Delayed complications of discontinuation of intrathecal baclofen therapy: resurgence of dyssynergic voiding, which triggered off autonomic dysreflexia and hydronephrosis.
METHODS
Case report.


OBJECTIVE
To report insidious development of autonomic dysreflexia and hydronephrosis due to dyssynergic voiding following discontinuation of intrathecal baclofen therapy.


METHODS
Regional Spinal Injuries Centre, Southport, UK.


METHODS
A male patient with paraplegia at T-5 (ASIA-A) had implantation of Medtronic Synchromed 8615 s programmable pump to control intractable spasms. After 4 years, the baclofen pump needed replacement because of battery exhaustion. At this time, he was taking oxybutynin 2.5 mg twice a day. He wore a penile sheath and performed intermittent catheterisation three times a day. Intravenous urography showed no dilatation of pelvicalyceal systems or ureters. During the course of the next 4 months, the dose of baclofen had to be increased gradually to 820 microg/day in order to control the spasms. Investigations revealed disconnection of the tube from the pump. The patient decided to undergo explantation of the pump and discontinue intrathecal baclofen therapy altogether. Following removal of the pump, he was prescribed baclofen 20 mg four times a day and diazepam 5 mg twice a day. He continued penile sheath drainage with oxybutynin 2.5 mg twice a day. Although spasms were controlled with oral baclofen and diazepam, he started getting transient, mild headache during reflex voiding. After nearly 2 years, he developed unbearable and pounding headache while passing urine.


RESULTS
The dose of oxybutynin was increased to modified release formulation, 20 mg, once daily. He was prescribed modified release alfuzosin 10 mg once a day. Indwelling urethral catheter drainage was instituted. Intravenous urography showed dilation of left renal pelvis and calyces, and left ureter. After a fortnight, the dose of modified release oxybutynin was increased further to 25 mg once a day. After a month, he started performing self-catheterisation every 3 h and symptoms of autonomic dysreflexia subsided completely. A follow-up intravenous urography performed 6 months later, showed normal appearances of the left kidney.


CONCLUSIONS
Spinal cord injury patients, in whom intrathecal baclofen therapy is terminated, need close monitoring of their urological status. Medications, which are prescribed for neuropathic bladder, and the method of bladder drainage, may need suitable changes, as discontinuation of intrathecal baclofen therapy can result in reappearance of detrusor-sphincter dyssynergia in previously susceptible patients.
Vaidyanathan
S
S
Regional Spinal Injuries Centre, District General Hospital, Southport, UK.
Soni
B M
BM
Oo
T
T
Hughes
P L
PL
Singh
G
G
Mansour
P
P
D000293:Adolescent; D020211:Autonomic Dysreflexia / Q000000981:diagnostic imaging / Q000188:drug therapy*; D001418:Baclofen / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D006869:Hydronephrosis / Q000000981:diagnostic imaging / Q000188:drug therapy*; D007278:Injections, Spinal; D008297:Male; D010264:Paraplegia / Q000000981:diagnostic imaging / Q000188:drug therapy; D011859:Radiography; D001743:Urinary Bladder / Q000000981:diagnostic imaging; D014555:Urination Disorders / Q000000981:diagnostic imaging / Q000188:drug therapy*
D001418:Baclofen