Continuous intrathecal infusion of baclofen in patients with spasticity caused by spinal cord injuries

The aim of this study was to determine the efficacy and safety of intrathecal baclofen therapy delivered by a programmable pump for the chronic treatment of spinal spasticity. Twelve patients with intractable spasticity caused by spinal cord injuries underwent implantation of a programmable continuous infusion pump after significant reduction in spasticity following an intrathecal test bolus of baclofen. No deaths or new permanent neurological deficits occurred following surgery or chronic intrathecal baclofen therapy. The follow-up (12 months) shows a reduction in rigidity in the lower limb of 2.0 points on the Ashworth scale and in the upper limb of 1.2 points. Muscle spasms were reduced from a mean preoperative score of 2.8 to a mean postoperative score of 1.0. In two cases, we observed postoperative catheter dislocation, a complication which could be corrected surgically. This study demonstrates that chronic intrathecal baclofen infusion is a safe and effective form of treatment of intractable spasticity in patients with spinal cord injury. There is considerable reduction in the risk of infection in view of the fact that interrogation and programming of the implanted programmed pumps is noninvasive. Electronic Publication     

Continuous intrathecal pump infusion of baclofen with antibiotic drugs for treatment of pump-associated meningitis. Case report

Intrathecal baclofen administered by means of an implantable pump is being increasingly used for successful treatment of spasticity. Meningitis following intrathecally administered baclofen is a rare but serious complication that is difficult to treat without removal of the pump. Because success rates with intravenously administered antibiotic drugs for the treatment of meningitis have been low, intrathecal administration of antibiotic agents is often required to eradicate the pathogen. The authors report the case of a patient in whom Staphylococcus epidermidis meningitis developed after insertion of an intrathecal baclofen pump. The patient was successfully treated by intrathecal coadministration of vancomycin and baclofen.     

Treatment of cerebral origin spasticity with continuous intrathecal baclofen delivered via an implantable pump: long-term follow-up review of 18 patients.

OBJECT: The goal of this study was to assess the long-term benefits of managing severe spasticity by using continuous infusion of intrathecal baclofen delivered via an implantable pump. METHODS: Eighteen patients with severe spasticity of cerebral origin, who failed to respond adequately to more conservative treatments, have-been treated with continuous infusion of intrathecal baclofen delivered via an implanted pump. Follow-up review of these patients has lasted between 12 months and 9 years. The patients have been assessed using a variety of tools. Seventeen have had a significant reduction in tone and all have benefited by a reduced need for nursing care or increased function or both. CONCLUSION: Long-term continuous infusion of intrathecal baclofen delivered via an implantable pump offers an effective method for dealing with otherwise intractable spasticity.     

Long-term intrathecal baclofen infusion for treatment of spasticity

Seven patients with spasticity of spinal cord origin have been maintained for up to 2 years with continuous spinal intrathecal infusion of baclofen. Prior to treatment, all of the patients had severe rigidity in their lower limbs and most had frequent and extensive spontaneous spasms, all of which greatly interfered with their activities of daily living. Oral antispasmodic medications were ineffective or caused central side effects. The patients underwent implantation of a programmable drug pump connected to a lumbar subarachnoid catheter. Within days of beginning continuous intrathecal baclofen infusion, the muscle tone was reduced to normal levels and spasms were eliminated. Over the ensuing months, muscle tone remained normal, but short-duration spasms could be induced by some activities. The greatest benefits to the patients were improvement in activities of daily living and better sleep due to reduced spasms. The baclofen doses were increased over the first few months but then were stabilized or only increased slightly, with the maximum dose being 650 micrograms/day. The most serious complications were two drug overdoses which took several days to clear up and were due to malfunctions of an earlier pump model. Baclofen clearance from the cerebrospinal fluid occurs with a half-life of 5 hours. The most serious concern in maintaining patients indefinitely on intrathecal baclofen is whether drug tolerance will eventually occur.     

