Pain Clinic 101: Fools Rush In . . .

Class, today we will discuss the follow-up LP for patient Kim Dolce. (Groans from graduate students sitting in the front row.)

To briefly review, Kim had a painful and unsuccessful lumbar puncture in March of 2012, and was then scheduled for an LP performed under fluoroscopy in April. The LP provided the delivery system for a bolus of liquid baclofen, after which she would undergo six hours of testing to become a candidate for intrathecal baclofen pump surgery for relief of MS spasticity.

(Grad student in front row makes an origami angel and launches it at the feet of the professor, which he ignores.)

Kim was placed on her stomach and given an I.V. of Versed and fentanyl. This was conscious sedation, as she had to recover quickly in order to undergo those six hours of testing. The LP was painless and successful, and she was rapidly transported to Physical Medicine for the rest of her testing.

(Professor shifts one foot, crushing the origami angel with his heel.)

The walking test showed that Kim's ability to step heel-to-toe had improved with the baclofen test dose. At 50 mcg, this dose was rather strong and resulted in "noodle legs." Her doctor then told her that the test was successful and that she is a candidate for the pump.

But Kim still has reservations about the pump. She questioned her doctor about what maintenance was involved. The surgery requires an overnight stay in the hospital followed by a week of recovery. If there were no complications, she would then have the baclofen dose slowly titrated until she attained the "sweet spot," that balance between tone and relaxation in her legs. This process could take weeks or months to accomplish. During this titration period, she must do physical rehab three days a week for an unspecified length of time.

Once the sweet spot is reached and PT ends, she will be encouraged to maintain a regular exercise and stretching regimen at home. If her spasticity level changes and the doctor determines that she needs a dose adjustment, she must return to PT to acclimate her body to the new dose. This physical therapy program must be done each time the dose is readjusted. The drug must be refilled every six months, and the entire pump must be replaced via surgery every seven years. Kim must travel 45 minutes to the hospital for all of these procedures.

Kim's main concern is that this kind of care runs contradictory to her overall goal of simplifying her MS care and bringing all of her doctoring local. These procedures carry a much larger out-of-pocket expense than the very inexpensive oral baclofen. Her budget is strained already, since she struggles to pay her ever-increasing medical debts and prescription co-pays on a stagnant Social Security income.

Currently she takes 60 mg of oral baclofen and frequently adjusts her dosage based on the sometimes daily changes in her muscle tone, which can cause cramping and pain. If she gets the pump, dose adjustments are completely out of her hands. She knows that patients cannot take more than 120 mg of oral baclofen, so she is at the halfway point in her dosage and has some wiggle room. At this point, she prefers to stay on oral baclofen and try to establish a daily exercise routine that she can tolerate. The pump would be a last resort if she reaches the maximum dose of 120 mg and has no choice but to go to the pump.

(Professor lifts his foot and picks up the origami angel, now scuffed and gritty, and rubs off the dirt with his thumb.)

"Anybody read Alexander Pope?" the professor asks, gazing at the origami angel.

"I have," says the grad student who had made the angel and thrown it at the professor. "He wrote the line: 'Fools rush in where angels fear to tread.'"

"Is Kim a fool, or an angel?" the professor asks.

The grad student clears her throat. "A fool makes hasty decisions in ignorance, whereas wiser heads--"

"Are you then suggesting that Kim is wise to delay this decision?" says the professor.

"Uh, yes," says the grad student in an uncertain tone.

The professor pulls out a paper and scans it. "It says here that both her neurologist and her physical med doctor have reported that their patients who chose the pump are very happy with it and doing better. The physical med doctor has written a paper on ITB pumps as a disease-modifying therapy. She claims that it has kept MS patients walking longer over their disease course." He glances at the grad student. "You're a literature major, aren't you?"

The grad student nods.

"Good," he says, "and what was Pope referring to when he wrote that essay?"

The grad student thinks for a minute. "The rash or inexperienced will attempt things that wiser people are more cautious of. In Pope's essay, he speaks of critics attempting to mediate a discussion about which they know little."

"Would you agree, then, that Kim's level of experience and knowledge is better than those of her doctors?"

"Well, no," says the grad student, "but her reasoning for delaying the surgery was thoughtful and sound."

"Then," the professor begins, "you would not describe her decision to 'throw out the baby with the bathwater,' a total rejection of an established, proven medical procedure in this case, as a rash, dismissive folly based mostly in fear?"

"I got the impression that Kim is neither rash, nor fearful, nor ignorant--"

"Didn't Pope also coin the phrase: 'A little learning is a dangerous thing?'" the professor asks.

"So," the grad student says in a lower tone, "you're saying that Kim only absorbed enough information to support a decision she had already made prior to the ITB trial dose? That she started out with a bias?"

"Great topic for our next class discussion. How about you lead that one?" He hands her the origami angel and she gently grasps it, shaking her head. "If you want to earn some extra credit," he tells her, "bring me an origami fool." He smiles. "I wonder who it will resemble."