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Gober J, Seymour M, Miao H, Curry DJ, Thomas SP. Management of severe spasticity with and without dystonia with intrathecal baclofen in the pediatric population: a cross-sectional study. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000407. [DOI: 10.1136/wjps-2021-000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/19/2022] [Indexed: 11/04/2022] Open
Abstract
ObjectiveTo investigate the differences in delivery mode, daily dose, and catheter tip location in pediatric patients using intrathecal baclofen (ITB) pumps with spasticity plus dystonia versus spasticity alone.MethodsA single-center, cross-sectional study was performed by collecting retrospective data from electronic medical records. Demographic and diagnostic information was obtained, comparing patients with spasticity with or without dystonia. The data were analyzed for group differences using a two-tailed Student’s t-test. Categorical data were analyzed for group differences using Pearson’s χ2 test.ResultsA total of 137 patients met the criteria. The majority (114) had spasticity plus dystonia whereas only 23 were documented as spasticity alone. Simple continuous dosing was the most common delivery mode, but flex dosing was used more than twice as frequently with spasticity plus dystonia compared with spasticity alone (42% vs 17%). Patients with spasticity plus dystonia also had more rostral catheter tip locations.ConclusionsWhile it has been discussed anecdotally, this study confirms the supposition that patients with spasticity plus dystonia have increased dose requirements when compared with those with spasticity alone. Although there are no clear standards of care when managing these patients, they are often on higher daily dosages, are more likely to require flexed dosing method, and have higher catheter placements. Still, there are few studies that demonstrate improvements in dystonia with the use of ITB. In general, these patients would benefit from the development of universal standardizations as well as the confirmation that this is an appropriate treatment.
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Saenz A, Grijalba M, Mengide JP, Argañaraz R, Ford F, Mantese B. Baclofen pump with pre-brainstem catheter tip placement: technical note and case series. Childs Nerv Syst 2021; 37:203-210. [PMID: 32504173 DOI: 10.1007/s00381-020-04679-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/13/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aims to describe a new baclofen pump implantation technique with pre-brainstem catheter placement and to demonstrate the benefits that this procedure has in treating spasticity and dystonia. METHODS We described a new technique to place a baclofen pump catheter anterior to the brainstem. To illustrate the technique, we presented five patients with both spasticity and dystonia in whom conventional treatment was not effective. They each received a baclofen pump with a pre-brainstem catheter. We evaluated the results using the Ashworth scale for spasticity, the Barry-Albright scale for dystonia, and the PedsQL for quality of life assessment. Each patient was evaluated before a surgery and after 6 months of follow-up. RESULTS There were statistically significant differences in all the physical examination evaluated areas using the Barry-Albright and modified Ashworth scales between the preoperative and the postoperative period. The same applies to the results of the PedsQL quality of life scale. CONCLUSION We presented an innovative baclofen pump implantation technique with pre-brainstem catheter placement that could be a therapeutic alternative in patients with dystonia and spastic quadriparesis for whom conventional therapy is not effective.
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Affiliation(s)
- Amparo Saenz
- Division of Pediatric Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Combate de los Pozos 1881, 1245, Buenos Aires, ZC, Argentina.
| | - Miguel Grijalba
- Division of Pediatric Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Combate de los Pozos 1881, 1245, Buenos Aires, ZC, Argentina
| | - Juan Pablo Mengide
- Division of Pediatric Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Combate de los Pozos 1881, 1245, Buenos Aires, ZC, Argentina
| | - Romina Argañaraz
- Division of Pediatric Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Combate de los Pozos 1881, 1245, Buenos Aires, ZC, Argentina
| | - Fernando Ford
- Division of Kinesiology, Hospital de Pediatría Juan P. Garrahan, Buenos Aires, Argentina
| | - Beatriz Mantese
- Division of Pediatric Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Combate de los Pozos 1881, 1245, Buenos Aires, ZC, Argentina
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Intrathecal baclofen in mucopolysaccharidosis type II (Hunter syndrome): case report. Childs Nerv Syst 2018; 34:2325-2327. [PMID: 29860540 DOI: 10.1007/s00381-018-3857-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 05/28/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE Intrathecal baclofen administration is commonly used in the treatment of children's spasticity. In general, candidates for baclofen pump are patients with spastic form of cerebral palsy. Intrathecal baclofen in the treatment of spasticity due to a metabolic disorder is rarely reported. METHODS Authors report on an 11-year-old boy with mucopolysaccharidosis type II (Hunter syndrome) with progressive stiffness and contractures followed by profound loss of joint movement range and tiptoe walking pattern. Patient was indicated for baclofen test with subsequent pump insertion and continuous intrathecal baclofen administration. RESULTS Postoperatively, patient was gradually set to current baclofen dose of 250 μg/day. At mentioned dose, we observed not only increased active and passive range of movements and facilitation in fine motor skills, but also better walking pattern. CONCLUSIONS Despite intrathecal baclofen administration in patients with spasticity related to mucopolysaccharidosis type II is not widely reported, we consider it as feasible treatment. To emphasize, enzyme replacement therapy is the primary treatment, and improvement is attributed to both enzyme substitution and intrathecal baclofen therapy.
