Intrathecal Baclofen Administration Research Articles

Intrathecal Baclofen for Spasticity: Is There an Effect on Bladder Function? Report of Three Cases and Review of the Literature.

traumatic brain injury (TBI) is very often associated with spasticity. Medical interventions may include medications such as baclofen, a Gamma-Aminobutyric Acid (GABA) -receptor agonist of poor lipid solubility. Intrathecal baclofen (ITB) administration is a contemporary treatment option which minimizes adverse effects in contrast with the oral form of the drug. Regarding low urinary tract dysfunction, TBI, as a suprapontine lesion, results in neurogenic detrusor overactivity. Frequency, urgency and urge incontinence are the predominant signs and symptoms of this condition. Our study aims to report the potential changes in bladder function in patients with spasticity, due to TBI, after the implantation of the baclofen pump and the control of spasticity. We report three cases of TBI whose spasticity responded well to ITB. We evaluated our medical reports regarding bladder function retrospectively, before and after baclofen pump implantation. We compared the data of bladder diaries and urodynamic parameters. Bladder function was improved in all patients. Regarding bladder diaries; the number of incontinence and micturition episodes was decreased and the volume per void was slightly increased. Regarding urodynamic parameters; bladder capacity and reflex volume increased, Pdetmax decreased, PVR was the same and DLPP was slightly decreased. Although the baclofen pump is implanted to treat spasticity, detrusor activity may be also affected. Therefore, patients' urologic profiles should also be reevaluated after ITB. Further prospective studies are required to investigate the effect of ITB on bladder function in the clinical field and also at the basic science level.

Results of Intrathecal Baclofen Treatment in Sixteen Spasticity Patients According to Four Different Measurement Scales:A Retrospective Analysis.

IntroductionSpasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes. It occurs as a result of overstimulation of the stretch reflex and is a component of the upper motor neuron syndrome. Intrathecal Baclofen (ITB) pump administration in patients with a diagnosis of spasticity may be a suitable option for reducing the complaints of the patients and increasing their quality of life. The aim of this study is to analyze clinically and statistically the diagnosis, treatment criteria, and post-treatment results of patients with spasticity who were treated in our clinic.Materials and MethodSixteen patients who were diagnosed with spasticity and placed on an intrathecal Baclofen pump between January 2015 and December 2020 were included in this study. An intrathecal Baclofen trial was first applied to patients who were candidates for the Baclofen pump. The spasticity levels of the patients who decided to have an intrathecal Baclofen pump were scored according to the modified Ashworth scale (MAS) and Penn spasm frequency scale (PSFS). In addition, the scaling of the patients' own conditions according to the visual analogue scale (VAS) and ambulation status according to the modified functional ambulation classification (MFAC) were recorded. All these evaluations were repeated in the preoperative, early postoperative, and follow-up periods.ResultsThe sex distribution of the patients included in the study was equal to eight women and eight men. The age distribution was between 18 and 76. The average age was 40.62 (standard deviation ±17.79). The average preoperative modified Ashworth scale score was 3.73, and the average Penn spasm frequency scale score of the patients was 3.67. The average preoperative modified functional ambulation classification score was 1.87, and the average visual analogue scale score was 6.67. At the end of the second postoperative week, the average modified Ashworth scale score was 1.80 and the average Penn spasm frequency scale score was 1.67. The modified functional ambulation classification score was 2.60 and the visual analogue scale score was 4.58. The average follow-up period of the patients was 64 months. At the end of the follow-up periods, the average late-period modified Ashworth scale score was 1.87, and the Penn spasm frequency scale score was 1.67. The average modified functional ambulation classification score was 3.00, and the average visual analogue scale score was 4.50. Statistically, there was a significant difference between preoperative and postoperative results in both modified Ashworth scale and Penn spasm frequency scale scores (P<0.05). Modified functional ambulation classification preoperative and postoperative comparison results (P<0.05) and visual analogue scale results (P<0.05) were also statistically significant. No significant difference was found between the early postoperative period and the late postoperative period in all measurements (P=1.00).ConclusionIntrathecal Baclofen administration is one of the many treatment options for spasticity. In this way, it has been shown that greater Baclofen efficacy is achieved and its side effects are reduced. It should always be remembered that the process of this treatment is teamwork that requires the participation of more than one specialty branch. Physical therapists, neurologists, pediatricians, and neurosurgeons should be included in this teamwork.

