Baclofen bridging, weaning protocol and pain management of a person with T6 paraplegia who required removal of intrathecal baclofen pump due to wound infection

BMJ Case Reports, 2021 · DOI: 10.1136/bcr-2021-242686 · Published: September 15, 2021

Spinal Cord Injury Pain Management Neurorehabilitation

Simple Explanation

This case report describes the management of a patient with severe spasticity and pain after spinal cord injury whose intrathecal baclofen pump had to be removed due to complications. The authors suggest an effective strategy for transitioning the patient from intrathecal to oral baclofen to manage spasticity and pain while preventing baclofen withdrawal symptoms. The strategy includes a combination of oral baclofen, clonazepam, tizanidine, and propofol, along with pain management using paracetamol and tramadol.

Study Duration

Not specified

Participants

One patient with T6 paraplegia

Evidence Level

Case report

Key Findings

1
Sudden removal of an intrathecal baclofen pump can lead to severe withdrawal symptoms, including increased spasticity, pain, and seizures.
2
A bridging protocol using oral baclofen, tizanidine, clonazepam, and propofol can effectively manage spasticity and prevent withdrawal symptoms after ITB pump removal.
3
A multimodal approach addressing nociceptive pain, musculoskeletal pain, and neurogenic bladder can help control spasms and reduce the need for opioid and neuropathic pain medications.

Research Summary

Intrathecal baclofen is recognised as an effective treatment option for severe symptoms of segmental spasticity after spinal cord injury. We suggest an effective bridging and weaning protocol for oral drug titration to treat spasticity and pain as a blended syndrome in this challenging situation. The case illustrates our approach to baclofen bridging and weaning after ITB pump failure.

Practical Implications

Clinical Practice

Close monitoring and oral replacement bridging protocols are essential to avoid side effects of sudden baclofen withdrawal after ITB pump removal.

Surgical Considerations

Meticulous review for noxious stimuli is crucial for patients undergoing spinal surgery, irrespective of the severity of the original spinal cord injury.

Pain Management

Pain should be evaluated as a differential of nociceptive, somatic, and/or visceral origins and treated promptly.

Study Limitations

1
Qualitative/anecdotal reporting of pain perception is a limitation of this report.
2
The use of objective pain scores throughout the experience, such as the Numeric Graphic Rating Scale or Scale of Pain Intensity (SPIN) screen would have been beneficial
3
Single case study limits generalizability.

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