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Winter G, Beni-Adani L, Ben-Pazi H. Intrathecal Baclofen Therapy-Practical Approach: Clinical Benefits and Complication Management. J Child Neurol 2018; 33:734-741. [PMID: 30009656 DOI: 10.1177/0883073818785074] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intrathecal baclofen is an expanding accepted treatment for children with cerebral palsy and other causes of spasticity and dystonia. The aims of this review are therefore to (1) delineate the clinical benefits of intrathecal baclofen therapy in pediatric spasticity and dystonia and (2) increase awareness of the potential complications and emergency management measures of intrathecal baclofen therapy. A current literature review demonstrates the benefits and complications of this minimally invasive device. Practical guides for recognizing acute conditions and management recommendations are included. Intrathecal baclofen is increasingly being used to help individuals attain realistic functional goals. Therefore, families and health care professionals should be aware of potential complications, symptoms, and emergency management.
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Affiliation(s)
- Gidon Winter
- 1 Pediatric Movement Disorders, Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem
| | - Liana Beni-Adani
- 2 Pediatric Neurosurgery, Shaare Zedek Medical Center, Jerusalem
| | - Hilla Ben-Pazi
- 1 Pediatric Movement Disorders, Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem
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Towns M, Rosenbaum P, Palisano R, Wright FV. Should the Gross Motor Function Classification System be used for children who do not have cerebral palsy? Dev Med Child Neurol 2018; 60:147-154. [PMID: 29105760 DOI: 10.1111/dmcn.13602] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED This literature review addressed four questions. (1) In which populations other than cerebral palsy (CP) has the Gross Motor Function Classification System (GMFCS) been applied? (2) In what types of study, and why was it used? (3) How was it modified to facilitate these applications? (4) What justifications and evidence of psychometric adequacy were used to support its application? A search of PubMed, MEDLINE, and Embase databases (January 1997 to April 2017) using the terms: 'GMFCS' OR 'Gross Motor Function Classification System' yielded 2499 articles. 118 met inclusion criteria and reported children/adults with 133 health conditions/clinical descriptions other than CP. Three broad GMFCS applications were observed: as a categorization tool, independent variable, or outcome measure. While the GMFCS is widely used for children with health conditions/clinical description other than CP, researchers rarely provided adequate justification for these uses. We offer recommendations for development/validation of other condition-specific classification systems and discuss the potential need for a generic gross motor function classification system. WHAT THIS PAPER ADDS The Gross Motor Function Classification System should not be used outside cerebral palsy or as an outcome measure. The authors provide recommendations for development and validation of condition-specific or generic classification systems.