On the recovery of disorders of consciousness under intrathecal baclofen administration for severe spasticity-An observational study.

BackgroundOccasionally, patients show dramatic recovery from disorders of consciousness (DOC) under intrathecal baclofen (ITB), an established treatment option for severe supraspinal spasticity. Anecdotal explanations for ITB‐related recovery of cognition include modulation of afferent impulses at the spinal level, thereby reducing spasticity‐related proprioceptive information overload within cortico–thalamo–cortical connections.ObjectiveIn this retrospective patient chart analysis, we assessed whether a reduction in spasticity would be associated with an increase in Coma Recovery Scale revised (CRS‐R) scores in a larger sample of patients than previously published.MethodsFrom a hospital‐based ITB treatment register, we extracted data from 26 patients with DOC and severe supraspinal spasticity who improved by >2 points on the Coma Recovery Scale revised (CRS‐R) within 6 months after ITB treatment initiation. We assessed Modified Ashworth scale (MAS) scores and CRS‐R scores on admission (PRE) and 3 and 6 months after initiation of ITB treatment (3M, 6M). We performed correlation analysis of the scores and their respective changes (PRE to 3M, 3M to 6M). We also correlated the time from acute event until ITB initiation to CRS‐R scores at 3M and 6M.ResultsITB led to significant improvement in spasticity based on MAS scores, which did not correlate to the improvements seen in CRS‐R total and subscale scores. Daily ITB dose did neither correlate to MAS scores nor to CRS‐total scores in the whole patient group, but after 3 months, ITB dose correlated to some CRS‐R subscale scores in some patient subgroups. Time until ITB treatment did not correlate to CRS‐R scores later on.ConclusionsOur data confirm that ITB may exert beneficial effects in selected DOC patients with respect to improved cognitive functions, which, however, do not correlate to its antispastic effect. The lack of correlation between time to ITB and CRS‐R outcome, but significant CRS‐R improvements following pump implantation, renders spontaneous remissions unlikely and leaves room for alternative pharmacological mechanisms.

Improvement of Memory Functions in Chronic Spinal Cord Injury After Long-Term Intrathecal Baclofen Delivery for Spasticity Relief

Intrathecal baclofen (ITB) pump delivery systems are safe and effective in the treatment of generalized spasticity in chronic spinal cord injury (SCI). Despite its widespread use, few and discrepant data are available in animal studies on the effects of ITB on cognitive functions, such as memory. The effects of chronic administration of baclofen on humans have not been investigated to date. The aim of this study is to find out, whether a long-term administration of ITB has any effects on cognitive functions in SCI subjects. In 11 out of 22 subjects with chronic SCI, we performed comprehensive neuropsychological assessment carried out using specialized tests focused on memory and other higher cognitive domains and emotional state. All patients receiving ITB treatment for spasticity relief improved significantly in RAVLT Trials 1-5 (p=0.049), Logical memory-immediate recall (p=0.019) and Logical memory-delayed recall (p=0.008). Visual memory, long-term semantic memory, attention, executive, perceptual and spatial functions, and mood status remained stable. No significant decline in memory functions were detected following one year of ITB delivery, creating an opportunity for careful prescription of this treatment in chronic SCI. Moreover, we have detected a significant increase in short-term auditory-verbal memory and logical memory performance.

Movement Disorders in Children with a Mitochondrial Disease: A Cross-Sectional Survey from the Nationwide Italian Collaborative Network of Mitochondrial Diseases.

