Multimodal surgical strategy for mixed refractory hypertonia in a patient with cerebral palsy: C1–2 puncture and pectoral pocket for baclofen pump implantation following lumbosacral ventral-dorsal rhizotomy. Illustrative case

BACKGROUND Intrathecal baclofen pump (ITBP) therapy has been successfully used to treat hypertonia in children with cerebral palsy (CP) since its Food and Drug Administration approval in 1984. CP affects multiple organ systems, leading to the accumulation of medical access and implantable devices, increasing the medical complexity of these children. The authors present the case of a patient with extreme surgical complexity and review the medical decision-making and surgical details. OBSERVATIONS A 16-year-old male with a history of quadriplegic mixed hypertonia secondary to CP presented for ITBP replacement in the setting of pump end of service (EOS). The patient had short bowel syndrome (SBS) and severe scoliosis with a nonhealing costopelvic wound adjacent to the EOS pump. Intrathecal baclofen wean failed due to limited bioavailability from the SBS. The authors performed catheter placement to the skull base via a right C1–2 puncture and pectoral pump pocket creation. Treatment was well tolerated, with no procedural complications. LESSONS Surgical complexity prompts creative problem-solving. It is critical to consider the nuances of each patient’s history and body habitus to promote ITBP longevity. The authors present the case of a patient with CP who underwent catheter access via C1–2 puncture and pectoral pocket creation. In this case, surgery was effective, with an uncomplicated postoperative course. Surgeons should not hesitate to consider alternative implantation strategies in similar circumstances.