Functional benefits and cost/benefit analysis of continuous intrathecal baclofen infusion for the management of severe spasticity

OBJECT: Intrathecally delivered baclofen has been used as a treatment for severe spasticity since 1984. Despite this, there are uncertainties surrounding the benefits of treatment and the costs involved. The authors assessed the evidence of benefits and identified costs and the cost/benefit ratio for continuous intrathecal baclofen infusion in the treatment of severe spasticity. METHODS: A systematic literature review was conducted to estimate the effect of continuous intrathecal baclofen infusion on function and quality-of-life (QOL) measures in patients with severe spasticity. Outcomes were related to standard QOL scores to estimate potential gains in quality-adjusted life years (QALYs). Information on the costs of continuous intrathecal baclofen infusion was obtained from hospitals in the United Kingdom. This information was combined to estimate the cost/benefit ratio for the use of continuous intrathecal baclofen infusion in patients with different levels of disability from severe spasticity. Studies indicate that bedbound patients are likely to improve their mobility and become able to sit out of bed. Patients with severe spasm-related pain are likely to have major improvement or complete resolution of this pain. Many other benefits are also reported. Such benefits are related to costs per QALY in the range of 6,900 pounds to 12,800 pounds ($10,550-$19,570 US). CONCLUSIONS: In carefully selected patients who have not responded to less invasive treatments, continuous intrathecal baclofen infusion is likely to lead to worthwhile functional benefits. Continuous intrathecal baclofen infusion has an acceptable cost/benefit ratio compared with other interventions that are funded by the health service.     

Intrathecal baclofen for treatment of spasticity in patient with cerebral palsy--a preliminary report]

Spasticity is a common symptom of upper neuron damage which requires continuous research for new treatment strategies. The aim of this paper is to present the result of intrathecal baclofen infusion in treatment of spasticity in patients with cerebral palsy. Three patients (aged 16 to 21 years) in whom baclofen pumps were implanted underwent clinical and neurophysiological assessment both before and after pump implantation. Early results of spasticity treatment in cerebral palsy with intrathecal baclofen infusions are very promising.     

Epidural analgesia in a patient with an intrathecal catheter and subcutaneous pump to deliver baclofen

Baclofen is used for the treatment of spasticity. Small doses administered intrathecally achieve high cerebrospinal fluid concentrations with reduced side-effects. Pediatric anesthesiologists are often reluctant to consider epidural analgesia in children receiving baclofen via an intrathecal catheter and subcutaneous pump. This reluctance is based on concerns for damaging the intrathecal catheter and introducing infection. In addition, the acute cessation of intrathecal baclofen can precipitate a life-threatening withdrawal state. We report a case of successful epidural analgesia in a patient receiving intrathecal baclofen and discuss the steps we took to minimize the chance of harm with this technique. We conclude that an intrathecal catheter and subcutaneous pump to deliver baclofen should not preclude the use of an epidural catheter for perioperative analgesia.     

Baclofen pump pocket infection: a case report of successful salvage with muscle flap

Programmable pump for continuous infusion of intrathecal baclofen, an agonist of the inhibitory neurotransmitter gamma-aminobutyric acid, is nowadays being widely used to control spasticity. The most common complications leading to explantation of the pumps are skin breakdown and infection at the pump implantation site which cannot be effectively treated without pump removal. We report a 37-year-old man who developed a baclofen pump pocket infection that did not respond to antibiotic therapy. Because the continuation of intrathecal baclofen administration was critical to the patient, and because the high cost of the pump precluded its prompt replacement, the pump was salvaged using the ipsilateral rectus abdominis muscle that was elevated on its inferior vascular pedicle and wrapped around the pump. Abdominal skin was then approximated, leaving a small portion of exposed muscle overlying the refill site that was covered by a split-thickness skin graft. Continuous intrathecal baclofen administration was never discontinued. Three months later, the pump's refill site could be easily identified manually for pump refill. There were no signs of recurrent infection during the 2-year follow-up period.     

Rapid progression of scoliosis following insertion of intrathecal baclofen pump

Placement of an intrathecal baclofen pump is a common treatment of spasticity in cerebral palsy patients. Though effective, the hardware is prone to malfunction, and multiple revisions are often necessary. Additional complications have also been described, including infection and drug toxicity or withdrawal. The authors report another complication of intrathecal baclofen therapy: accelerated progression of scoliosis after pump insertion. A retrospective chart review was performed on four patients who showed accelerated scoliotic progression after intrathecal baclofen pump insertion for treatment of spasticity. Cobb angles were measured from preoperative and postoperative radiographs to determine the rate of scoliotic degeneration both before and after pump insertion. Although there may not be a direct correlation between intrathecal baclofen and scoliosis, the authors consider the issue important enough to warrant discussion with any patient considering intrathecal baclofen.     