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Affiliation(s)
- Megan Towns
- Bloorview Research Institute, Toronto, ON, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Peter Rosenbaum
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada.,Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Robert Palisano
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada.,Physical Therapy and Rehabilitation Science Department, Drexel University, Philadelphia, PA, USA
| | - F Virginia Wright
- Bloorview Research Institute, Toronto, ON, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada.,Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
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Intrathecal Baclofen Therapy for the Control of Spasticity. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00072-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Delhaas EM, Harhangi BS, Frankema SPG, Huygen FJPM, van der Lugt A. Plain radiography in patients treated with intrathecal drug delivery using an implantable pump device. Insights Imaging 2017; 8:499-511. [PMID: 28840489 PMCID: PMC5621993 DOI: 10.1007/s13244-017-0568-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Intrathecal drug administration using an implanted pump system is well established in intractable spasticity and pain. However, despite continuous advancements in manufacturing technology, adverse events related to the pump and catheter still occur. Most of them, such as migration, damage, disconnection and occlusion, are related to the spinal catheter. The aim of this overview is to update radiologists on how plain radiography of the implanted delivery system for intrathecal drug administration should be interpreted and to increase awareness for the need of urgent and timely multidisciplinary troubleshooting. METHODS Plain radiographic images of patients treated with intrathecal drug administration using an implantable drug delivery system were analysed in a multidisciplinary setting at our (university) referral centre for complications in intrathecal drug administration. RESULTS Examples of catheter-related adverse events are described and a proposal is made for stepwise interpretation of standard plain radiographic images. CONCLUSIONS Plain radiological images are the mainstay for the diagnosis of catheter-related adverse events in intrathecal drug delivery. Radiologists play an important role in an early diagnosis. An awareness of abnormal radiological findings seems important to avoid a life-threatening withdrawal syndrome. TEACHING POINTS • Untimely cessation of intrathecal drug delivery can lead to a life-threatening withdrawal syndrome. • Initially mild symptoms can lead to an exacerbation of a withdrawal syndrome. • Most intrathecal catheter-related problems are visible on plain radiography. • Common causes of catheter problems are migration, lacerations, occlusion and disconnection. • Knowledge on implanted intrathecal catheters is crucial for interpretation of plain radiography.
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Affiliation(s)
- Elmar M Delhaas
- Center for Pain Medicine, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Biswadjiet S Harhangi
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sander P G Frankema
- Center for Pain Medicine, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Frank J P M Huygen
- Center for Pain Medicine, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Robinson S, Robertson FC, Dasenbrock HH, O'Brien CP, Berde C, Padua H. Image-guided intrathecal baclofen pump catheter implantation: a technical note and case series. J Neurosurg Spine 2017; 26:621-627. [DOI: 10.3171/2016.8.spine16263] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEMedically 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.METHODSData 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.RESULTSOf 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.CONCLUSIONSImage-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.
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Affiliation(s)
| | | | - Hormuzdiyar H. Dasenbrock
- 2Harvard Medical School
- 3Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
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Rushton PRP, Nasto LA, Aujla RK, Ammar A, Grevitt MP, Vloeberghs MH. Intrathecal baclofen pumps do not accelerate progression of scoliosis in quadriplegic spastic cerebral palsy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:1652-1657. [PMID: 27154169 DOI: 10.1007/s00586-016-4598-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/28/2016] [Accepted: 04/29/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To compare scoliosis progression in quadriplegic spastic cerebral palsy with and without intrathecal baclofen (ITB) pumps. METHODS A retrospective matched cohort study was conducted. Patients with quadriplegic spastic cerebral palsy, GMFCS level 5, treated with ITB pumps with follow-up >1 year were matched to comparable cases by age and baseline Cobb angle without ITB pumps. Annual and peak coronal curve progression, pelvic obliquity progression and need for spinal fusion were compared. RESULTS ITB group: 25 patients (9 female), mean age at pump insertion 9.4 and Risser 0.9. Initial Cobb angle 25.6° and pelvic tilt 3.2°. Follow-up 4.3 (1.0-7.8) years. Cobb angle at follow-up 76.1° and pelvic tilt 18.9°. Non-ITB group: 25 patients (14 female), mean age at baseline 9.2 and Risser 1.0. Initial Cobb angle 29.7° and pelvic tilt 7.1°. Follow-up 3.5 (1.0-7.5) years. Cobb angle at follow-up 69.1° and pelvic tilt 21.0°. The two groups were statistically similar for baseline age, Cobb angle and Risser grade. Mean curve progression was 13.6°/year for the ITB group vs 12.6°/year for the non-ITB group (p = 0.39). Peak curve progression was similar between the groups. Pelvic tilt progression was comparable; ITB group 4.5°/year vs non-ITB 4.6°/year (p = 0.97). During follow-up 5 patients in the ITB group and 9 in the non-ITB group required spinal fusion surgery for curve progression (p = 0.35). CONCLUSIONS Patients with quadriplegic spastic cerebral palsy with and without ITB pumps showed significant curve progression over time. ITB pumps do not appear to alter the natural history of curve progression in this population.
