So Elizabeth Mora is a nurse practitioner at the Goodman Campbell Brain and Spine Institute and Is going to talk to us today about functional neurosurgery Specifically the the baclofen pump and everything you've ever wanted to know about baclofen I Know the general perception of baclofen pumps and my goal is a little bit to help everybody change their mind And my background is neurotrauma I worked neurotrauma I see before going back to NP school my Goal when I went back to NP school was to work in palliative care after seeing what I see you Prolongation of life without quality of life kind of entailed. Unfortunately when I graduated there weren't any Palliative care jobs readily available and this kind of fell into my lap And so I've been masquerading as a neurosurgery NP with a love of palliative care So when this opportunity opened it made Kind of all my dreams come true So I'm going to talk a little bit about functional neurosurgery just for those who don't work with it regularly And then we'll get into the nitty-gritty of baclofen pumps so functional neurosurgery is This idea that you don't have to have some gross abnormality of your physiology to have a problem so the image to your Right. I'm guessing everybody could figure out what's wrong with that Yeah, spinal cord injury big break C5 the image to your left anything stand out on that anything likes Like hit you like a ton of bricks Nope That is a person with a traumatic brain injury they had an anoxic I believe is what I wrote down TBI Both of these patients are my patients both have Medically refractory spasticity as a result of their imaging, but you would not necessarily look at image to and think there's a big problem Other things dealt with in functional neurosurgery epilepsy other movement disorders Parkinsonian tremors chronic pain you know, there's a wide range and there's a lot of advancements coming through functional neurosurgery in the world of Psychosurgery so using implanted neurosurgery devices to treat things like medically refractory depression, you know Tourette's addiction Nicotine like there's all sorts of stuff that is coming down the pipeline that just hasn't really been implemented in the larger population But you know, maybe we'll see When we talk about implanted devices and functional there's three big pools that things fall into I assume most of you are fairly familiar with shunts In functional I think of shunts more for NPH All of our favorite idiopathic intracranial hypertension patients pseudotumor Stimulators there's a wide and varied Implementation think DBS for movement disorders think VNS for seizures think Your neuro stimulators, you know spinal cord stems peripheral nerve stems all that kind of good stuff And then the third tier is where we're gonna focus this talk in the pumps world So Interthecal pumps the I found this interesting back in 1898 soon after the discovery of cocaine as a local anesthetic This doctor injected it into his own interthecal space So that was the first documented time that somebody like put drug into the interthecal space trying to elicit a response Sure, okay What do we use it for today they kind of fall into two broad categories So interthecal pumps are often used for either narcotic delivery or interthecal baclofen delivery There's very few medications that have been FDA approved to go into pumps to be delivered into the interthecal space in the Pain category you have morphine duromorph. You have pre-alt which is a non narcotic. I don't Don't manage that population, but I believe it is a snail venom of sorts And what I've been kind of understood is the like therapeutic ranges like this and there's hallucinations down here and there's hallucinations up here So getting people to a therapeutic level with pre-alt is rather difficult So in case you run into a pump that has that in there just be aware that it's really difficult to manage in the world of interthecal baclofen, there's Two main brands that have been FDA approved Leorasol and Gablifen you can also run into people who do their own compounding and there's some like non Like generic brands that are coming to market, but largely it's Leorasol gablifen as the two brands the indication for interthecal baclofen pumps I Bolded the top five diagnoses that I see the largest population of which being cerebral palsy Stroke spinal cord injury TBI MS and then there's always a handful of just other random diagnoses that they have this functional problem They have this medically refractory spasticity and and we find that they benefit as well These are what the pumps physically look like and I'm pretty loud so I'm gonna start moving away from my podium I brought some pumps to show you because I always think it's nice to be able to hold in your hand what a pump physically looks like when you're talking to a patient I say, I don't have access to a synchromed, so I don't have the fluonix, the prometra 2, or the cotton But this is the synchromed 2 from Medtronic They are made of metal I always tell my patients they're about the size of a hockey puck that's shaped like a teardrop It Is nice to see what they look like under x-ray because that's often how you find them the patient came in as a trauma We did a you know an abdominal series. They have this weird Alien going on in there. What does it look like? So you can kind of see What the internals look like as well for at least the fluonix and the synchromed This also is helpful because if you need to get the rep there You kind of need to know what type of pump it is and if your patient's intubated