Prepontine placement of an intrathecal baclofen pump catheter for treatment of dystonia

Background: Cerebral palsy with medically refractory spasticity and dystonia is a condition that often benefits from intrathecal baclofen pump therapy to treat these symptoms. In this case report, an intracranial baclofen catheter was placed in the prepontine space to improve withdrawal symptoms in a patient unable to undergo new lumbar catheter placement due to infection. Case Description: A 22-year-old female with past medical history of cerebral palsy presented with baclofen pump failure and was unable to undergo placement of a new lumbar baclofen catheter due to an infection in her lower back precluding safe and efficacious catheter placement. It was decided the patient would benefit from intrathecal baclofen administered in the prepontine space as a means to avoid a lumbar catheter and thus bypass this prior infection site. An endoscopic third ventriculostomy (ETV) was performed with the endoscope and the distal end of the baclofen pump catheter was fed through this ETV into the prepontine space. Placement in the prepontine space was confirmed by a follow-up head computed tomography. There was a significant improvement in autonomic symptoms and spasticity. By postoperative day 5, the patient was surgically and medically cleared for discharge. Conclusion: In cases of severe baclofen withdrawal due to dysfunctional pumps, immediate reversal is preferred but may not be feasible due to factors such as infection. This case report has demonstrated that prepontine catheter placement can be effective for the administration of baclofen to reverse withdrawal symptoms in these types of patients.

Delayed death after hyena bite in a 3-year-old Tanzanian boy: the unique reality of neurosurgery in a resource-limited setting

A 3-year-old boy presented after a hyena bite to the skull in Tanzania. A large degloving wound with herniating cerebrum was seen in the right parietotemporal region. A CT scan confirmed a large 8-cm skull defect. The patient was taken for irrigation and debridement, but due to significant tissue loss, the skin could not be closed. CSF leaked from the wound, and two additional operations for attempted closure were undertaken but failed. The plastic surgery team was consulted, but no closure was done because of the procedure’s complexity, lack of resources, and cost. CSF diversion could not be performed due to no available lumbar catheter or external ventricular drain. Meningitis developed, leading to severe hyponatremia and death. The current case highlights both the unique mechanism of a hyena bite requiring neurosurgical intervention and the realities of practicing neurosurgery in a low-resource setting.

Epidural Anesthesia to Effectively Manage Pain and Facilitate Rehabilitation in a Pediatric Case of Complex Regional Pain Syndrome

There is a paucity of information related to treatment of pediatric CRPS. Treatment of CRPS in pediatric patients has been guided by adult recommendations, which consist of a multidisciplinary approach involving pharmacotherapy, physical therapy, and psychotherapy, as appropriate. Patients unable to tolerate physical therapy with traditional oral pharmacotherapy may require more invasive pain management techniques such as sympathetic blocks, epidural infusion of analgesics, or spinal cord stimulation to facilitate restoration of function. This case report describes the successful use of epidural infusion of fentanyl, clonidine, and bupivacaine through a tunneled epidural lumbar catheter for pain management in an 11-year-old girl who developed complex regional pain syndrome I (CRPS I) approximately 2 months after sustaining an injury to her right knee. Following short-lasting pain relief from 3 repeated blocks, she underwent an implant of a tunneled epidural catheter (TEC) and a 4-week infusion of fentanyl (2 mcg/mL), clonidine (1 mcg/mL), and bupivacaine (0.04%). At last follow-up, approximately 3.5 months after implant of the TEC, the patient’s pain and symptoms were completely resolved, her range of motion and function were completely restored, and her physical activity had returned to pre-injury levels. Key words: Complex regional pain syndrome (CRPS), tunneled epidural catheter, pediatric, continuous regional anesthesia, epidural analgesia, continuous epidural anesthesia, interventional pain management

Fluoroscopic-Guided Paramedian Approach for Lumbar Catheter Placement in Cerebrospinal Fluid Shunting: Assessment of Safety and Accuracy

BACKGROUND Spinal catheter insertion in lumboperitoneal (LP) shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) is frequently associated with technical difficulties especially in patients with obesity and elderly patients with vertebral deformities. OBJECTIVE To elucidate the accuracy and safety of image-guided spinal catheter placement using a paramedian approach (PMA). METHODS We retrospectively analyzed 39 consecutive iNPH patients treated by LP shunting with spinal catheter insertion via the PMA. The success rate of catheter placement and the number of changes in puncture location were evaluated. Accuracy of catheter insertion was assessed by measuring both vertical and horizontal deviations in the point of catheter dural penetration from the center of the interlaminar space. RESULTS The success rate of catheter placement was 100% (39/39). The difficulty rate for catheter insertion, measured by the number of changes in puncture location, was 2.6% (1/39). No bloody punctures or surgical infections were observed. Accuracy of catheter insertion, measured as the degree of deviation, was 0.5 ± 1.9 mm horizontally and 0.0 ± 2.4 mm vertically. The rates of minor complications, including caudal catheter insertion, transient low-pressure headache, and root pain, were 5.1% (2/39), 10.4% (4/39), and 0% (0/43), respectively. Subdural hematoma requiring surgical intervention occurred in 1 case (2.6%). During the mean follow-up period of 36 mo, spinal catheter rupture at the level of the spinous processes was not observed. CONCLUSION Fluoroscopic-guided spinal catheter placement via the PMA was safe, accurate, and reliable, even for use in geriatric and obese patients.

Effect of intrathecal milrinone injection via lumbar catheter on delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

OBJECTIVEDelayed cerebral ischemia (DCI) is an important complication after aneurysmal subarachnoid hemorrhage (aSAH). Although intrathecal milrinone injection via lumbar catheter to prevent DCI has been previously reported to be safe and feasible, its effectiveness remains unknown. The goal of this study was to evaluate whether intrathecal milrinone injection treatment after aSAH significantly reduced the incidence of DCI.METHODSThe prospectively maintained aSAH database was used to identify patients treated between January 2010 and December 2015. The cohort included 274 patients, with group assignment based on treatment with intrathecal milrinone injection or not. A propensity score model was generated for each patient group, incorporating relevant patient variables.RESULTSAfter propensity score matching, 99 patients treated with intrathecal milrinone injection and 99 without treatment were matched on the basis of similarities in their demographic and clinical characteristics. There were significantly fewer DCI events (4% vs 14%, p = 0.024) in patients treated with intrathecal milrinone injection compared with those treated without it. However, there were no significant differences between the 2 groups with respect to their 90-day functional outcomes (46% vs 36%, p = 0.31). The likelihood of chronic secondary hydrocephalus, meningitis, and congestive heart failure as complications of intrathecal milrinone injection therapy was also similar between the groups.CONCLUSIONSIn propensity score–matched groups, the intrathecal administration of milrinone via lumbar catheter showed significant reduction of DCI following aSAH, without an associated increase in complications.