Movement disorders are increasingly being recognized as a manifestation of childhood-onset mitochondrial diseases (MDs). However, the spectrum and characteristics of these conditions have not been studied in detail in the context of a well-defined cohort of patients. We retrospectively explored a cohort of individuals with childhood-onset MDs querying the Nationwide Italian Collaborative Network of Mitochondrial Diseases database. Using a customized online questionnaire, we attempted to collect data from the subgroup of patients with movement disorders. Complete information was available for 102 patients. Movement disorder was the presenting feature of MD in 45 individuals, with a mean age at onset of 11 years. Ataxia was the most common movement disorder at onset, followed by dystonia, tremor, hypokinetic disorders, chorea, and myoclonus. During the disease course, most patients (67.7%) encountered a worsening of their movement disorder. Basal ganglia involvement, cerebral white matter changes, and cerebellar atrophy were the most commonly associated neuroradiological patterns. Forty-one patients harbored point mutations in the mitochondrial DNA, 10 carried mitochondrial DNA rearrangements, and 41 cases presented mutations in nuclear-DNA-encoded genes, the latter being associated with an earlier onset and a higher impairment in activities of daily living. Among our patients, 32 individuals received pharmacological treatment; clonazepam and oral baclofen were the most commonly used drugs, whereas levodopa and intrathecal baclofen administration were the most effective. A better delineation of the movement disorders phenotypes starting in childhood may improve our diagnostic workup in MDs, fine tuning management, and treatment of affected patients.

Baclofen therapeutics, toxicity, and withdrawal: A narrative review.

Baclofen is an effective therapeutic for the treatment of spasticity related to multiple sclerosis, spinal cord injuries, and other spinal cord pathologies. It has been increasingly used off-label for the management of several disorders, including musculoskeletal pain, gastroesophageal reflux disease, and alcohol use disorder. Baclofen therapy is associated with potential complications, including life-threatening toxicity and withdrawal syndrome. These disorders require prompt recognition and a high index of suspicion. While these complications can develop following administration of either oral or intrathecal baclofen, the risk is greater with the intrathecal route. The management of baclofen toxicity is largely supportive while baclofen withdrawal syndrome is most effectively treated with re-initiation or supplementation of baclofen dosing. Administration of other pharmacologic adjuncts may be required to effectively treat associated withdrawal symptoms. This narrative review provides an overview of the historical and emerging uses of baclofen, offers practical dosing recommendations for both oral and intrathecal routes of administration, and reviews the diagnosis and management of both baclofen toxicity and withdrawal.

Effects of intrathecal baclofen therapy in subjects with disorders of consciousness: a reappraisal

Baclofen is a structural analogue of gamma-amino-butyric acid (GABA), which reduces spastic hypertonia of striated muscle due to a mechanism of GABAB-ergic inhibition of mono- and polysynaptic reflexes at the spinal level. There are reports of patients with severe disorders of consciousness that presented a substantial improvement following intrathecal baclofen (ITB) administration for severe spasticity. The neural mechanisms underlying the clinical recovery after ITB have not yet been clarified. Baclofen could modulate sleep-wake cycles that may be dysregulated and thus interfere with alertness and awareness. The diminished proprioceptive and nociceptive sensory inputs may relieve thalamo-cortical neural networks involved in maintaining the consciousness of the self and the world. ITB treatment might also promote the recovery of an impaired GABAergic cortical tone, restoring the balance between excitatory and inhibitory cortical activity. Furthermore, glutamatergic synapses are directly or indirectly modulated by GABAB-ergic receptors. Neurophysiological techniques (such as transcranial magnetic stimulation, electroencephalography, or the combination of both) can be helpful to explore the effects of intrathecal or oral baclofen on the modulation of neural cortical circuits in humans with disorders of consciousness.

頚椎症性脊髄症による下肢痙縮に対してバクロフェン髄腔内投与療法（ITB療法）を施行し歩行可能となった1例

頚椎症性脊髄症による下肢痙縮に対してバクロフェン髄腔内投与療法（ITB療法）を施行し歩行可能となった1例

Evaluation of Risk Factors for Cerebrospinal Leakage in Pediatric Patients With Cerebral Palsy Treated With Intrathecal Baclofen.