sedated And they can't talk to you at least your imaging can help direct who you need to call to get somebody in there to interrogate it So Very briefly because this is a room of APP's I'm not going to go into the specifics of the surgical placement But I think to understand why things go wrong you have to know what it looks like for things to go, right? so The pump is traditionally placed in the left abdomen. We try to preserve the right abdomen Abdomen or gallbladder at the other emergencies that may pop up on this side So typically left abdomen under the fat sometimes you'll get a subfascial placement depending on the patient There are some doctors who also do it kind of back here in the low back upper buttocks area We could discuss placement Choice further if you really want to get into it, but in general the catheter then gets threaded around to the spinal segment and then there's a spinal incision where you go in with a lammy and You actually place you puncture the dura and get the catheter in and then under fluoro you thread the catheter up to your desired level Catheter placement does become important because the baclofen pump tends to work best at the level of the catheter tip and below So if you have an individual with lower limbs spasticity and their uppers are rather unaffected There's no real reason to get their catheter threaded up to the cervical spine You can pretty much get a good if you get it mid thoracic get good relief in the lower extremities with just a lower Some surgeons are doing a top-down approach Dr. J who presented earlier does a top-down approach for his Pediatric cases the idea being that the incision is made up in the neck versus in the lumbar spine so if you're dealing with issues of incontinence where your incision is going to be At risk of infection a surgeon cervical approach may You know eliminate that risk. The problem is if you do have catheter migration if it's in a lumbar placement It's going to migrate down. So you're not gonna get Like it's not going to affect areas higher up versus if you have a top-down and you thread the catheter down to say C5 if it migrates up it could start to affect your breathing muscles So there's there's trade-off with both This is just I borrowed this slide from dr. Martin Samuels He's at Brigham and Women's with the neurology department When we start talking about how the drug works and why we want to get that drug into the intrathecal space It's important to understand where the baclofen works on the pathway. And so Baclofen is a GABA-B agonist. So if you look from the cortex to the cortical motor areas, there's GABA Links all along that chain, so unfortunately Like the oral baclofen which we'll touch on here in a minute does not cross that blood-brain barrier Well to be able to get the drug to that receptor site and so by mechanically bypassing the blood-brain barrier with inserting the Catheter directly into the intrathecal space we get the drug to where it needs to be to work its best Movement disorders are wide and varied. So if you are Most by the time hopefully the patient gets to you They've been thoroughly worked up by their neurology PM&R developmental peds Whoever else for having a disorder of spasticity versus some of the other movement disorders But spasticity falls into like This like movement disorders in general are too much or too little movement All right Are they not moving enough and we can't get those feet up and off the like cement floor or are they like? Moving all the time where they can't you know function Spasticity with you when we go back to thinking about what diseases we see Spasticity in it makes sense to where the damage occurs. So CP traumatic brain injury stroke. We're talking about damage to these areas of motor neurons and so I Don't want to get too much into the pathophys because we all did that in school, but it's there if we want to review it Spasticity is Velocity-dependent, can I borrow you for a second? Dependence if you see these patients in clinic and you're like Where's the spasticity? Good to go and so a lot of times I'll take their arm and it's not that I'm necessarily doing a fast exam But I'll start with like a basic range of motion to understand if there's any fracture or what else is going on And then I start like jerking their arm all around Because I'm trying to put velocity behind it and so I apply I may not have any resistance with a smooth slow motor but as soon as I give it that quick jerk the catch occurs and that's what you're looking for as a You may also see clonus you may also see like if they're really bad They have that lead pipe where you can't even try to move them because they are just rigid out there So this is a video this is a pediatric case this little girl got her head caught in a Like a window in a car and and she got She had an anoxic injury and so She is kind of in a backwards C-shape so this is like this is you can't miss this spasticity, but This is a kid who can't leave her house So her parents her caregivers can't leave their house Think how isolating that is This is a kid who can't interact with other children Think how developmentally Traumatizing that is This is a kid who's gonna get joint contractures. Can you get her dressed? Can you put clothes on her let alone get her out of the house? How do you do her hygiene? How do you prevent urinary tract infections? How do you prevent skin breakdown? You know so after pump. This is what she looks like This is a kid who can get in a wheelchair This is a kid who can go interact with her peers This is a kid whose