Intrathecal baclofen pump infection management: immediate versus delayed reimplantation. A single-center, 24-year experience.

Abstract

Objective: Intrathecal baclofen (ITB) pumps (ITBPs) are commonly used to provide symptomatic relief and facilitate patient care for children with spasticity. Unfortunately, patients are at long-term risk for device-related infections. Removal of infected pumps can require complicated, prolonged hospital stays for systematic reduction of preexisting high doses of ITB. The management strategy for ITBP infections has not been clearly defined. In this study, the authors sought to determine whether immediate reimplantation after wound washout is a viable strategy when managing ITBP infections rather than the more standard-of-care approach of removal and delayed reimplantation.

Methods: A retrospective review was performed for patients who underwent ITBP placement at Children's National Hospital from 1999 to 2023 (24 years) with subsequent infection requiring removal and reimplantation. Demographics, timing of reimplantation, and outcomes were collected. Statistical analysis was performed with unpaired t-tests.

Results: Over 24 years, 356 baclofen pump implantation surgeries were performed with an overall infection rate of 9.8%. Seven patients underwent ITBP removal and delayed reimplantation, and 16 underwent washout with immediate reimplantation followed by extended intravenous antibiotic therapy. There was a statistically significant decrease/wean in ITB dose prior to surgery in the delayed group compared with the immediate reimplantation group (dose decreased by a mean of 209.1 vs 15.6 μg/day, p = 0.01) with a resultant increase in preoperative length of stay for baclofen weaning (2.57 vs 1.19 days), overall hospital stay (mean 13.14 vs 7.63 days), and postoperative baclofen withdrawal (42.9% vs 6.3%, p = 0.03). There was a significantly increased risk of reinfection in the immediate reimplantation cohort (63% vs 14%, p = 0.03). However, 33% of the patients with successful immediate reimplantation were able to maintain their current baclofen dose and did not require a prolonged ICU stay. Eighty percent of patients who experienced reinfection after immediate reimplantation chose final removal, while 86% of patients who underwent delayed reimplantation still have an existing ITBP.

Conclusions: There is a lower risk of reinfection with removal and delayed reimplantation of ITBPs, and more patients in this cohort ultimately maintained their device. However, for patients on high ITB doses, immediate reimplantation in select cases may help to shorten hospital stays and prevent dangerous baclofen withdrawals and is successful for long-term pump utilization (without infection) one-third of the time.