Epidural catheter placement in children with baclofen pumps

Abstract

Background Children with cerebral palsy often suffer from increased tone, which can be treated with intrathecal baclofen via implanted pump. Additionally, they often require major orthopedic surgery for hip reconstruction; however, the presence of an intrathecal baclofen pump is a relative contraindication to regional anesthesia due to concerns about damaging the intrathecal baclofen pump system. Aims (a) To evaluate adverse events related to placing epidural catheters in children with intrathecal baclofen pumps and (b) describe our multidisciplinary approach to the care of these complex patients. Methods Children with cerebral palsy and intrathecal baclofen pump in situ who underwent hip reconstruction between 2010 and 2019 and had a perioperative epidural placed were reviewed retrospectively. Charts were assessed for adverse events or intrathecal baclofen complications. Fluoroscopic images were reviewed to evaluate the proximity between epidural and intrathecal baclofen catheters. The process of coordinating multiple services was examined. Results Sixteen children met the inclusion criteria. There were no major complications following epidural placement. Postoperative pump interrogation was normal for all patients. Fluoroscopy was utilized for 9/16 (56%) epidural procedures. Epidurogram was used to confirm 11/16 catheters (68%). Children with an intrathecal baclofen pump were identified by orthopedic surgeons at the time of surgical booking and referred to the regional anesthesia team for review. The neurosurgical, pain, and regional anesthesia teams determined the appropriateness and safety of approaching the neuraxis. Pain and/or regional anesthesiologists with competency in spine fluoroscopy were scheduled on the day of surgery for fluoroscopically guided epidural placement. Postoperatively, catheters were managed by the acute pain team. Intrathecal baclofen pumps were interrogated by the baclofen pump team prior to patient discharge. Discussion In this case series, not only was epidural placement feasible but also there were no observed complications. This work highlights the importance of a multidisciplinary approach to complex regional anesthetic techniques, as well as the importance of basic competency in spine fluoroscopy for regional anesthesiologists.

Regional anesthesia in pediatric patients with preexisting neurological disease

“…Neuraxial anesthesia has been established as both a safe and effective method for pain management in CP patients 79‐82 . In those with previous spinal fusions, where epidural placement is more challenging, caudal catheters have been used as alternatives.…”

Error traps in pediatric regional anesthesia

“…20,21 In the largest study to describe the feasibility of epidural catheters in these patients, fluoroscopy was utilized for placement in nine of the 16 patients, and 11 were confirmed with epidurograms by interventional pain specialists. 20 No complications were reported in this retrospective series. In situations where fluoroscopy is to be avoided, additional information can be gathered by reading the operative report.…”

“…However, the presence of an intrathecal pump is often considered a contraindication to neuraxial anesthesia. Arguments against neuraxial blockade include the risk of damaging the intrathecal tubing, leads and/or the subcutaneous pump when performing the procedure, the potential for epidural catheter misdirection, and concerns for seeding infection to implanted hardware 19,20 . Yet, there have been a number of case reports that detail successful epidural placement 20,21 .…”

“…Arguments against neuraxial blockade include the risk of damaging the intrathecal tubing, leads and/or the subcutaneous pump when performing the procedure, the potential for epidural catheter misdirection, and concerns for seeding infection to implanted hardware 19,20 . Yet, there have been a number of case reports that detail successful epidural placement 20,21 . In the largest study to describe the feasibility of epidural catheters in these patients, fluoroscopy was utilized for placement in nine of the 16 patients, and 11 were confirmed with epidurograms by interventional pain specialists 20 .…”

“…19,20 Yet, there have been a number of case reports that detail successful epidural placement. 20,21 In the largest study to describe the feasibility of epidural catheters in these patients, fluoroscopy was utilized for placement in nine of the 16 patients, and 11 were confirmed with epidurograms by interventional pain specialists. 20 No complications were reported in this retrospective series.…”