brain can learn to the best of its new ability and developmentally progress This is why pumps have a role. I know that they are difficult, and I know that they can cause like Cause all of us a little bit of anxiety But when it works it can work so well And it can radically change the life of not just the patient, but the entire community that surrounds that patient These are some tools you can look up on your own leisure about how to quantify your exam the Ashworth score that that catch You can kind of put it on there I don't want to focus too much on this because I don't focus I document it But I don't necessarily tell patients I'm gonna get you from an Ashworth 4 to an Ashworth 1 because I may not be able to get it But I'm gonna try to work on some of these other things so You have to prove to me that you need a pump because the therapy is lifelong and it is taxing So, why don't we try not doing a pump? Let's see what else we can do before we tell you that this is the best option. So oral baclofen This is your gold standard. This is your kind of what everybody takes The part I want to focus on is there at the bottom It oral baclofen does give the patient a sense of control They can take that pill when they feel like they need it Which gives them agency in their care and these are a lot of these patients are Totally dependent and everything else they have no say-so and where they go when they go When they get their bath when they get their meals like they're at the whim of whoever's caring for them So having something that they have control over is important. So I don't want to take that away from them always but Whether or not it helps them, you know totally manage their spasticity oral baclofen has some some hang-ups The Most being people tell me it makes them feel like a zombie I have to be on such high doses to get a good effect that like I'm sleeping 18 hours a day I'm not I'm not doing so good. They may also get some GI upset nausea And it can also lower seizure threshold if you use it in high doses So if you have a kid who already has a seizure disorder and you put them on high-dose Oral baclofen and you throw their seizures out of whack It's just not going to be the right balance of therapy There's other non-surgical options, there's a whole host of medications, you know long-term benzo use not ideal But Botox does have a role and I I think there's a lot of good use of Botox unfortunately Botox like the first time you do it tends to work the best and then your body does gradually build up antibodies So if you're doing it over a course of years you get like a decreasing effect So sometimes people like it worked great for about two years and then I it didn't really do much Plus you're talking about a lot of sticks months after months Months after months I Found one study that kind of said that if you did six hours of stretching a day, you could get pretty good spasticity control Let me know who has six hours to stretch Um other Surgical options, you know, these can be with or without a pump. So I kind of just put them all in one slide. Um, I See I've seen a big move away from the selective dorsal rhizotomy, I think maybe 15-20 years ago This was what a lot of people did Unfortunately, if you had somebody who was ambulatory you may take their ambulation away If you had somebody who had bowel bowel and bladder control, you may take that away. It's irreversible So if they didn't like how they felt after it or whatever, you can't go back and undo it Um So you have this patient They they have just failed everything or they don't get good control or they're still having issues. So Now we start the conversation of whether or not having a pump is the right choice for them And there's a lot of factors to be discussed before I'd want to put a pump in somebody The biggest thing is I always want to make them aware that this is a lifelong therapy You are gonna have to come back and see me a minimum of twice a year You know, like we got it. We got to have a relationship We're gonna be a little bit married to each other if you choose to go this route You know and telling that to the parent of a six-year-old and then seeing them again when they're 18 19 20 years old They're like we've been doing this forever like and then we start to say, okay Do we make any changes and then we start to lower their dose and they realize oh, we still really do need this Okay, I see. Um, I Talk to my patients. I'm like you live in a rather large city I live in an Indianapolis if you have any plans to move to Alaska Don't get this pump because you're not gonna have a provider in Alaska If you're you need to know that you are tied to cities now that have providers because I Mean what do you think in Indiana like maybe? 