P.154 Subcutaneous intrathecal catheter and port implants for administration of Nusinersen in patients with Spinal Muscular Atrophy

Background: Until recently, no effective treatment was available for spinal muscular atrophy (SMA). In 2017, Health Canada approved intrathecal Nusinersen a medication that prevents degeneration of the motor neurons in the spinal cord. The administration is intrathecally most commonly via lumbar puncture (LP) to have a direct effect on the motor neurons of the spinal cord. Many older patients with SMA and concomitant spinal deformities present technical challenges to access the thecal sac. Different routes have been described for delivery of the medication whoever these techniques may require sedation, are associated with radiation exposure, and demand experience personnel. Methods: A new surgical technique has been proposed to overcome these obstacles by combining two Health Canada approved devices: 1) an intrathecal catheter designed for intrathecal baclofen pumps and 2) an implantable subcutaneous port designed for intravascular medication administration Results: We describe the technical nuances and outline the clinical outcomes of six patients with complex spine deformities who have undergone such an implant for administration of Nusinersen. Conclusions: We discuss the benefits of the procedure which includes: 1) administration in the outpatient setting without sedation, 2) avoidance of costly imaging and experienced personnel, and 3) placement of the catheter in the cervicothoracic junction.

P.227 Investigating the changes in ITP after CSF drainage in patients with acute traumatic SCI: Results from a Quaternary Spinal Care Center

Background: Mean arterial pressure augmentation is one current established practice for management of patients with SCI. We present the first data investigating the effectiveness of Intrathecal Pressure (ITP) reduction through CSF drainage (CSFD) in managing patients with acute traumatic SCI at a large academic center. Methods: Data from 6 patients with acute traumatic SCI were included. A lumbar intrathecal catheter was used to monitor ITP and volume of CSFD. CSFD was performed and recorded hourly. ITP recordings were collected hourly and the change in ITP was calculated (hour after minus before CSFD). 369 data points were collected and change in ITP was plotted against volume of CSFD. Results: Data across all patients showed variability in the ITP over time without a significant trend (slope=0.016). We found no significant change in ITP with varying amounts of CSFD (slope=0.007, r2=0.00, p=0.88). Changes in ITP were not significantly different across groups of CSFD but the variation in the data decreased with increasing levels of CSFD. Conclusions: We present the first known data on changes in ITP with varying degrees of CSFD in patients with acute traumatic SCI. These results may provide insight into the complexity of ITP changes in patients post-injury and help inform future SCI management.

RISK FACTORS, CLINICAL MANIFESTATION AND PREVENTION OF POST-DURAL PUNCTURE HEADACHE IN THE OBSTETRIC FIELD

Introduction: Over the past decades, the number of wo­men choosing to have epidural analgesia or undergoing spinal anesthesia during labor is steadily increasing. Con­sequently, a risk for complications is increasing. Post-dural puncture headache (PDPH) is considered one of the most common complication following accidental dural puncture (ADP). Sources and a method: A literature overview were con­ducted via search engine “PubMed (Medline)” and “Goo­gle Scholar”. Randomized controlled trials, meta – analy­sis, retrospective, prospective trials and systemic reviews on PDPH were selected. Aim of the review: To evaluate the most commonly des­cribed risk factors, clinical presentation and prevention of PDPH in the obstetric field. Results: The occurrence of ADP during neuraxial anest­hesia reported in the literature is relatively small – 0,1 – 1,5%. PDPH is a potentially expected complication after any lumbar punction. It presents as a headache within five days of the puncture due to low cerebrospinal fluid pressure. The pain is often bilateral, located in the frontal or occipital areas. Symptoms, such as vision and hearing impairment, neck pain and nausea might follow. Usually, the symptoms fade out spontaneously within two weeks. Risk factors for PDPH are modifiable (technique of the injection and anesthesiologist’s skills) and non-modifia­ble (pregnancy, low body mass index (BMI), dehydra­tion, history of PDPH). The goal of preventing PDPH is to identify and correct the risk factors associated with this condition. Main described means being equipment and experience, conservative measures, administration of epidural morphine, intravenous dexamethasone or co­syntropin, epidural blood patch and intrathecal catheter. Conclusions: 1. PDPH manifests as an orthostatic hea­dache with or without ocular, neural, hearing and other symptoms. 2. Young pregnant women with low BMI are more likely to suffer from PDPH. 3. PDPH preven­tion consists of risk factor correction and proper medi­cal techniques.

Intrathecal catheter for severe low back pain during deep brain stimulation placement: illustrative case

BACKGROUND Deep brain stimulation (DBS) is a U.S. Food and Drug Administration–approved therapy for medically refractory Parkinson’s disease, essential tremor, and other neurological conditions. The procedure requires prolonged immobility and can result in significant patient discomfort, potentially limiting patient selection. In addition, surgical requirements necessitate avoidance of medications that may alter or suppress the patient’s arousal or baseline tremor during macrostimulation testing. OBSERVATIONS In this study, the authors describe the use of continuous spinal anesthesia with local anesthetic to manage a patient with severe back pain who was intolerant of semisupine position during stereotactic computed tomography and stage 1 of DBS placement. LESSONS Continuous spinal anesthesia is an effective strategy to manage patients with severe back pain undergoing DBS surgery for upper extremity motor symptoms.

An efficient multidisciplinary approach in a pregnant patient with hereditary spastic paraparesis treated by intrathecal baclofen therapy: A case report

Literature regarding cases of pregnant patients with hereditary spastic paraparesis (Strumpell-Lorrain disease) and those treated by intrathecal baclofen therapy is sparse. There are currently no specific guidelines to manage pregnancy and delivery in these patients. A 42-year-old woman presented to our clinic with hereditary spastic paraparesis and was treated with intrathecal baclofen for spasticity. She conceived twice and delivered successfully by caesarean section under subarachnoid anaesthesia. The two pregnancies had favourable outcomes with no increase in spasticity and no problems encountered with the intrathecal device. In this report, we discuss the evolution of both pregnancies and the anaesthetic management for deliveries in the presence of an intrathecal catheter. Keywords: Caesarean section; case report; hereditary spastic paraparesis; intrathecal baclofen; pregnancy.