Mark Joshua Williams, MD
Resident Physician
University of Miami / Jackson Health
MIAMI, Florida, United States
Andrew Logan, MD
Interventional Pain Fellow
University of Miami / Jackson Health System
Coral Springs, Florida, United States
Nicole L. Pontee, MD
Assistant Professor
University of Miami
Miami Shores, Florida, United States
Dennis J. Patin, MD
Attending Physician, Associate Professor
University of Miami
MIAMI, Florida, United States
Patient is a 36 y/o Male who suffered an intracranial hemorrhage at 17 due to an arteriovenous malformation resulting in severe spastic quadriparesis requiring baclofen pump placement. His dose of intrathecal baclofen had been stable at 1600mcg daily since 2019. He presented to clinic for his regular baclofen refill and was noted to have erosion of the pump through the skin. He was sent to the ER and the pump was removed one day later. A temporary intrathecal catheter was placed for baclofen weaning. The dose given was initially half of his daily infusion dose given in three boluses, then each subsequent day the dose was halved until discontinued altogether. He was closely monitored during this time in the Neuro ICU, and was successfully weaned off intrathecal baclofen. His course was complicated by periods of withdrawal requiring bolus doses and adjustment of his enteral antispasmodic medications and supportive care.
Discussions:
Acute cessation of baclofen can lead to baclofen withdrawal syndrome, which includes symptoms such as pruritus, agitation and hyperthermia. If baclofen withdrawal goes untreated, it can lead to respiratory failure, seizure, rhabdomyolysis, and ultimately multi-system organ failure which can culminate in death. There is a paucity of literature regarding appropriate titration of intrathecal baclofen after baclofen pump removal. We utilized scheduled boluses of intrathecal baclofen, but unfortunately our patient still experienced withdrawal symptoms. Additional treatment with enteral and IV medications were warranted to reduce his withdrawal symptoms
Conclusions:
The use of scheduled and as needed boluses of intrathecal baclofen may help mitigate baclofen withdrawal after acute baclofen pump removal, but further research is necessary. Supportive care in an intensive care unit setting is most appropriate to monitor vitals closely. Adjunctive therapy with enteral antispasmodics and IV treatments are appropriate to mitigate withdrawal symptoms.