20 providers across the state do this work You know, and I I mean, we're not like the biggest like metropolitan area, but we're not like totally podunk And I sometimes really struggle getting my patients to a provider if they can't make the drive to Indianapolis So the next step is okay. We think you would benefit from this But before we put this device inside of you and put you through the rigors of surgery, let's make sure you actually get a good response. So we do a lumbar puncture test dose. So we bring them into the hospital. Some places do this in the outpatient setting, just kind of personal choice. We do a lumbar puncture. Before we do the lumbar puncture, we have a specialized physical therapist who comes in and does a pre-exam. They are a neutral, independent party. They have no tie to whether or not we put a pump in this patient. We put in, instead of drawing off cerebral spinal fluid, we inject the drug into the CSF. And then, like an hour later, PT comes back. Let's see what happened. Let's get this objective observer to tell me, do they have a change in their tone? How did it work for them? Because if it didn't help, we're not putting a pump in. But I will say, most of the time it really does help. The Greenberg Handbook of Neurosurgery, anybody have that book? Yeah, everybody. These are the criteria, which really aren't the criteria. So if you read that Greenbook and you're like, oh, I think my patient should get it, and you read this criteria, just know that that's not really what I see in practice. Certainly, I see patients getting pumps in the pediatric population, able to give informed consent at a lot of nonverbal, TBI patients, CP patients. I will say, we don't put pumps in until they're about a year away from injury. So if it's a spinal cord injury or a TBI, we do wait 12 months. Yeah, some of this other, I see pumps with pacemakers. That's not uncommon. Females with the childbearing potential, there's just no robust study on this. I personally, in my practice, have had four women get pregnant while they have a pump and do fine. So I'm not sure that that totally should disqualify them either. No history of stroke, I find unusual, since we put this in for stroke-associated spasticity, but okay. So before we go to surgery, I try to have a real conversation about what our goals of this pump are, because you have to, if they have unreasonable expectations, they are only gonna be disappointed. So I talk to them at every pre-op, while they're getting the baclofen testos post-surgery. Okay, here's what we're working towards. Quality of life. I don't care what your Ashworth score is. I don't care if you're having clonus or not. I wanna know how you feel. Do you feel better? What's your day-to-day life experience? Are you getting better spasticity control? Are you sleeping better, because your spasms aren't waking you up? Are you doing more care? Can you feed yourself? Can you participate in your care in a higher capacity? Are we working on range of motion, wounds, UTIs? And if my patient isn't verbal or can't talk to me, talk to the caregiver. How are you doing? Are you able to get them in the bathtub easier? Are you able to get under their armpits and in their crevices? Are you fighting with them, or are things easier? Can you get them in their wheelchair to get them up and around now? Those are the day-to-day quality of life things that I really want the treatment to work on, versus some number that we're trying to achieve. We do a lot of things with dosing, patterns, rates, things like that. If you want to get into that conversation, come find me. Otherwise, it's a totally different talk. But I do let them know after surgery, you're probably gonna come see me about every two weeks until we get you at a good rate. Maybe not perfect, but a good rate. And then we do need to do refills at least every six months, maybe more frequently, depending on how things are going. And after a refill, or adjustment, 24 to 48 hours for that new dose to reach a steady state in your CSF so that you can kind of assess whether or not it's what it should be. Which is why in the outpatient, I try not to do adjustments any more frequently than every two weeks, because I don't want them to just come back, oh, I came in yesterday, I don't feel any result. Okay, let's just, let's take a breath, it'll be okay. Give it a couple weeks, see what happens. You can get the dosing too high, so there are some limiting factors. So if they're like, man, I feel real sleepy, and I got my adjustment four days ago, and I'm having a hard time keeping my head up, come on back, I'll turn you down. Like, I won't hold up an appointment if they're feeling too medicated. And some of my patients want some tone. They don't wanna be a wet noodle. They want to be able to kind of use some of their spasticity to do their stand pivot transfers. They want some of their spasticity to do some functional work. So we talk about that as well. This is a young lady with a mitochondrial disease. I really like this video because I think it gives you a good idea of what spasticity looks like. So you can see the toe walking she's doing. As she comes down the stairs, you're gonna see her with a pretty pronounced spastic gait, or scissor gait, excuse me. So you can kind of see those legs tightly crossing over each other. You can see how her arms are drawn up. I don't wanna necessarily have you watch the whole video, but, so this is after a pump. Again, this is a young woman who can go for a walk with her friends. She's not gonna get skin breakdown between her knees because they continually have friction. She can put her own shoes on, as she's gonna demonstrate here in just a second. That arm swing, that more normalized gait. Again, I have been on the receiving end of the ER saying I got a pump down here, I'm gonna need you guys to come figure shit out. I'm sorry. And I know the deep sigh that comes with it, but I promise you, if you were able to see these patients over the course of their lifetime and what it does, it really would change your tone. So this is what a pump refill looks like. What? Mitochondrial disease. So patients often wanna know what it looks like to get their pump refilled. So the pumps are under the skin. So I get in there, I feel around on them. You do a lot by manual palpation to get things kind of oriented. You clean it, sterile access it with a