Intrathecal baclofen administration for the treatment of spasticity. Clinical considerations (original) (raw)
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Intrathecal Delivery of Baclofen As Functional Treatment of Severe Spasticity
2016
In some patients severe spasticity of cerebral or spinal origin cannot be treated successfully with conventional oral medication or physical modalities. Intrathecal baclofen therapy with implanted pump has represented effective treatment from mid-80’s. Baclofen (Lioresal) is a muscle relaxant and a potent GABA agonist that acts via GABAb receptors at the posterior columns of spinal cord level, to inhibit the release of excitatory neurotransmitters by inhibiting calcium ions influx into presynaptic terminals. This direct binding on spinal cord receptors leads to higher efficiency compared to peroral therapy in which baclofen does not pass the brain-blood barrier. The article overviews indications and contraindications for intrathecal baclofen therapy, selection and preparation of patients for surgery, the surgical procedure of pump implantation, long term follow-up with pump refill procedure and possible complications of intratecal baclofen therapy. The experiences of the Center for ...
Continuous intrathecal baclofen delivery in severely disabling spasticity
2018
Background/Aim. Spasticity is the consequence of several clinical conditions including cerebral palsy, brain injury, spinal cord injury, multiple sclerosis, aneurysm bleeding, and some other neurological disorders. The aim of this study was to determine the efficacy of intrathecal baclofen (ITB) treatment in medically intractable severely disabling spastic-ity and present the challenges encountered during pump im-plantation surgery on these patients. Methods. The patients who underwent intrathecal baclofen pump implantation surgery between the years 2012 and 2015 with minimum follow-up of six months were recruited from the clinic archives. Twenty two patients with severe spasticity who had Modified Asworth Spasticity Scale (MASS) score of 3 or 4 were enrolled in our series. Eight of twenty-two patients were at pediatric age and they all were non-ambulant before surgery. Results. All of the patients underwent program-mable intrathecal baclofen pump implantation surgery. Catheters were placed via percutaneous technique into to the subarachnoid space in 18 patients while, we had to perform partial hemi-laminectomy in order to place the cathe-ters in 4 patients. All the patients improved significantly and 5 began using upper extremities and 3 adults became am-bulant following physical therapy. Mean of the MASS scores improved from 3.59 to 1.32 (p < 0.001). Conclusion. The ITB therapy obviously increased quality of life and functional outcome in patients with disabling spasticity. As a result , physical treatment was more useful for these patients. Although some spinal abnormalities due to spasticity may necessitate partial hemilaminectomy to implant the pump, patients with intractable spasticity should be given the chance of intrathecal baclofen treatment at the earliest period of their lifetime disability.
Intrathecal Baclofen Infusion for the Treatment of Movement Disorders
Neurosurgery Clinics of North America, 2019
INTRODUCTION: NATURE OF THE PROBLEM Movement disorders owing to spinal or cerebral dysfunction are common in adult and pediatric patients. The first-line therapy for the treatment of these conditions often involves oral agents including baclofen, benzodiazepines, and other antispasmodics. 1 Intramuscular injection of botulinum toxin can also be useful in reducing spasticity of select muscle groups. Despite this broad armamentarium of therapies, many patients struggle to obtain satisfactory control of their spasticity and/ or dystonia. This leads to complications, including pressure injury, pain, difficulty sitting in a wheelchair, bladder problems, difficulty performing basic hygiene, and overall degradations in quality of life. Some patients obtain significant relief from oral medications, but are unable to tolerate the side effects at the required dosage, such as sedation. 2,3 Baclofen is a medication commonly administered orally to patients suffering from spasticity or secondary dystonia. The medication is an agonist of GABA type B receptors. Baclofen inhibits reflexive muscle contraction by blocking the release of excitatory neurotransmitters via interference with voltage gated calcium channels. Despite these positive attributes, the bioavailability of the drug at its site of action, the central nervous system is poor because of the blood central nervous system barrier. 4,5 Owing to the marked number of problems associated with the oral treatment of spasticity and secondary dystonia, there was strong incentive to find new therapeutic options. In the 1980s, practitioners began to explore intrathecal baclofen infusion to achieve a high drug concentration at the site of action with relatively little systemic Disclosure Statement: The authors have nothing to disclose.
Chronic intrathecal baclofen administration for control of severe spasticity
Journal of Neurosurgery, 1990
✓ Baclofen, the most effective drug for treating spasticity, is a specific agonist of gamma-aminobutyric acid-B receptors, and is very abundant in the superficial layers of the spinal cord. Given orally, baclofen does not easily penetrate the blood-brain barrier, and is distributed equally to the brain and spinal cord. Direct intrathecal administration was given in order to change the distribution of the drug by preferentially perfusing the spinal cord. Eighteen patients presenting a severe spastic syndrome were treated with chronic intrathecal infusion of baclofen in the lumbar cerebrospinal fluid. After clinical preselection, 38 patients were implanted with a lumbar access port allowing long-term trials in order to determine the efficacy of baclofen therapy and the effective 12-hour dose. The 18 patients selected for chronic administration were implanted with a programmable pump. The pathology in these cases was: multiple sclerosis (6 cases), posttrauma spastic syndrome (eight cas...