Insertion of an intrathecal baclofen (ITB) pump can provide significant benefits in patients with cerebral palsy (CP). However, there are little data describing the risk of complications. Specifically, there is a lack of data describing the incidence of cerebrospinal fluid (CSF) leakage and risk factors following ITB placement. The purpose of our study was to describe risk factors for developing CSF leak in pediatric patients with CP treated with ITB and to report the treatment and outcome of CSF leaks. Following institutional review board approval, 720 ITB procedures in 341 children with CP were identified retrospectively over a 15-year study period. Patients' demographic characteristics, medical comorbidities, muscle tone patterns, feeding tube status, seizure history, inpatient events, ITB-related CSF leak and headache complaints and their management, and other complications were evaluated. Eighty-five (24.9%) patients experienced 90 CSF leak episodes over a follow-up time of 6.3±3.9 years. There were 72 episodes of headache as a result of CSF leakage in 61 (71.7%) of these 85 patients. There was a positive correlation between the risk of CSF leak and preoperative comorbidities such as epilepsy/seizure history, feeding tube, mixed type CP, and dystonic type CP. The risk of CSF leak after primary ITB administration was 5.8% (20/341), and the risk after secondary ITB procedures due to complications was 24.2% (32/132). There was no significant relationship between CSF leak and primary ITB (P=0.21), but the risk of CSF leak was positively correlated to the secondary ITB due to complications (P<0.05). CSF leak was fairly common (25% incidence), and it correlated with epilepsy/seizure history, feeding tube, mixed type CP, and dystonic type CP. Recurrent ITB procedures were a risk factor for CSF leak. Half of these patients had self-limited symptoms that improved with conservative medical treatment, and the epidural blood patch was successful in resistant cases. Successful treatment of CSF leakage complications allows patients to continue ITB. Level III.

Restoration of rostral cerebrospinal fluid flow to solve treatment failure caused by obstruction in long-term intrathecal baclofen administration

Objects: We describe five traumatic spinal cord injury (SCI) patients with an intrathecal baclofen administration (ITB) failure caused by a rostral CSF flow obstruction referred to our expert center between January 2014 and January 2019. We discuss the diagnostic workup, rostral CSF flow obstruction as the cause of the ITB failure and treatment. Methods: When we could not determine the cause of the ITB failure through the patient’s history, physical spasticity examination, pump readout, absence of fluid in the pump reservoir during aspiration, or plain radiography, we performed pump catheter access port (computed tomography [CT]) myelography. When CT myelography did not reveal the diagnosis, we used scintigraphy. In an obstruction, we aimed for CSF flow restoration. In three cases, we conducted a laminectomy with microsurgical adhesiolysis. In two of these patients, we could not achieve CSF flow restoration; thus, we placed an intradural catheter bypass. Recently, in three patients, we applied a less invasive technique of percutaneous fenestration of the obstruction. Results: In one case, we performed a successful catheter replacement. In another case using surgical adhesiolysis, spasticity control was complete. In two cases, we could obtain improvement with an additional intradural bypass, followed by a percutaneous fenestration of the obstruction, resulting in further improved CSF flow restoration. In one case, percutaneous fenestration was the first line of treatment. In all cases with percutaneous fenestration, we experienced spasticity control. Conclusion: Preliminary results showed that the restoration of rostral CSF flow might result in an effective ITB treatment in patients with an intrathecal obstruction.

