Stephen Chien, BA
Medical Student
Drexel University College of Medicine
West Lawn, Pennsylvania, United States
Michael Juszczak, MD
Resident Physician
Reading Hospital Rehabilitation at Wyomissing / Tower Health
Reading, New York, United States
William Gleason, MD
Assistant Program Director, Tower Health PM&R Residency; Assistant Professor of Medicine, Drexel COM
Tower Health
Wyomissing, Pennsylvania, United States
Kevin Moser, MD
Physiatrist
Tower Health
Sinking Spring, Pennsylvania, United States
Somkiat Hemtasilpa, MD
Program Director
TowerHealth
wyomissing, Pennsylvania, United States
Kelley Crozier, MD, MBA
Chair of PM&R
Reading Hospital Rehabilitation at Tower Health
Wyomissing, Pennsylvania, United States
A 28-year-old male with AIS A T5 spinal cord injury (SCI) resulting in paraplegia, neurogenic bladder, and spasticity requiring an intrathecal baclofen (ITB) pump presented with 2 days of worsening spasms, tremors, hyperhidrosis, and hypertension. Laboratory studies did not show evidence of a leukocytosis, elevated inflammatory markers, or illicit substance abuse. Pump interrogation indicated the reservoir was full, suggesting a mechanical issue based on the timing of the last medication refill. An abdominal x-ray and catheter dye study confirmed pump malfunction as no dye was visualized in the intrathecal space. Neurosurgery was consulted and the patient ultimately underwent a pump revision procedure.
Discussions:
When assessing for ITB pump malfunction, it is crucial to rule out common causes of increased spasticity and sympathetic symptoms, such as infection, autonomic dysreflexia (AD), and illicit substance use. ITB withdrawal can occur with pump failure, presenting as pruritus, fever, and increased spasticity, with severe cases leading to AD and seizures. Elevated creatinine kinase may indicate concurrent rhabdomyolysis. Radiographs are utilized to help evaluate the integrity of the ITB system. Treatment involves baclofen to alleviate spasticity, IV fluids to prevent organ damage, and close monitoring of vital signs given the high risk of clinical decompensation.
Initially, this patient’s symptoms were thought to be related to AD, however, a negative urinalysis ruled out infection and there was no evidence of urinary or stool retention. Despite management efforts, symptoms persisted, leading to imaging and device interrogation that confirmed pump malfunction and inadequate baclofen delivery.
Conclusions:
This case highlights the importance of conducting a thorough evaluation to systematically rule out life-threatening conditions when ITB pump malfunction is suspected. Though rare, pump malfunction should be considered when patients present with AD related symptoms. Ruling out infection, utilizing imaging and laboratory studies, and device interrogation are essential for timely treatment.
