Spasticity / Movement Disorders
Amaan Sheikh, DO
Resident Physician
Johns Hopkins School of Medicine
Baltimore, Maryland, United States
Daniel Krasna, MD
Assistant professor
Johns Hopkins
Baltimore, Maryland, United States
Jennifer Viola, DO
Resident physician
Johns Hopkins
Baltimore, Maryland, United States
Jenny Xu, MD
Resident
Johns Hopkins University PM&R Program
Baltimore, Maryland, United States
Amaan Sheikh, DO
Johns Hopkins School of Medicine
Baltimore, Maryland, United States
The patient presented with a three-day history of erythema, purulent drainage, and wound dehiscence at the site of her intrathecal baclofen pump in the right lower quadrant of her abdomen. Given the high risk of infection and potential complications due to her ventriculoperitoneal shunt, the neurosurgery team was consulted and urgently removed the pump. She had been receiving intrathecal baclofen 600 mcg/day for over a year and was thus transferred to the ICU for baclofen withdrawal monitoring and treatment of a methicillin-resistant Staphylococcus aureus (MRSA) infection. Postoperatively, she developed severe withdrawal symptoms, including myoclonic jerks and irritability, requiring IV dexmedetomidine, cyproheptadine, diazepam, and enteral baclofen via nasogastric tube. Dexmedetomidine was gradually weaned while diazepam dosing was increased. Cyproheptadine was discontinued, and she transitioned to oral diazepam with reduced baclofen dosing. At discharge, spasticity was increased but controlled with oral medications, and close outpatient follow-up was arranged.
Discussions: This case illustrates the complexity of managing acute ITB withdrawal after urgent pump explantation. The patient required oral baclofen titrated up to 120 mg/day post explantation, with frequent, closely monitored adjustments by the PM&R consult team. Given the life-threatening potential of abrupt ITB cessation and limited guidance in the literature, this case underscores the importance of timely, individualized, and multidisciplinary care in managing severe withdrawal symptoms. It also highlights the need for clear transition protocols, collaboration between neurosurgery, critical care, and rehabilitation specialists, and ongoing outpatient follow-up to ensure long-term stability, optimization of spasticity, and reduce the risk of recurrent complications.
Conclusions:
Baclofen withdrawal management post-pump explantation is not well-established. This case emphasizes the vital role of the PM&R team and the successful use of oral baclofen, diazepam, and IV dexmedetomidine in helping control the patient's symptoms.