Intrathecal Baclofen Trial Before Device Implantation: 12-Year Experience With Continuous Administration

ObjectiveTo report our experience using continuous intrathecal baclofen (ITB) administration prior to a possible ITB device implantation. DesignRetrospective open label study. Mean duration of follow-up 64 months. SettingPrimary-care and referral center, ambulatory and hospitalized care. ParticipantsPatients (N=116) undergoing continuous ITB trials between 2006 and 2017. InterventionsContinuous application of baclofen via a temporary intrathecal catheter connected to an external pump. Main Outcome MeasuresAssessment of the modified Ashworth Scale and range of movement prior versus end of ITB trial. According to the Barthel Index, definition of high-level patients (60-100 scoring points) and low-level patients (0-55 scoring points). Calculation of the Rivermead Mobility Index in high-level patients prior versus end of ITB trial. Evaluation of occurring adverse events. ResultsA total of 119 ITB trials were performed in 116 patients (78 men, mean age 41±16), 113 patients completed the trials (31 of 113 high level, 82 of 113 low level). The median modified Ashworth scale improved from 4 (interquartile range [IQR] 3-4) to 2 (IQR 1-2; P≤.001), the range of movement from 2 (IQR 1-3) to 3 (IQR 3-3; P≤.001). The Rivermead Mobility Index increased from 9 (IQR 6-12) to 10 (IQR 7-12.5; P=.004) in high-level patients. Eighty-eight out of 113 patients (78%) were appropriate candidates for ITB device surgery, 75 of 88 (85%) proceeded to an implantation. A total of 69 adverse events occurred in 57 of 119 trials (48%), 37 of 69 (54%) were drug related, 32 of 69 (46%) were procedure related, and 42 of 69 (61%) were minor. The ITB device was implanted in 69 of 75 patients (92%) at last follow-up. ConclusionsContinuous administration of ITB is an effective and useful alternative to ITB bolus application during ITB screening period. Half of the patients experienced adverse events; the majority were minor events.

Improved response after intrathecal administration of baclofen in a patient with impaired consciousness – A case study

Disorders of consciousness present some of the most difficult diagnostic and therapeutic challenges in brain rehabilitation. Within the spectrum of these disorders, diagnosis remains clinical and depends on the response to various stimuli in the environment rather than objective physiological markers. In recent years, various cases have been reported in the medical literature in which patients with such diagnoses reacted to various stimuli indirectly. Spasticity is a common sequela of brain injury and may significantly impair a patient's ability to respond to stimuli in their environment. A case study of a patient in a state of minimal reactivity demonstrating significantly improved responses to their environment following intrathecal injection of Baclofen. A 59-year-old man who was admitted for rehabilitation following subarachnoid hemorrhage secondary to anterior coronary artery aneurysm (ACA) requiring subsequent periventricular shunt placement. At admission, the patient presented in a vegetative state. During hospitalization, there was a temporary improvement in level of consciousness until the appearance of infection along the VPS drain necessitating removal of the shunt. Upon completion of treatment, the patient returned to our department with inconsistent, minimal reactivity on exam. Due to severe spasticity in all four limbs unresponsive to oral treatment and local injection, a one-time intrathecal injection of Baclofen was administered. Directly following treatment, the patient demonstrated decreased tone and immediate improvement in responsiveness and ultimately the production of a number of intelligible words and phrases. In evaluating patients suffering from disorders of consciousness, it is important to recognize that limited responsiveness results not only from the impairment of information reception, processing, and response initiation, but also from tonal disturbances that may be causing difficulty in performing such movements. This case study supports previous literature demonstrating improved communication following cellophane pump implantation following severe head injury.

Simultaneous Selective Dorsal Rhizotomy and Baclofen Pump Removal Improve Ambulation in Patients with Spastic Cerebral Palsy.

