ITB Best Practices Screening

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ITB Best Practices Screening Linda E. Krach, MD

Disclosures • Dr. Krach has no disclosures for this presentation

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Objectives Upon completion of the session, delegates will understand the advantages and disadvantages of intrathecal baclofen trialing Pre-trial preparation Patient/family education Technical details Assessments Adverse effect management Post-trial/pre-implant planning

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Pre-trial preparation • Patient/family education • Define goals of screening test • Evaluate for medical stability – Free of infection, wound, other problems that could result in increased tone – Assessment of anticoagulation status – Considerations regarding chemoneurolysis – Considerations regarding weaning oral medications

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Education

• Ongoing process • On/off effect of test dose vs. constant infusion • What to expect on the day of the trial • What to expect after the trial

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Goal setting-for ITB

• Tone reduction • Comfort/positioning • Functional changes

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Tone reduction

• Need a means to assess tone during trial – Ashworth Scale – Modified Ashworth Scale – Tardieu Scale – Pendulum test – Patient assessment of spasms-frequency and intensity

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Be consistent in what is used!

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Pendulum test

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Tardieu

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Functional evaluations – Functional Mobility • • • •

Bed mobility Transfers Ambulation as appropriate Consider manual muscle testing –

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Reassure individual about residual strength

When to wean oral medications? • Consider if one of the goals is to ultimately wean off of oral medications – Customized for each individual

• Timing of botulinum toxin, phenol or alcohol injections – Don’t want to mask effect of trial

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Anticoagulation considerations

• Anticoagulation/antiplatelet therapy – Consult with prescribing physician to weigh risks and benefits – Guidelines for discontinuation of specific agents during neuraxial anesthesia as a guideline • Horlocker 2011. Br J Anaesth • Narouze et al 2015. Reg Anesth Pain Med

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Where to do the procedure?

• Safe delivery of medication, monitoring, and evaluation • Accessible environment • Place to do assessments • Access to fluoro or ultrasound, as appropriate • Consideration for IV access

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Trial itself

• Patient positioning – Dependent on deformity present, pain, etc.

• Sterile technique for LP – Standard dose 50 mcg • Alterations in standard? • Need to repeat? Wait at least 24 hours

– Barbotage • Improve distribution of drug

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Barbatoge

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Monitoring

• Cardiopulmonary parameters frequently during first 2 hours post injection • Tone assessment at least twice within first 4 hours post injection • Functional activities also at least twice within first 4 hours • D/C once tone is returning

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Adverse events

• Spinal headache – Due to LP, not medication – Up to 30% – Small, pencil point needle to decrease likelihood – Headache worse when upright – Treatment • • • • 17

Bedrest Caffeine Good hydration Blood patch if persistent

Adverse effects

• Nausea/vomiting~ 2% • Drowsiness/sedation~6% • Hypotension~1% • Respiratory depression <1% • Urinary retention <1%

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Post-Procedure

• Review results-plan subsequent intervention – Communicate with implanter • Dose and delivery mode, catheter tip level, pump size • Presence of GT or VP shunt

– Communicate with primary care provider – Communicate with referring physician and pump managing provider

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Post-procedure

• Plan for pre-implant assessment of – Nutritional status – Bowel and bladder status – Consideration of post implant rehabilitation services – Prior authorization for implant and any needed rehab services

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