By D. Sanuyem. Eastern Michigan University.
Implanting the pump under the fascia makes it less prom- inent order imuran 50mg visa, and it is very important to implant the pump so the scar is not overlying the im- plant purchase imuran 50 mg on-line, as this has a higher risk of breaking down than normal skin The pump is inserted under general anesthesia into a lateral abdominal subcutaneous location or under the external oblique and rectus fascia (Fig- ure R13). A catheter is tunneled subcutaneously and connected to an intra- thecal catheter. The catheter enters the subarachnoid space of the spinal canal at the lumbar spinal level. To increase the effect of intrathecal baclofen on the upper extremities, the catheter can be placed at midthoracic level (T6–T7) rather than T11–T12. The pump is programmed to deliver a continuous infusion, which assists with diffusion of baclofen into the spinal cord. Postoperatively the patient remains supine for 48 hours to limit spinal leak and headache. For nonambulators, postoperative dose adjustments can be made daily even during bed rest. For ambulators, it may be necessary to wait until they are cleared to be out of bed to ambulate before adjusting the dose. The first follow-up visit should be at 7 to 10 days and then monthly for the first 6 months. It may take 6 to 9 months to gradually titrate the dose to the desired clinical response. In some cases, the dose may need adjustment for the first 2 years after implantation. As noted above, pa- tients with VP shunt may require a lower dose. The pump reservoir is refilled by percutaneous puncture through a sep- tum in the pump at intervals of 1 to 3 months. Dosage adjustments are made via an external computer/programmer and transmitted to the pump by a hand- held radiofrequency wand.
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