Background: Intrathecal baclofen (ITB) administration via an implanted programmable pump and selective dorsal rhizotomy (SDR) are both used for the treatment of cerebral palsy (CP) spasticity.Objective: To examine whether SDR can improve ambulation in children who have been receiving ITB therapy for spastic cerebral palsy.Methods: We reviewed 13 patients who received prior ITB placement with subsequent simultaneous SDR and ITB removal. Patients also completed a follow-up survey to document long-term motor function.Results: In our 13-patient cohort, patients received ITB treatment for an average of 4.4 pm 1.8 years and the mean age of ITB removal/SDR was 12.5 pm 5.8 years. The follow-up period ranged from 3 to 19 months (mean duration: 6.9 pm 5 months). Pre-operatively, all patients had Gross Motor Function Classification System (GMFCS) scores between 2 and 4. Nine patients were diagnosed with spastic diplegia, two had spastic triplegia and two had spastic quadriplegia. SDR and ITB removal led to improved lower limb spasticity and ambulation. GMFCS scores remained stable in all patients. One patient developed a cerebrospinal fluid (CSF) collection in the abdominal wall due to a CSF leak from the baclofen pump site. All 11 patients who completed the follow-up survey noted improved motor function.Conclusion: This study demonstrates that SDR can reduce spasticity and improve mobility after years of ITB treatment for spastic cerebral palsy.

Title: Quantifying the change of spasticity after intrathecal baclofen administration: A descriptive retrospective analysis

ObjectivesExploratory research quantifying the change of spasticity among patients who underwent baclofen intrathecal drug delivery system (IDDS) implantation.Patients and Methods: 88 patients with a baclofen IDDS were identified. Patient characteristics, spasticity scores pre/post intrathecal baclofen test dose, and IDDS perioperative implantation records were collected. The primary outcome was to quantify the extent to which there was a change in Modified Ashworth Scores (MAS) pre/post-intrathecal baclofen test dose administration. Secondary outcomes included the prevalence of perioperative IDDS implantation complications. ResultsThe mean age at IDDS implant was 44.2 years (range, 19–71), and 62.5% were male. 45.5% had spasticity of spinal cord origin, 9% of cerebral origin, and 45.5% of other upper motor neuron dysfunction. Reduction of MAS in the spinal cord origin group was 2.6 (mean, 3.5 to 0.9), cerebral origin group was 2.9 (mean, 3.3 to 0.4), and other origin group was 2.5 (mean, 3.6 to 1.1). In all patients, post dural puncture headache was the most commonly reported complication at 22.7%. ConclusionThis report offers novel findings documenting a quantifiable change of at least two points on the MAS before and after intrathecal baclofen test dose as statistically significant and could prove to be useful information to enhance the decision making process to proceed with intrathecal baclofen beyond assessment of functional abilities.

Intrathecal Baclofen Injection to Avoid Withdrawal in a Multiple Sclerosis Patient Undergoing Lumbar Spine Surgery: A Case Report.

Spasticity of spinal or cerebral origin is frequently treated with baclofen. Treatment interruption initially results in rebound spasticity; life-threatening withdrawal symptoms may follow. Severe rebound spasticity of leg muscles occurred in a multiple sclerosis patient after a 10-hour long perioperative pause of oral baclofen intake. In a subsequent spine surgery, recurrence was prevented by substituting a cumulative 12-hour oral baclofen dose with an intraoperative intrathecal injection. Administration of intrathecal baclofen during prolonged surgery in patients dependent on oral baclofen may improve patient comfort and prevent early withdrawal symptoms. The most optimal conversion ratio from oral to intrathecal baclofen is still undetermined.

