Intrathecal Baclofen Pump Wean and Risk of Exposure in a Large TBSA Burn Wound Patient: A Case Report.

Abstract

Burn injuries in patients with significant pre-existing medical conditions provide unique challenges in both medical management and surgical planning. Spasticity, if left untreated, can be one of the most disabling consequences of a neurologic injury. Treatment is largely dependent on pharmacologic management with anti-spasmodic agents such as baclofen. Baclofen's effectiveness when taken orally is often limited by its systemic side effects, which mostly affect the central nervous system (CNS). Intrathecal baclofen (ITB) can circumvent these intolerable adverse effects while achieving symptom relief via a more targeted therapeutic route. However, abrupt cessation of chronic baclofen use can precipitate an acute life-threatening withdrawal syndrome. We present a case of a 47-year-old female who sustained 54% total body surface area (TBSA) full-thickness flame burns to the circumferential bilateral lower extremities, left arm, left anterior and posterior trunk, flank, and perineum. She had a pre-morbid C5 spinal cord injury resulting in spastic paraplegia for which she had an ITB pump implanted into her left abdominal wall for symptom management. This pump was directly beneath her operative burn wounds. We discuss the complex issues that were encountered throughout her care related to medication reservoir supply, life-threatening risk of baclofen withdrawal, pain-specialist availability, medical-legal barriers, and the multi-staged surgical plan for coverage, balancing proper wound debridement with risk of device exposure and infection. To our knowledge, this is the only case report detailing the cohort of obstacles that may be associated with these devices, specifically with burn patients.