Baclofen Pump

The treatment of severe spasticity may require a combination of approaches. One of the most common treatments for spasticity is oral baclofen, which is a muscle relaxant. Although this works for many people, some children need high doses to manage their spasticity. Higher doses may cause side effects, such as weakness, drowsiness, and nausea. However, even high doses may still not treat some children’s spasticity effectively. These patients may want to consider a baclofen pump.

Spasticity involves tight, stiff muscles that make movement — especially of the arms and legs — difficult or uncontrollable. It happens when there is an injury to a part of the central nervous system (the brain or spinal cord) that controls voluntary movements. Common conditions associated with spasticity include cerebral palsy, brain injury, stroke, multiple sclerosis, and spinal cord injury. Spasticity can sometimes be very difficult to control and can get in the way of daily living.

A baclofen pump is a little machine that is placed under the skin of one side of the abdomen (belly) near the hip bone. It is used to deliver baclofen directly into the spinal canal.

The pump is attached to a catheter (tube), which helps direct the medicine right to a specific area of the spinal cord (called the intrathecal space). This allows the medication to be delivered exactly where it works to help reduce the spasticity. When the same medication is given by mouth, only a tiny bit of it actually gets to the area where it works.

The pump delivers medication constantly throughout the day to help relieve spasticity. It can also be programmed to deliver different amounts of medication at different times of the day, if needed. A programmer (a very small computer) is used to tell the pump how much medicine to give. It uses telemetry (similar to radio waves) to communicate with the pump.

Once the pump is implanted and the dose is increased gradually to a level that is working for your child, there will be a notable improvement in their spasticity and comfort. There are no major limitations on activities once the surgery site is healed. Patients can do all the things they were doing previously.

If your doctor recommends a baclofen pump for your child, you will meet with the baclofen pump nurse practitioners and learn about the pump to make sure it is appropriate for your child.

From there, the baclofen pump nurse practitioners will help schedule an appointment with a neurosurgeon. You and your child will meet with the neurosurgeon to discuss the baclofen pump further and plan for the surgery.

Baclofen pump therapy is not suitable for every child, so a trial helps you and your doctors decide if it’s right for you. Having a trial does not mean your child will definitely get a pump as there are many influencing factors. All of them will be discussed with you before any decision is made.

• A physical therapist will examine your child in the morning prior to the procedure to learn his or her baseline level of spasticity.
• Your child will have a local or general anesthetic and will be given an injection (called a lumbar puncture) of baclofen into the space surrounding the spinal cord. This happens in the operating room.
• Your child should not have any pain during the procedure because of the anesthetic. During the day, your child may develop a headache. This can be a side effect of the lumbar puncture.
• After the procedure, your child will go to a recovery room and nurses will care for and observe him or her while the effects of the anesthetic wear off. Side effects can include drowsiness, nausea, and vomiting.
• The baclofen will begin to work about two to three hours after the medicine is injected. At that time, a doctor and physical therapist will examine your child again to see if the baclofen has had any effect on your child’s muscles.

If the trial is successful and your child responds well to the baclofen, we will proceed with placement of the baclofen pump, usually the next day, if this is what you decide.

The trial is a single dose of baclofen and may have a big effect on the tone (tension in the muscles) of your child’s legs. Remember, this effect may be more or less dramatic than the effect from the pump. This is because the pump dosing will be continuous and will be adjusted specifically for your child.

If you and your child’s doctors decide that a baclofen pump is appropriate, the surgery is usually performed the day after the trial. Surgery lasts about two to three hours. The length of surgery will be reviewed at your initial appointment with the surgeon. If your child has had a spine fusion, the procedure may last a little longer.

After the surgery, your child will need to stay in a bed for 24 hours to help prevent headache. After that, your child can get out of bed after getting used to sitting up. You child will stay in the hospital for two to five days after surgery, depending on his or her individual recovery.

At first, the pump is programmed for a very low dose. The team will see your child on an outpatient basis every one to two weeks for small adjustments until the spasticity is improved.

Your child will have one incision at the abdomen (belly) and one incision over the lower spine (low back). There will be dressings over the incisions that include Steri-Strips (white tape strips) across the incisions, which will fall off on their own. Keep them dry for one week after surgery. If they don’t fall off, you may take them off two weeks after surgery. Your child may bathe, swim, or submerge the incisions after two weeks if the incisions are healed.

For a few days to weeks after surgery, your child may have some swelling around the top and sides of the pump. This is from fluid and it is normal. An ace wrap or abdominal binder around the belly helps provide pressure to limit the swelling and to improve comfort. Your child should wear the binder for six to eight weeks after surgery.

If you notice any drainage from the incisions or any redness, contact the Baclofen Pump Team on call through the hospital pager at #7867 (PUMP).

• Activity: Your child will need to limit bending, twisting, or turning at the waist for six weeks. This limits stress on the incision and helps the catheter heal into place in your child’s back. Regular activities are fine. Flying on an airplane is OK, but you should let airport security know about the pump because it may set off security alarms.
• Medications: You may give your child acetaminophen (Tylenol®) every four to six hours for pain if needed. Never stop anti-spasticity medicines like baclofen or Dantrium suddenly. This can cause withdrawal symptoms and may lead to illness. These medicines need to be stopped slowly. Once your child has a good result from the pump (which may take a couple of months), we will make a plan to begin stopping the oral baclofen.
• Constipation: Constipation will sometimes get worse with a baclofen pump. Your child should have a bowel movement at least every two to three days. Keep your child on their bowel medicines if they use them. Ask your child’s doctor for help with this if needed.
• School: Your child should be able to return to school within a week or so after coming home from the hospital. The school nurse will not need to address the pump but may need to reposition the binder to ensure it remains in the correct position in the first couple of months after surgery.
• Coordination with other health care providers: Be sure to let you child’s other health care providers know that he or she has a pump.
• Pump information: Always carry the emergency card and plastic guide that will be mailed to you after the surgery by Medtronic. This card will inform emergency personnel of the pump.
• Follow-up appointments: Appointments will be scheduled with the baclofen pump nurse practitioner every one to two weeks to adjust the dose of baclofen given through the pump until the correct dose is reached. Your child will also see the neurosurgeon about four weeks after surgery to check the incision for proper healing.

Your child’s baclofen pump will need to be refilled every two to six months depending on the dose. On the front of the pump, there is a silicon port (opening) in the middle. A long, thin needle is used to inject the baclofen through the silicon into this port.

Your child will have the baclofen pump refilled in a clinic at Boston Children’s Hospital or a Boston Children’s Hospital satellite clinic. The visit takes 30 to 45 minutes.

• The skin over the pump will be numbed so your child will not feel the needle stick. The numbing cream is put on at home and should stay on for at least 60 minutes before the procedure starts.
• The area over and around the pump will be cleaned with a topical antiseptic solution to eliminate any germs in the area.
• A special paper drape is placed over the stomach with an open circle to expose the pump. A small plastic template is placed on the pump to help locate the refill port.
• A needle is inserted into the port of the pump. The old medicine in the pump is replaced with new medicine. The numbing cream used earlier will prevent your child from feeling any pain.
• Once the refill is complete, a device is used to program the pump to indicate that it has been filled with new medicine. The device will also report when the next refill is due.
• The nurse practitioner will schedule another refill appointment for your child before you leave.

We keep track of when your pump needs to be filled. If you need to change a refill visit, call your nurse practitioner immediately. You must reschedule the visit when you call. If you miss a refill visit, your child could have withdrawal symptoms and need to stay in the hospital.