1226 Two cases of central sleep apnea in patients on intrathecal baclofen (ITB)

Central sleep apnea (CSA) has been reported in association with baclofen, a GABAB receptor agonist. Few studies have described CSA in patients using intrathecal baclofen (ITB). Here we describe two such patients seen in sleep clinic. A 32-year-old male was referred for snoring and gasping sensations. History was significant for treated childhood astrocytoma and strokes resulting in left hemiparesis, spasticity and functional deficits. He had been on ITB for nine years prior to presentation. Apnea-hypopnea index (AHI) was 154.3 events/hour, including 332 central apneas. CPAP failed to resolve central apneas, but adaptive servo-ventilation (ASV) at 9 cm H2O resolved both obstructive and central apneas. A 40-year-old male with spastic tetraplegia from a traumatic brain injury (TBI) in 1995 was seen for unrefreshing sleep and excessive daytime sleepiness. He had been using an ITB for 10 years prior to presentation. A polysomnography (PSG) showed an overall AHI of 42, predominantly from 238 central apneas, which improved after treatment with ASV. CSA has previously been described in patients on baclofen therapy for alcohol withdrawal, but few studies have described CSA in patients with ITB for spasticity. Baclofen decreases minute ventilation in animals, but the mechanism by which it does so is unclear at this time. A pilot study revealed bolus administration of ITB can worsen pre-existing sleep apnea, whereas a continuous infusion did not significantly affect previous sleep disordered breathing. It may be important to perform PSG in patients prior to ITB pump placement. Another study demonstrated changes in sleep architecture and minor decreases in mean oxygen saturations following administration of oral baclofen, but limited effects on sleep-disordered breathing (SDB). It is possible that TBI and/or stroke may have contributed to the SDB observed in our patients. Our patients experienced improvement in CSA following ASV.

Image-guided intrathecal baclofen pump catheter implantation: a technical note and case series.

OBJECTIVE Medically refractory spasticity and dystonia are often alleviated with intrathecal baclofen (ITB) administration through an indwelling catheter inserted in the lumbar spine. In patients with cerebral palsy, however, there is a high incidence of concomitant neuromuscular scoliosis. ITB placement may be technically challenging in those who have severe spinal deformity or who have undergone prior instrumented thoracolumbar fusion. Although prior reports have described drilling through the lumbar fusion mass with a high-speed bur, as well as IT catheter implantation at the foramen magnum or cervical spine, these approaches have notable limitations. To the authors' knowledge, this is the first report of ITB placement using cone beam CT (CBCT) image guidance to facilitate percutaneous IT catheterization. METHODS Data were prospectively collected on patients treated between November 2012 and June 2014. In the interventional radiology suite, general anesthesia was induced and the patient was positioned prone. Imaging was performed to identify the optimal trajectory. Percutaneous puncture was performed at an entry site with image-guided placement of a sheathed needle. CBCT provided real-time 2D projections and 3D reconstructions for detailed volumetric imaging. A biopsy drill was passed through the sheath, and subsequently a Tuohy needle was advanced intrathecally. The catheter was threaded cephalad under fluoroscopic visualization. After tip localization and CSF flow were confirmed, the stylet was replaced, the external catheter tubing was wrapped sterilely in a dressing, and the patient was transported to the operating room. After lateral decubitus positioning of the patient, the IT catheter was exposed and connected to the distal abdominal tubing with typical pump placement. RESULTS Of 15 patients with Gross Motor Function Classification System Levels IV and V cerebral palsy and instrumented thoracolumbar fusion, 8 had predominantly spasticity, and 7 had mixed spasticity and dystonia. The mean age of patients was 20.1 years (range 13-27 years). Nine patients underwent initial catheter and pump placement, and 6 underwent catheter replacement. The procedure was technically successful, with accurate spinal catheter placement in all patients. The median hospital stay was 4 days (IQR 3-5 days). One patient had an early postoperative urinary tract infection. With a mean follow-up of 25.8 months (median 26, range 18-38 months), no CSF leakage or catheter failure occurred. One late infection due to Pseudomonas aeruginosa (requiring pump explantation) occurred at 4 months, probably secondary to recurrent urinary tract infections. CONCLUSIONS Image-guided CBCT navigation resulted in accurate percutaneous placement of the IT catheter for ITB pumps in patients with prior instrumented thoracolumbar fusion. The multimodality approach is an alternate technique that may be used for IT catheter insertion in patients with complex lumbar spine anatomy, extending the potential to provide safe, durable ITB therapy in this population.