Intrathecal baclofen for children with chronic pain related to severe spasticity: advantages of tunneling the catheter in the testing phase

OBJECTIVE: To document the effectiveness and safety of intrathecal baclofen administered through a tunneled catheter during a diagnostic procedure, prior to implantation of a subcutaneous pump, in children with chronic pain due to severe spasticity. METHODS: This was a retrospective study of 6 children with intense chronic pain due to spasticity caused by cerebral palsy or genetic dystonia. Increasing doses of intrathecal baclofen in continuous perfusion through a tunneled catheter were tested. RESULTS: Lumbar intrathecal catheters were tunneled for 48 to 80 hours in 5 males and 1 female aged 8 to 18 years old. Intrathecal baclofen was administered in continuous perfusion up to maximum rates that ranged between 105 and 570 microg/day. For 5 patients the score on the visual analog pain scale (0-10) changed from over 7 to 0 by the end of the test. In 2 patients, side effects of analgesia were noted, specifically sedation, bradycardia, and bradypnea. No serious complications, such as meningitis, spinal abscess, or hematoma, were reported. The families of 4 patients chose to accept implantation of a subcutaneous pump. Pump therapy remained effective and free of complications when checked 23 or 55 months after placement. CONCLUSIONS: Performing a trial of increasing doses of intrathecal baclofen therapy in continuous perfusion through a tunneled catheter facilitated selection of patients for whom chronic administration of intrathecal baclofen is effective and free of complications.     

Bladder stones – red herring for resurgence of spasticity in a spinal cord injury patient with implantation of Medtronic Synchromed pump for intrathecal delivery of baclofen – a case report

Background

Increased spasms in spinal cord injury (SCI) patients, whose spasticity was previously well controlled with intrathecal baclofen therapy, are due to (in order of frequency) drug tolerance, increased stimulus, low reservoir volume, catheter malfunction, disease progression, human error, and pump mechanical failure. We present a SCI patient, in whom bladder calculi acted as red herring for increased spasticity whereas the real cause was spontaneous extrusion of catheter from intrathecal space.

Case Presentation

A 44-year-old male sustained a fracture of C5/6 and incomplete tetraplegia at C-8 level. Medtronic Synchromed pump for intrathecal baclofen therapy was implanted 13 months later to control severe spasticity. The tip of catheter was placed at T-10 level. The initial dose of baclofen was 300 micrograms/day of baclofen, administered by a simple continuous infusion. During a nine-month period, he required increasing doses of baclofen (875 micrograms/day) to control spasticity. X-ray of abdomen showed multiple radio opaque shadows in the region of urinary bladder. No malfunction of the pump was detected. Therefore, increased spasticity was attributed to bladder stones. Electrohydraulic lithotripsy of bladder stones was carried out successfully. Even after removal of bladder stones, this patient required further increases in the dose of intrathecal baclofen (950, 1050, 1200 and then 1300 micrograms/day). Careful evaluation of pump-catheter system revealed that the catheter had extruded spontaneously and was lying in the paraspinal space at L-4, where the catheter had been anchored before it entered the subarachnoid space. A new catheter was passed into the subarachnoid space and the tip of catheter was located at T-8 level. The dose of intrathecal baclofen was decreased to 300 micrograms/day.

Conclusion

Vesical calculi acted as red herring for resurgence of spasticity. The real cause for increased spasms was spontaneous extrusion of whole length of catheter from subarachnoid space. Repeated bending forwards and straightening of torso for pressure relief and during transfers from wheel chair probably contributed to spontaneous extrusion of catheter from spinal canal in this patient.

     

Paralytic ileus: a complication after intrathecal baclofen therapy

INTRODUCTION: Baclofen is frequently used in the management of spasticity. When the therapeutic benefit of oral baclofen is not satisfactory, intrathecal administration should be considered. This method reduces side effects due to a reduction in dosage compared to oral administration. CASE DESCRIPTION: This study presents a 52-year-old man with tetraplegia after a brainstem stroke. Four days after the placement of a Synchromed II infusion pump (100 mcg per day), the patient presented a paralytic ileus. The treatment was conservative and the dosage of intrathecal baclofen was reduced to lowest drug flow. After 15 days of treatment the ileus was resolved and the dosage progressively increased without incident. CONCLUSION: Ileus should be considered as a rare side effect after intrathecal baclofen administration, especially in cases of brainstem injury because baclofen seems to act directly over vegetative brainstem nuclei. Based on this case, it is strongly recommended to decrease the dose of intrathecal baclofen as one of the main therapeutic options.     

