Intra-Operative Computed Tomography Confirmation of Intrathecal Drug Delivery System Catheter

A 56 year old female presented with severe continued spasticity after revision of an implanted intrathecal drug delivery system for baclofen administration. The patient suffered a left temporal intracerebral hemorrhage with subsequent right spastic hemiplegia, upper extremity worse than lower. She underwent an initial intrathecal drug delivery system implant with catheter placement at T10. The medication did not affect spasticity of the right upper extremity. Therefore, the catheter position was revised to T4. Following the procedure, the patient was transferred to a skilled nursing facility for medical management and intrathecal baclofen dose titration. Despite titration of baclofen, the spasticity still persisted. Imaging studies, including radiograph, computed tomography and Magnetic Resonance Imaging demonstrated that the catheter tip was adherent to the dorsal membranes, consistent with placement in the subdural space, but possibly not the subarachnoid space. During the second revision of the catheter, intraoperative-computed tomography imaging of the patient’s spine was used to confirm placement prior to closure. This technique clearly demonstrated that the intrathecal catheter entered through the laminectomy at T7 and terminated at T4 in the intrathecal space as anticipated. Future use of this technique may demonstrate the improper placement of an intrathecal drug delivery system catheter. This would allow immediate revision of the catheter and prevent unnecessary returns to the operating suite.