Bomba intratecal de baclofeno, ¿una intervención terapéutica útil y segura en pacientes con espasticidad? Presentación de casos

Spasticity may cause immobility, prostration, chronic pain, bedsores, infections, thrombosis and pneumonia; the purposes of its treatment are to control pain, improve mobility and quality of life, and reincorporate the patient to its daily activities by means of oral anti-spastic drugs; however, patients suffering from severe spasticity may require high oral doses of these medications, which may lead to adverse effects. In such cases, intrathecal baclofen has been proposed as a solution. This procedure has not been widely used in Colombia, so that protocols to perform it have not been established. We report the results obtained with the intrathecal administration of baclofen in four severely spastic patients, who had not previously responded to oral anti-spastic drugs, including high doses of baclofen. Pain, spasticity and quality of life significantly improved in three of them. The remaining one presented tolerance to the medication. Intrathecal baclofen pump is a useful and safe procedure for patients with severe spasticity and poor response to oral treatment.

Spinal GABA-B receptor modulates neutrophil recruitment to the knee joint in zymosan-induced arthritis.

Recent studies have demonstrated that the central nervous system controls inflammatory responses by activating complex efferent neuroimmune pathways. The present study was designed to evaluate the role that central gamma-aminobutyric acid type B (GABA-B) receptor plays in neutrophil migration in a murine model of zymosan-induced arthritis by using different pharmacological tools. We observed that intrathecal administration of baclofen, a selective GABA-B agonist, exacerbated the inflammatory response in the knee after zymosan administration characterized by an increase in the neutrophil recruitment and knee joint edema, whereas saclofen, a GABA-B antagonist, exerted the opposite effect. Intrathecal pretreatment of the animals with SB203580 (an inhibitor of p38 mitogen-activated protein kinase) blocked the pro-inflammatory effect of baclofen. On the other hand, systemic administration of guanethidine, a sympatholytic drug that inhibits catecholamine release, and nadolol, a beta-adrenergic receptor antagonist, reversed the effect of saclofen. Moreover, saclofen suppressed the release of the pro-inflammatory cytokines into the knee joint (ELISA) and pain-related behaviors (open field test). Since the anti-inflammatory effect of saclofen depends on the sympathetic nervous system integrity, we observed that isoproterenol, a beta-adrenergic receptor agonist, mimics the central GABA-B blockade decreasing knee joint neutrophil recruitment. Together, these results demonstrate that the pharmacological manipulation of spinal GABAergic transmission aids control of neutrophil migration to the inflamed joint by modulating the activation of the knee joint-innervating sympathetic terminal fibers through a mechanism dependent on peripheral beta-adrenergic receptors and central components, such as p38 MAPK.

5. Neurophysiological assessment of spasticity in multiple sclerosis

Objective Spasticity is a frequent and often disabling feature of multiple sclerosis (MS). Up to 80–85% of MS cases suffer from different levels of spasticity. Appropriate management of spasticity is therefore an important part of the patient’s care. Muscle hypertonia is generally easy to recognize clinically, quantifying it is quite a complex matter. Correlation between the clinical and neurophysiological measures makes it especially difficult. The aim of the study is to review the main methods of evaluating spasticity published in the scientific literature with stress on our own experience. Methods In this session we will present neurophysiological tests used in assessment of spasticity with a special stress on the comparison of commonly used Modified Ashworth Scales scores (MAS), H-reflex testing, cutaneous and cortical silent periods, and brainstem reflexes. The main treatment options of pharmacological and non-pharmacological approaches will be discussed. Results Oral antispastic medication, therapeutic exercise and physical modalities are commonly used. From a pharmacological perspective of spasticity treatment, it is strongly recommended to use local chemodenervation with botulinum toxin for intramuscular administration under the EMG guidance. A modern approach to treat generalised spasticity is a continuous intrathecal baclofen (ITB) administration directly into the cerebrospinal fluid under neurophysiological monitoring. Conclusion Adequate evaluation and management of spasticity requires multidisciplinary approach and the setting of realistic goals that need to be achieved on an individual level, with regard to every single patient’s needs. Different options for spasticity management are available, however, choice of treatment hinges on a combination of the extent of symptoms, patient preference, and availability of services. Supported by Research Project of Charles University PRVOUK P34, Czech Republic.