Regression of vasomotor disorders under intrathecal baclofen in a case of spastic paraplegia.

Continuous intrathecal baclofen infusion via a subcutaneously implanted programmable pump has been used in the treatment of severe spasticity. Improvement classically concerns the neurological (hypertonia, spasms, hyperreflexia), urological (bladder function) and other clinically relevant outcomes, such as functional status of daily living. This short note reports on another effect of intrathecal baclofen on vasomotor disorders and cyanosis in the lower limbs, described in a patient with spastic paraplegia.     

Successful intrathecal ethanol block for intractable spasticity of AIDS-related progressive multifocal leukoencephalopathy.

OBJECTIVE: To study the efficacy of intrathecal ethanol block to relieve intractable spasticity in AIDS-related progressive multifocal leukoencephalopathy (PML) when long-term intrathecal baclofen infusion cannot be used. METHODS: A 33-year-old man with AIDS-related PML developed very severe spastic paraparesis (Ashworth rigidity score, 4) and painful muscle spasms. The patient was unable to sit in his wheelchair and remained bed bound. Combined oral baclofen and tizanidine at therapeutical doses were used without any effect on the spasticity. The patient refused the placement of an intrathecal catheter for long-term baclofen infusion. A single intrathecal ethanol (6 ml) injection in the L2-L3 intervertebral space with the patient placed in a lateral Trendelenburg (40 C) position was performed. RESULTS: The procedure was very effective in improving the stiffness (Ashworth rigidity score. 2, after the technique) and the muscle spasms disappeared. No side effects during or after the injection were observed. CONCLUSION: Intrathecal ethanol block is a last but very useful choice for treatment of intractable spasticity in PML and other neurologic disorders in AIDS patients when other oral treatments have failed and intrathecal baclofen infusion is not suitable.     

Efficacy of dorsal longitudinal myelotomy in treating spinal spasticity: a review of 20 cases

The authors report their experience using dorsal longitudinal myelotomy in treating spasticity in 20 patients with complete spinal cord injuries. These patients suffered from severe painful flexor/extensor spasms that prevented them from wheelchair ambulation and/or their decubitus ulcers healing. All were receiving large doses of various oral drugs, including baclofen, which had failed to control their spasticity, and all underwent a modification of a posterior T-myelotomy as first described by Bischof. All 20 patients enjoyed immediate complete relief of their painful spasms, although two (10%) eventually experienced return of their spasms and are thus classified as long-term failures. Seventeen patients succeeded in markedly reducing, or being completely weaned from, their antispasmodic medications. In 11 of 14 patients, nonhealing decubitus ulcers subsequently healed with treatment. Bladder function was unchanged from the preoperative status in all patients. Chronic intrathecal baclofen infusion has recently been reported as an effective treatment of the spasticity of paraplegia. The results of this study, along with previous reports advocating dorsal longitudinal myelotomy, suggest that this approach is an efficacious alternative to chronic baclofen infusion in reducing spasticity for complete paraplegics. Considering the cost of the infusion pump, along with the fact that chronic intrathecal baclofen therapy necessitates long-term medical supervision, it appears that myelotomy is superior for this select group of patients who have no hope of regaining voluntary motor function.     

Treatment of spasticity in a spinal cord-injured patient with intrathecal morphine due to intrathecal baclofen tolerance--a case report and review of literature

STUDY DESIGN: Case report. OBJECTIVE: To report treatment of spasticity in a spinal cord-injured person with intrathecal morphine after the person developed tolerance to intrathecal baclofen. METHOD: Spasticity in a 36-year-old man with T6 complete paraplegia was treated with increasing doses of intrathecal baclofen. When he developed tolerance to intrathecal baclofen, he was given continuous infusion of morphine intrathecally. SETTING: Regional Spinal Injuries Centre, UK. RESULTS: Spasticity was adequately controlled by intrathecal morphine. CONCLUSION: In spinal cord-injured patients with severe spasticity, who become tolerant to intrathecal baclofen, treatment with intrathecal morphine may be useful.     