needle. The needle's smaller than an IV, it's a 22 gauge. So people tolerate it really well. I don't use a lot of Emla cream or topical lidocaine because in my adult population, by that point, they're pretty tough. So for the most part, we just kind of go, because we're only going a few millimeters or a few centimeters under the skin. We're not digging around too much, so they do really well. So the problem becomes when the pump doesn't work the way you want it to. So there are lots of troubleshooting things we can do. When I'm doing a refill, I always check the anticipated volume versus the actual volume. Maybe we make some changes with how they're getting the med because I'm great during the day, but at night, man, those spasms still wake me up. Doesn't mean their pump's not working, it just may not be the right amount or dosing strategy. Sometimes we do run into problems with the catheter, so we do side ports. Anybody who has the pump in their hand, if you look at the teardrop part, there's a very tiny little hole. That's your side port. So if you can get a needle into there, that's actually where you can access the catheter, which would give you an idea of how things are working between the catheter and the intrathecal space. I do want to touch on seeing patients after an MRI. The Synchromed II pump is MRI compatible, although it will go into a stall mode while in MRI, so we always recommend somebody checking that pump to make sure it's adequately recovered from a stall. The Fluonix pump is also MRI compatible, but you have to completely empty the reservoir, otherwise the magnet will flood the drug into the CSF. So you need to see them before an MRI to make sure that everything is taken out, and then you'll have to see them after to re-put it back in. You can bill for all of this, good to know. Dr. Turner, who was at the practice before I started, did some work on autonomic dysfunction, and so putting the catheters into the intraventricular space, and getting some good results for thalamic storming, autonomic dysfunction. He had a paper that showed pretty good ability to wean them off their autonomic dysfunction medications. So if you have a TBI that has spasticity and autonomic storming, you may think about that. Although there are very few centers that do intraventricular placement. This is my colleague, Ember. She's been doing this for 16 years, which I think has earned her a special place in heaven. And she kind of told me this. She goes, look, by the time your patients get a baclofen pump, their life has been rough. They don't have a great normal whatever. So when you show up with a bad attitude because you don't want to deal with their baclofen pump, it only compounds their existence. So I really try to remember that so that I can kind of go in and be cheerful and make sure they know we're gonna take care of you, we're gonna figure this out to the best of our ability. We'll work on this together. So for those of you in the inpatient setting, there are some acute issues that you need to know about and how to deal with them. Overdose being one. Withdrawal, CSF leak, wound breakdown. When there's a problem with the pump, the most likely culprit is the catheter. Sometimes the pumps do weird things, but in general, they tend to work pretty well. So you're neurosurgery, you're the expert. Let's, what are we doing? You got a pump. What are we doing? All right, let's ask some questions, right? That's how we usually get through things. Who, like who is this person? Why do they have a pump? What do they have in their pump? Is it pain medicine or is it baclofen? Because we're gonna treat that very differently. Where is the pump? Did somebody put this in their brain? Is it in their spine? We should probably know. When were they last seen? Was this a recent OR case? Because those issues post-surgical are gonna be different than like somebody's had a pump in there for five years. When were they last seen in clinic? Did they make a change? Did you get your pump filled? What happens? And then what's going on? Because a lot of things can mimic an acute worsening of your spastic tone. So if they have a UTI, pressure sore, wound breakdown, they may have an exacerbation of their tone without any problem to their pump. And we need to make sure we treat the other medical problem. Or are they just in the hospital for something else? Because I literally think that if my patient had a severed toe, they would still call me thinking there was a problem with the pump. Medical workup first. Like push back on your ER doctor. Say I want a good medical workup. I don't look at a lot of lung studies, but anybody see a problem with that? There's a monkey over here hanging out. I joke that like once you have an implanted device, nobody can see anything but the implanted device. So let's remember that these are whole people with whole people problems. So they may have pancreatitis. They may have other problems. So let's try to make sure we're addressing all of those things. Sometimes serotonin syndrome can really mimic some of the issues with spasticity. So if they started on a new SSRI, you want to get a good medication history so that you don't miss that. And if they have a disease that's not static, like MS, where there is progressive decline over time, is that what's going on? Are they having an MS flare versus something being acutely wrong with their pump? Oh, what did I do? That's my surgeon I work with, Dr. Lee. We have these cards that we give to our nurse practitioners that kind of go through some triage questions. And because