Baclofen pump

What is Intrathecal Baclofen Therapy?
Intrathecal Baclofen Therapy (ITB) is a drug delivery system used to treat muscle spasticity. The system is composed of a pump that delivers the medication through a small catheter placed into the spinal fluid space (intrathecal space) surrounding the spinal cord. The pump delivers a small continuous dose of baclofen, the drug used to treat spasticity. The pump and spinal catheter are placed during a surgery.

What is an Intrathecal Baclofen Pump (ITB)?
The ITB pump is a round metal device that is about one inch thick and three inches in diameter and weighs about 6 ounces. Most of the device is a chamber that holds the medication; it also has an internal battery and a very small pump. It is implanted in the tissues of the abdomen. The pump is connected to a flexible catheter that is tunneled under the skin from the pump to the spine, and into the spinal fluid space, where it is placed to deliver the medicine into the spinal fluid.

What are the benefits of ITB therapy?

• An ITB pump helps eliminate the risks and side effects associated with taking an oral form of baclofen
• It is considered a more effective for of treatment for spasticity because it brings the medicine into direct contact with the spinal fluid
• By reducing the spasticity, it often significantly reduces pain and can lead to improved mobility

What are the risks of ITB therapy?
Your child's neurosurgeon will discuss with you and your child the risks of ITB therapy as a form of treatment. As with any surgery, there is a chance of infection. Although infections are often not severe, it can require the removal/replacement of the pump. Other side effects – such as becoming too loose - are temporary and can often be resolved by adjusting the dose of medication released by the pump. It is also important to know and understand the signs and symptoms of baclofen overdose and withdrawal as this may be caused by a device malfunction (see 'When should I call the doctor?')

Is my child a candidate for ITB therapy?
Most patients who will benefit from intrathecal baclofen can be identified at a doctor's visit and with appropriate examination. In some cases, a test dose of baclofen will need to be performed to see if your child qualifies for an ITB pump. During the test dose, your child's doctor will inject a small amount of baclofen directly into the spinal fluid in your child's lower back by way of a spinal tap. Doctors and nurses will monitor your child over the course of several hours to see the medication's effects. If your child's muscles loosen or relax, then he or she may respond well to an ITB pump. However, if your child's muscles show no sign of release then your child's physician may decide to repeat the test to see if your child's spasticity would respond better to a higher dose of baclofen. The injection during the screening process wears off after 5-8 hours, and your child's level of spasticity will return to their previous state. In some cases, a temporary increase in muscle tone will occur. If your child had a positive response to the treatment, he or she may be a good candidate for an ITB pump.

Implanting the ITB pump
If surgery to implant a baclofen pump is recommended, your child will be referred to a Children's pediatric neurosurgeon, who will review with you the surgical procedure, the expected hospital stay, and the risks of surgery. When the child comes to the hospital for the surgery, you and your child will meet with the rest of the surgical team responsible for these procedures - OR nurses, anesthesiologists, and others helping them – who will further explain the process.

During surgery, the neurosurgeon will fill the pump with baclofen and implant it just under the tissues of the abdomen, between the waistline and the edge of the ribs. The catheter connected to the pump will be routed to the lower back, where a second incision will be made to place the catheter into the intrathecal space. In the operating room, the pump will be programmed to deliver a small daily dose of baclofen.

What happens after my child receives the ITB pump?
After implantation surgery, your child will need to stay at Children's for one to two nights, depending on how he or she feels. Some weakness, discomfort, or tenderness after the surgery is normal. The child will typically stay in bed for rest of the day after surgery, and much of the following day before starting to get up. Over the next 1-2 days the physicians will assess how well the medication is working, and will usually adjust the pump (with an electronic programmer) once or twice a day.

Once discharged, your child may need to wear a lower back binder for several weeks to help keep the pump in place as it heals. The hospital team will give you instructions about keeping the wounds clean and about bathing/showering. Your child will likely feel some level of tenderness and discomfort at the incision sites for a period of time, and should limit physical activity for four to six weeks to allow his/her body to adjust and heal.

Once the incision sites have healed well, the pump doesn't require unique care.

The medicine in the pump will need to be emptied and refilled on a regular basis (the timing will be defined by the amount of medication that is ultimately needed for control of the spasticity). Refills are done via a small needle that a physician inserts through the skin directly into the pump reservoir. If the amount of medicine in the pump or battery begins to get low, the device will beep to inform you that it needs to be checked. In addition, the device’s battery should last between 4 to 7 years, at which time the entire device will be replaced.

Follow-up care is very important in maintaining the quality and effectiveness of the ITB pump. Your child's physician will let you know how often your child needs to be seen.

When should I call the doctor?
You should call your child's physician if:

• Your child begins to show signs of drug overdose (loose/floppy muscles, sleepiness, trouble breathing, seizures, vomiting)
• Your child complains of severe pain
• Your child shows signs of underdose or withdrawal (increased muscle tightness, sweating, irritability, random itchiness without a rash)
• The pump alarm goes off