title: Bladder stones - red herring for resurgence of spasticity in a spinal cord injury patient with implantation of Medtronic Synchromed pump for intrathecal delivery of baclofen - a case report.
abstract: BACKGROUND
  Increased spasms in spinal cord injury (SCI) patients, whose spasticity was previously well controlled with intrathecal baclofen therapy, are due to (in order of frequency) drug tolerance, increased stimulus, low reservoir volume, catheter malfunction, disease progression, human error, and pump mechanical failure. We present a SCI patient, in whom bladder calculi acted as red herring for increased spasticity whereas the real cause was spontaneous extrusion of catheter from intrathecal space.
  
  
  METHODS
  A 44-year-old male sustained a fracture of C5/6 and incomplete tetraplegia at C-8 level. Medtronic Synchromed pump for intrathecal baclofen therapy was implanted 13 months later to control severe spasticity. The tip of catheter was placed at T-10 level. The initial dose of baclofen was 300 micrograms/day of baclofen, administered by a simple continuous infusion. During a nine-month period, he required increasing doses of baclofen (875 micrograms/day) to control spasticity. X-ray of abdomen showed multiple radio opaque shadows in the region of urinary bladder. No malfunction of the pump was detected. Therefore, increased spasticity was attributed to bladder stones. Electrohydraulic lithotripsy of bladder stones was carried out successfully. Even after removal of bladder stones, this patient required further increases in the dose of intrathecal baclofen (950, 1050, 1200 and then 1300 micrograms/day). Careful evaluation of pump-catheter system revealed that the catheter had extruded spontaneously and was lying in the paraspinal space at L-4, where the catheter had been anchored before it entered the subarachnoid space. A new catheter was passed into the subarachnoid space and the tip of catheter was located at T-8 level. The dose of intrathecal baclofen was decreased to 300 micrograms/day.
  
  
  CONCLUSIONS
  Vesical calculi acted as red herring for resurgence of spasticity. The real cause for increased spasms was spontaneous extrusion of whole length of catheter from subarachnoid space. Repeated bending forwards and straightening of torso for pressure relief and during transfers from wheel chair probably contributed to spontaneous extrusion of catheter from spinal canal in this patient.
authors.affiliation: Regional Spinal Injuries Centre, District General Hospital, Southport, PR8 6PN, UK. vaidyanathansiu@hotmail.com
authors.forename: Subramanian
authors.initials: S
authors.lastname: Vaidyanathan
authors.forename: Bakul M
authors.initials: BM
authors.lastname: Soni
authors.forename: Tun
authors.initials: T
authors.lastname: Oo
authors.forename: Peter L
authors.initials: PL
authors.lastname: Hughes
authors.forename: Gurpreet
authors.initials: G
authors.lastname: Singh
authors.forename: John W H
authors.initials: JW
authors.lastname: Watt
authors.forename: Pradipkumar
authors.initials: P
authors.lastname: Sett
mesh_terms: D000328:Adult; D001418:Baclofen / Q000008:administration & dosage / Q000009:adverse effects*; D004868:Equipment Failure; D006801:Humans; D015918:Infusion Pumps, Implantable; D008297:Male; D009125:Muscle Relaxants, Central / Q000008:administration & dosage / Q000009:adverse effects*; D009128:Muscle Spasticity / Q000188:drug therapy / Q000209:etiology*; D011859:Radiography; D013119:Spinal Cord Injuries / Q000150:complications*; D013375:Substance Withdrawal Syndrome / Q000150:complications*; D001744:Urinary Bladder Calculi / Q000150:complications / Q000000981:diagnostic imaging*
chemical_list: D009125:Muscle Relaxants, Central; D001418:Baclofen