Restoration of rostral cerebrospinal fluid flow to solve treatment failure caused by obstruction in long-term intrathecal baclofen administration

Abstract

Objects: We describe five traumatic spinal cord injury (SCI) patients with an intrathecal baclofen administration (ITB) failure caused by a rostral CSF flow obstruction referred to our expert center between January 2014 and January 2019. We discuss the diagnostic workup, rostral CSF flow obstruction as the cause of the ITB failure and treatment.Methods: When we could not determine the cause of the ITB failure through the patient's history, physical spasticity examination, pump readout, absence of fluid in the pump reservoir during aspiration, or plain radiography, we performed pump catheter access port (computed tomography [CT]) myelography. When CT myelography did not reveal the diagnosis, we used scintigraphy. In an obstruction, we aimed for CSF flow restoration. In three cases, we conducted a laminectomy with microsurgical adhesiolysis. In two of these patients, we could not achieve CSF flow restoration; thus, we placed an intradural catheter bypass. Recently, in three patients, we applied a less invasive technique of percutaneous fenestration of the obstruction.Results: In one case, we performed a successful catheter replacement. In another case using surgical adhesiolysis, spasticity control was complete. In two cases, we could obtain improvement with an additional intradural bypass, followed by a percutaneous fenestration of the obstruction, resulting in further improved CSF flow restoration. In one case, percutaneous fenestration was the first line of treatment. In all cases with percutaneous fenestration, we experienced spasticity control.Conclusion: Preliminary results showed that the restoration of rostral CSF flow might result in an effective ITB treatment in patients with an intrathecal obstruction.

Keywords: Balloon dilatation; CSF flow; ITB; Neurosurgery; Obstruction; Restoration.

Figure 1

Algorithm imaging of CSF flow obstruction.

Figure 2

Catheter access port (CAP) myelography (A) showed stagnation of contrast material (black arrow). The catheter tip is located above the contrast material (gray arrow). CAP CT myelography (B) with 4 consecutive sagittal reconstructions revealed a caudal flow of the contrast material (white arrow). Planar ¹¹¹Indium-DTPA scintigraphy 7 days (C) showed a limited rostral tracer spread, increased lumbar/thoracic gradient (gray arrow), increased caudal spread (black arrow), and insufficient cerebral cistern (white arrow).

Figure 3

CAP CT myelography (A) with 5 consecutive sagittal reconstructions revealed narrowed contrast material column (red arrow), suspicious for contrast material stagnation. ¹¹¹In-DTPA SPECT CT at 48 h (B) showed obstruction at the level of the spinal cord lesion (red arrow). ¹¹¹In-DTPA planar (C) revealed a lumbar/thoracic gradient (red arrow), limited cerebral cistern tracer spread (orange arrow). In vivo microscopic view with opened dura showed intrathecal catheter tip (yellow arrow), forceps (blue arrow), and baclofen medication crystallization (green arrow).

Figure 4

Planar ¹¹¹In-DTPA at 48 h (A, B). A patient without CSF flow obstruction with normal lumbar, thoracic, and cerebral cistern tracer spread (A). Case 4 with widened tracer activity caudal and at lumbar/low-thoracic transition (B, black arrow), thoracic gradient (B, gray arrow), and no cisternal tracer spread (B, white arrow).

Figure 5

¹¹¹In-SPECT CT with stagnation of tracer (white arrow), non-functional intradural shunt (A, E, green arrow), and no tracer activity above the tip of the shunt (A). Lumbar CT (3D) myelography with stagnation of contrast material at Th11 (B, C, white arrow), and with cervical CT (3D) at Th10 (D, E, yellow arrow). Intrathecal catheter (red arrow).

Figure 6

CAP myelography (A) and cervical CT myelography (B) with inhomogeneous stagnation (white arrow). Cervical CT myelography after percutaneous balloon fenestration (C) with restoration of contrast material spread (white arrow). Fluoroscopy during the procedure with inserted balloon (D, gray arrow). Cervical contrast material injection to evaluate the effect of balloon dilatation (black arrow): starting situation (E), some widening on the same level (F, G), and the result of the fenestration (I–J).