Spasticity and pain are common features of spinal cord disease that may be adequately treated with oral medications in many patients. However, for optimal results it is necessary to use intrathecal baclofen (ITB) or intrathecal morphine (ITM) delivered via a surgically implanted programmable pump in some patients [1–4]. Most patients who need ITB/ITM therapy respond well but in some clinical situations there are problematic issues, including: (1) Occasionally titration of ITB dose is difficult when relief of spasticity is associated with an unacceptable degree of muscle weakness; (2) Rarely patients on continuous long-term ITB therapy develop drug tolerance and cease to respond to escalating doses of ITB [5]; (3) Some patients with pain are intolerant to or rarely, inadequately responsive to intrathecal (IT) narcotics. Clonidine, an a2-adrenergic agonist, inhibits the release of excitatory amino acids from spinal interneurons and the dorsal reticulospinal tract and has anti-spastic and analgesic properties [2]. The hypotensive effects seen with oral clonidine prevent its widespread use in the treatment of spasticity and pain. Intrathecal clonidine (ITC) has been reported to be beneficial for pain relief and in addition, there is a case report on the relief of pain and spasticity in a spinal cord injury patient with the use of combination ITB and ITC [6, 7]. At our center, we have used long-term ITC administered singly or in combination in 21 patients with multiple sclerosis and in isolated cases of various spinal cord disorders (Tables 1, 2). All patients gave a written informed consent prior to the use of ITC. To review our experience, we conducted an IRB-approved retrospective chart analysis of all our patients on continuous ITC therapy. Our review showed that ITC was efficacious in the following circumstances: (1) as a single agent for relief of spasticity in patients who had an unacceptable degree of weakness with the use of ITB (P03, P05; Table 1); (2) as a single agent for relief of spasticity in patients who developed tolerance to ITB after long-term use (P02, P08; Table 1); (3) in patients with spasticity and significant weakness, addition of ITC to ITB enables a reduction in the dose of ITB necessary for spasticity relief, thereby decreasing the degree of weakness and optimizes functionality (P01, P04, P06, P07, P09, P10, P11, P12; Table 1); (4) in combination with ITB in patients with spasticity who also had significant neuropathic pain syndrome and were intolerant to narcotics (P01, P02, P04, P06, P08; Table 2); (5) for relief of pain in patients with intractable pain and suboptimal responses to ITM or ITM/ ITB therapy (Table 2). ITC therapy was empirically initiated at a dose of 30 lg/ day and at this dose clinically beneficial effects were seen in only one patient who required a lesser dose (P05; Table 1). Most patients required doses greater than 100 lg/ day and the maximum dose of ITC used was 750 lg/day (P08; Table 2). Our review shows that ITC is well tolerated over a prolonged period of time with 18 patients receiving ITC for 5 or more years and six patients for at least 10 years. Surprisingly, hypotensive episodes were not seen perhaps because of our low initial dose (30 lg/day) and gradual escalation thereafter. ITC did not appear to be associated with new onset depression or necessitate dose-adjustment J. K. Ho S. A. Sadiq (&) Multiple Sclerosis Research Center of New York, 521 West 57th Street, 4th Floor, New York, NY 10019, USA e-mail: ssadiq@msrcny.org