Archives of Physical Medicine and Rehabilitation, 2014
To assess the frequency and types of adverse events (AEs) related to intrathecal baclofen (ITB) therapy in adults, and associated risk factors. Design: A prospective, observational cohort study of adults followed up from January 1 to December 31, 2010. Setting: A neurologic rehabilitation department in a university hospital. Participants: All consecutive adult subjects (NZ158) receiving ITB via a pump, either implanted or followed up during the study period. Intervention: Not applicable. Main Outcome Measures: Frequency and type of AEs. Results: In 2010, 158 subjects were followed up for ITB therapy, of whom 128 were implanted before 2010 (nonsurgical subjects), and 30 underwent implantation in 2010 (surgical subjects). Of these 30 subjects, 20 were "newly implanted" and 10 were "replacements." The most frequent pathologic disorders were spinal cord injury (42%) and multiple sclerosis (28%). Twenty-eight subjects (18%) experienced a total of 38 AEs. The rate of AEs was .023 per month of ITB treatment. AEs were related to the surgical procedure in 53% of cases, to the device in 29% (predominantly catheter dysfunctions), and to adverse effects of baclofen in 18%. AEs related to the surgical incision (scar complications and collections) were more frequent in replacement than newly implanted subjects (PZ.009). No significant association between occurrence of an AE and subject characteristics (age, gait capacity, spinal vs cerebral spasticity, duration of ITB therapy follow-up) was found. Nearly half of the AEs were serious, extending admission time by a mean of 16 days. No AE induced long-term morbidity or death. Conclusions: The AE rate was relatively low in this cohort. This has to be balanced against the clinical, functional, and quality-of-life improvements, which are expected from ITB therapy.
Journal of Clinical Neuroscience, 2019
Intrathecal baclofen infusion trial is a sophisticated tool for selecting patients for permanent intra thecal baclofen infusion therapy We report our clinical experience of fifteen patients with refractory spasticity who underwent a continuous ITB trial using a temporary intraspinal indwelling catheter prior to permanent pump implantation. Patients underwent placement of a temporary intrathecal catheter that was connected to an external pump. Multisource feedback was obtained from the various healthcare professionals involved (Staff Nurse, Specialist nurse, physiotherapist, Doctor, family members, patient) regarding progress of test over 48-72 h. Average Modified Ashworth score after the trial was less than 2. Some degree of dose related minor adverse events (AEs) occurred in 8 patients, with the most common being nausea, constipation, urinary retention and hypotension. 10 patients received pump implant. 5 patients did not receive a pump because of AEs or because the goals were not met. 1 patient had pump removed after 4 years because of infection.
Best-practice surgical techniques for intrathecal baclofen therapy
Journal of neurosurgery, 2006
In March 2004, a multidisciplinary conference, "ITB Therapy Best Practice Forum," was held in Minneapolis, Minnesota. The goal of the conference was to develop recommendations for techniques to implant intrathecal baclofen (ITB) pump and catheter systems more effectively and with fewer complications. The authors present the techniques for optimal pump and catheter implantation, including subfascial pump placement; insertion of the Tuohy needle in an oblique, paramedian trajectory; and positioning of the catheter tip at levels commensurate with the therapeutic indication: approximately T10-12 for spastic diplegia, C5-T2 for spastic tetraparesis, and C1-4 for generalized secondary dystonia. Techniques to minimize the incidence of cerebrospinal fluid leakage are described, including the identification of preoperative occult hydrocephalus and the use of a suture ligature around the Tuohy needle at its exit site from the fascia. Techniques to minimize surgery-related infection ...
Intrathecal baclofen therapy in patients with severe spasticity
Acta Neurochirurgica Supplements
Introduction: Two patients previously implanted with intrathecal Baclofen (ITB) pumps for management of intractable spasticity due to multiple sclerosis (MS) were referred to our center for ongoing management of their spasticity. Initial evaluation of these patients revealed high levels of spasticity in the presence of ITB doses 10 times the average daily dose of our other MS patients. Clinical Facts: High doses of ITB required frequent clinical visits and result in high drug and procedure costs. Both patients' daily doses were greater than 1000 mcg/day resulting in clinical visits every 1-2 months with drug and procedure costs ranging from 16 to 23 thousand dollars annually based on Medicare national average pricing for physician's office. Of the 59 MS patients receiving ITB therapy at our institution, the mean, median, and mode daily doses for ITB are 184, 115, and 159 mcg/day, respectively. The high ITB doses in these patients and poor spasticity control raised suspicion for pump/catheter malfunction and prompted immediate troubleshooting. Findings: One patient's catheter was found to be disconnected from the pump and the other's catheter tip was outside the intrathecal space. In both cases, the patients were not receiving the therapy. After pump/catheter replacement, both patients received excellent clinical benefits from ITB at significantly lower daily doses. This reduction in dose resulted in decreased frequency of medication refills (twice annually) which resulted in decreased cost of care (12-19 thousand dollars savings annually per patient). Discussion: These cases illustrate the need for early ITB pump troubleshooting to identify catheter problems, improve efficacy, and avoid unnecessary healthcare costs.
Outcomes of intratechal baclofen (itb) therapy in spacticity
Turkish Neurosurgery, 2010
AIm: Spasticity is associated with various neurological conditions. Intrathecal baclofen (ITB) is one of the popular treatments for severe spasticity. In this paper we present our experience in treating 30 patients with both spinal and supraspinal spasticity with chronic infusion of Baclofen to evaluate the long term efficacy of this treatment on spasticity, disability and pain, and to evaluate the side effects of intrathecal Baclofen. mAterIAl and methOds: The medical records of 30 patients who underwent baclofen pump placement from 2000 to 2010 under Department of Neurosurgery at the University of Akdeniz at Antalya/Turkey, were reviewed. All study subjects had diffuse chronic, severe, and generalized spasticity (Ashworth score ≥ 3), and had shown inadequate response to various oral antispastic drugs including baclofen. All patients were evaluated by means of the Ashworth score, spasm frequency, Barthel index, Rankin scales and VAS. results: Spasticity and spasm frequency and pain scores were clinically and statistically decreased in all patients. COnClusIOn: ITB therapy increases the quality of lifestyle and functional independence by reducing not only cerebral but also spinal related spasticity in appropriately selected cases.