Attenuation of cerebellar tremor with implantation of an intrathecal baclofen pump: the role of gamma-aminobutyric acidergic pathways. Case report

The authors present the case of a 49-year-old woman with disabling bilateral upper-extremity cerebellar tremor that resolved unexpectedly after placement of an intrathecal baclofen pump for lower-extremity spasticity. The tremor amplitude decreased nearly linearly with increasing intrathecal baclofen dosage, and disappeared completely at a dose of 250 microg/day. In this report the authors demonstrate the role of the gamma-aminobutyric acidergic system in the pathogenesis of cerebellar tremor, and these findings may lead to a new treatment modality for patients disabled by this manifestation of their disease.     

Blessing or burden? Long‐term maintenance,complications and clinical outcome of intrathecal baclofen pumps

Aim

The intrathecal baclofen pump is an effective treatment for spasticity. However, long‐term results have reported patients’ dissatisfaction and perception of disability. Potential causes include a frequent need for baclofen pump refill and risks of complications. The aim of the present study was to evaluate the long‐term maintenance, complications and clinical outcome of intrathecal baclofen pumps.

Patients and Methods

We conducted a 16‐year retrospective cohort study of patients with spasticity treated with an intrathecal baclofen pump at a university hospital from 2000 to 2016. The primary outcome was the rate of infection per puncture for baclofen pump refill. Secondary outcomes included the incidence of other complications, such as running out of baclofen causing symptomatic withdrawal symptoms, pump mechanical failure, pump battery end of life and the need for pump replacement. The clinical outcome was assessed by the Modified Ashworth Scale (mAS).

Results

In total, 340 follow‐up episodes with pump refill procedures were recorded. The average interval between each pump refill was 57.3 days (±15.4 days). The average duration of admission for each pump refill was 4 h and 49 min (from 2 h 23 min to 10 h). There were two events with established infection after puncture for the refill, giving rise to an infection rate per puncture of 0.6 percent (2/340). For the long‐term clinical outcome, at an average follow‐up period of 7.6 years, the postoperative mAS for spasticity was 2.0 ± 0.756, which was significantly better than the preoperative mAS at 3.75 ± 0.462 (P = 0.001).

Conclusion

Long‐term aftercare with baclofen pump refill was safe, with an infection rate of 0.6 per cent per puncture for each refill. Long‐term intrathecal baclofen pump was effective in the treatment of spasticity with persistent significant improvement in the spasticity scale.     

Continuous intrathecal baclofen administration by a fully implantable electronic pump for severe spasticity treatment: our experience

AIM: With this 8-month study, we wanted to evaluate the efficacy of continuous intrathecal baclofen infusion delivery by a programmable pump for severe spasticity according to patient selection criteria, implantation technique and related parameters, and outcome after the initial follow-up period. METHODS: Intrathecal baclofen infusion was initiated in 30 patients within 24 h after a test dose of the agent resulted positive in spinal anaesthesia. During the procedure and the follow-up period, the following parameters were measured: incidence of anaesthesiological or surgical complications and adverse events, postdural puncture headache, prolonged motor block, difficulty in wound healing, infection, necessity to remove the pump; clinical response as measured on the Ashworth and spasms scales, quality of sleep, autonomy, quality of life and pain before and after intrathecal baclofen therapy. RESULTS: Perioperative vital parameters (mean duration of the operation, 86+/-13 min) were stable; no motor block or postdural puncture headache, early or late infection developed. The 1 case of delayed wound healing resolved with treatment; a dislocated catheter was repositioned in 1 other case. The differences in changes between pre- and posttreatment were statistically significant, with best results obtained on rigidity and pain. The mean length of hospital stay was 8+/-2 days. Baclofen tolerance was observed in 1 case, but resolved after baclofen holiday with morphine. One case of pump malfunctioning was resolved with replacement of the device; no new neurological deficits occurred thereafter. CONCLUSIONS: The good clinical response to treatment of spasticity and rigidity, improved quality of life, pain reduction and patient satisfaction with short length of admission demonstrate the efficacy of intrathecal baclofen therapy. Safe and efficacious, this mode of treatment appears to be the gold standard for treating severe spasticity.