Disclosures: Lauren M. Desmarais, DO: No financial relationships or conflicts of interest

Case Diagnosis: 3-year-old boy with anoxic brain injury

Case Description: A 3-year-old boy sustained anoxic brain injury due to a near drowning with return of spontaneous circulation after 45 minutes of cardiopulmonary resuscitation. Magnetic resonance imaging noted anoxic injury to the bilateral thalamic structures. Course was complicated by severe paroxysmal sympathetic hyperactivity, dystonia, and opisthotonic posturing which was refractory to multiple medications including Clonidine, Phenobarbital, Clonazepam, Baclofen, Dantrolene, Propranolol, and Morphine. With persistent opisthotonic posturing and dystonia present at 1 month post injury, patient underwent Abobotulinumtoxin A and Phenol injections at time of G-tube placement, and exam under sedation was notable for continued lumbar lordosis and bilateral hip extension with inability to flex hips to neutral. Severe dystonia and opisthotonic posturing persisted despite conservative management, so a week later, an intrathecal catheter was placed for intrathecal Baclofen (ITB) trial. In order to introduce the catheter, neurosurgery performed L3-L4 laminectomy as lumbar puncture was not possible given continued opisthotonic posturing under sedation.

Setting: Tertiary care pediatric hospitalAssessment/

Results: With a starting dose of 50 micrograms of Baclofen, patient was able to lay supine and hips were able to flex to neutral. ITB pump was subsequently placed a week later with catheter tip at C4. This patient has now been weaned off all tone medications, his hips are able to flex past neutral allowing him to sit in a wheelchair, and he was started on neurostimulants with continued progression in coma recovery scale testing.

Discussion: ITB pumps have been used in patients with significant tone and opisthotonic posturing. Interestingly, this patient continued to have severe hip extension and lumbar lordosis, even while fully sedated, leading to concern for hip extension contractures. His range of motion, however, dramatically improved after the pump was placed.

Conclusion: ITB can be useful in refractory opisthotonic posturing management.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/intrathecal-baclofen-pump-for-refractory-dystonia-and-opisthotonic-posturing-a-case-report/