Best-practice surgical techniques for intrathecal baclofen therapy

In March 2004, a multidisciplinary conference, "ITB Therapy Best Practice Forum," was held in Minneapolis, Minnesota. The goal of the conference was to develop recommendations for techniques to implant intrathecal baclofen (ITB) pump and catheter systems more effectively and with fewer complications. The authors present the techniques for optimal pump and catheter implantation, including subfascial pump placement; insertion of the Tuohy needle in an oblique, paramedian trajectory; and positioning of the catheter tip at levels commensurate with the therapeutic indication: approximately T10-12 for spastic diplegia, C5-T2 for spastic tetraparesis, and C1-4 for generalized secondary dystonia. Techniques to minimize the incidence of cerebrospinal fluid leakage are described, including the identification of preoperative occult hydrocephalus and the use of a suture ligature around the Tuohy needle at its exit site from the fascia. Techniques to minimize surgery-related infection are also detailed; most involve the use of iodine solutions multiple times intraoperatively. Techniques to insert intrathecal catheters during spinal fusion are addressed, particularly the technique of inserting the catheter cephalad to the fusion site. Panel members advocate the aforementioned techniques to improve the efficacy of and decrease the morbidity associated with ITB therapy.