was outside the intrathecal space. Despite this, he only reported worsening spasms without withdrawal symptoms. During his inpatient stay, after a 15% reduction in ITB and starting oral baclofen, he experienced increased spasticity followed by lethargy requiring IV medications, oral baclofen, and temporary pump up-titration. He was stabilized on oral baclofen, clonazepam, and tizanidine, with close monitoring at discharge. At follow-up, tapering the ITB pump caused withdrawal symptoms after a 15% reduction, leading to a 5% increase. He remains stable and is awaiting neurosurgical evaluation with serial cervical imaging.
Discussions: Catheter migration into the foramen magnum has not previously been reported. Typical ITB complications include fracture, occlusion, or disconnection, but distal migration poses unique risks such as CSF leak and potential neurological injury during retrieval. Remarkably, therapeutic benefit persisted despite the fracture and catheter displacement. This case underscores the diagnostic challenge of differentiating ITB underdosing, oral baclofen over-sedation, and withdrawal, particularly when both oral and intrathecal therapies overlap.
Conclusions: This case illustrates a rare ITB complication with significant management challenges. The absence of standardized protocols for tapering or discontinuing ITB in catheter dysfunction highlights the need for evidence-based weaning strategies and clinical guidelines to ensure patient safety.