I know you all love swag, I brought some of them. If anybody wants a card for their pocket about if you ever have to see a pump. It just kind of helps guide you through questions you should ask, information you should gather. So backlip and overdose. These are patients that are gonna come in, they're flaccid, they're lethargic, they're maybe not breathing so great. Medical support is paramount. If they're not breathing, get them breathing. Put a tube in, support their respiratory system before we worry about whatever. I'm trying to remember exactly, but I'm fairly certain that no pump has ever malfunctioned to the point where it independently delivers too much medication. Almost all overdoses are the result of somebody in clinic doing something wrong. You programmed the wrong rate. You put the drug into the side port, not the refill port. You did something, you put the wrong concentration of drug in. You thought you had a low concentration, you ended up putting a high concentration in, and you didn't change your rate to mimic that. So instead of getting 500 bike per mil, they're getting 2,000, and they're getting like four times the amount of drug they should get. So interrogate and proceed as needed. If you do think it's an overdose and you have some kind of data to support that, you can either do an LP or aspirate the side port to pull out the CSF, which would then withdraw the drug as well. Again, those are kind of the likely causes. Pumps alarming. So the reasons pump alarm is they're either in motor stall or they're empty. I can play that for you after, but we'll move forward. Baclofen withdraw is itchy, twitchy, bad behavior. There may be another B word you could sub in there for itchy, twitchy something. And the problem is because you lose this GABA-mediated inhibition. So they're tachycardic, they're fevering, they're like going into rhabdo because their tone is so kicked out. They can look really sick, and if you don't get to them, they can progress to multisystem organ failure and die. And it can be really scary. Don't be afraid to use oral baclofen with these patients. Don't be afraid, even though they have a pump, to give them some Valium. If they look sick, treat them like they're sick. And then we can get somebody in to figure out what's going on in the pump. But if they're tight and toned, give them something. Don't be afraid, oh, you have a pump, I can't give you anything else. Yes, you can. You can. Ask those questions that kind of figure out if it's human error or not. Go in and do surgery as indicated. If you get somebody in there who knows pumps and can work it up and can figure out if there's a problem, there is a host of reasons to do surgery that it's appropriate to fix the problem. You wanna have a surgeon that knows what the problems are and then how to fix it. If you're seeing a pump because there's a wound issue, remember, never put a needle through a hot pocket. If they look yucky, you don't wanna put a needle through that to figure out if their side port's working. If it looks yucky like that in clinic and you need to do a refill, you can't. So now you got a surgical problem because they're either gonna go into withdraw because you didn't fill their pump or you're gonna give them meningitis because you're gonna put infection with your needle as you pass through infection into their reservoir. You gotta kinda look at all that stuff. This guy also, it wasn't open, but he was getting a lot of infection that was growing across it. Imaging's always a little controversial, whether or not it's helpful. Sometimes you can get some helpful studies. X-ray, you cannot always see the catheter, so be aware. Sometimes you can, like on this one, but the new Ascenda catheters also are just there, but they're not radio, like they don't show up on X-ray. Catheter tips look like this, right up there, that little dot, so you do kinda need to know what you're looking for. So knowing where they should be can kinda help direct you, do I see it in that region or not? But it's not like, you know, hit you in the face. And then please, please, please never turn a pump off. If you don't know a lot about pumps, never say, oh, we're just gonna turn the pump off. Once you turn a pump off, if it's stalled for 48 hours, it stops working, so you can do other things to make sure they're not getting the medication, but please, please, please do not think that we can just turn a pump off unless you really know what you're doing in terms of pump. So if they look like they're overdosing and the ER doc says, oh, just turn it off for right now, be like, let me do some other magic, okay? You can also pull off CSF from your side port. You don't have to put them through a lumbar puncture. You can inject contrast through that side port to do like a CT milo without doing a lumbar puncture. So there's some other things that are nice to know. Make sure you document, put things, you know, I know it takes time, but the person behind you is gonna really appreciate knowing when they were filled, what's their rate, what's in there, when do they need to come back? So I lovingly call my patients the Island of Misfit Toys because it just, they kind of fall outside the normal scope of what we see in neurosurgery, but they're really wonderful, and the caregivers that you get to meet, the dedication and love they pour into these kids is really inspiring, so. That's all I got. Thank you.

functional neurosurgery

baclofen pump

neurotrauma

palliative care

intrathecal space

patient selection

oral baclofen

improving quality of life