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Affiliation(s)
- Paul R P Rushton
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
| | - Luigi A Nasto
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Ranjit K Aujla
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Amr Ammar
- Department of Neurosurgery, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Michael P Grevitt
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, NG7 2UH, UK
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Abstract
BACKGROUND Cerebral palsy is a disorder of movement and posture arising from a non-progressive lesion in the developing brain. Spasticity, a disorder of increased muscle tone, is the most common motor difficulty and is associated with activity limitation to varying degrees in mobility and self care.Oral baclofen, a gamma-aminobutyric acid (GABA) agonist, has been used in oral form to treat spasticity for some time, but it has a variable effect on spasticity and the dose is limited by the unwanted effect of excessive sedation. Intrathecal baclofen produces higher local concentrations in cerebrospinal fluid at a fraction of the equivalent oral dose and avoids this excessive sedation. OBJECTIVES To determine whether intrathecal baclofen is an effective treatment for spasticity in children with cerebral palsy. SEARCH METHODS We searched the CENTRAL, MEDLINE, EMBASE and CINAHL databases, handsearched recent conference proceedings, and communicated with researchers in the field and pharmaceutical and drug delivery system companies. SELECTION CRITERIA We included studies which compared the effect of intrathecal baclofen treatment on spasticity, gross motor function or other areas of function with controls. DATA COLLECTION AND ANALYSIS Two authors selected studies, two authors extracted data and two authors assessed the methodological quality of included studies. MAIN RESULTS Six studies met the inclusion criteria. The data obtained were unsuitable for the conduct of a meta-analysis; we have completed a qualitative summary.All studies were found to have high or unclear risk of bias in some aspects of their methodology.Five of the six studies reported data collected in the randomised controlled phase of the study. A sixth study did not report sufficient results to determine the effect of intrathecal baclofen versus placebo. Of these five studies, four were conducted using lumbar puncture or other short-term means of delivering intrathecal baclofen. One study assessed the effectiveness of implantable intrathecal baclofen pumps over six months.The four short-term studies demonstrated that intrathecal baclofen therapy reduces spasticity in children with cerebral palsy. However, two of these studies utilised inappropriate techniques for statistical analysis of results. The single longer-term study demonstrated minimal reduction in spasticity with the use of intrathecal baclofen therapy.One of the short-term studies and the longer term study showed improvement in comfort and ease of care. The longer term study found a small improvement in gross motor function and also in some domains of health-related quality of life.Some caution is required in interpreting the findings of the all the studies in the review due to methodological issues. In particular, there was a high risk of bias in the methodology of the longer term study due to the lack of placebo use in the control group and the absence of blinding to the intervention after randomisation for both participants and investigators. AUTHORS' CONCLUSIONS There is some limited short-term evidence that intrathecal baclofen is an effective therapy for reducing spasticity in children with cerebral palsy. The effect of intrathecal baclofen on long-term spasticity outcomes is less certain.The validity of the evidence for the effectiveness of intrathecal baclofen in treating spasticity in children with cerebral palsy from the studies in the review is constrained by the small sample sizes of the studies and methodological issues in some studies.Spasticity is a impairment in the domain of body structure and function. Consideration must also be given to the broader context in determining whether intrathecal baclofen therapy is effective. The aim of therapy may be, for example, to improve gross motor function, to increase participation at a social role level, to improve comfort, to improve the ease of care by others or to improve the overall quality of life of the individual. Intrathecal baclofen may improve gross motor function in children with cerebral palsy, but more reliable evidence is needed to determine this.There is some evidence that intrathecal baclofen improves ease of care and the comfort and quality of life of the individuals receiving it, but again small sample sizes and methodological issues in the studies mean that these results should be interpreted with caution.Further evidence of the effectiveness of intrathecal baclofen for treating spasticity, increasing gross motor function and improving comfort, ease of care and quality of life is needed from other investigators in order to validate these results.The short duration of the controlled studies included in this review did not allow for the exploration of questions regarding whether the subsequent need for orthopaedic surgery in children receiving intrathecal baclofen therapy is altered, or the safety and the economic implications of intrathecal baclofen treatment when long-term therapy is administered via an implanted device. Controlled studies are not the most appropriate study design to address these questions, cohort studies may be more appropriate.
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Affiliation(s)
- Monika J Hasnat
- The Royal Children's HospitalVictorian Paediatric Rehabilitation ServiceFlemington RoadParkvilleMelbourneVictoriaAustralia3052
| | - James E Rice
- Women's and Children's Health NetworkPaediatric Rehabilitation Department72 King William RoadNorth AdelaideAdelaideSouth AustraliaAustralia5006
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Skalsky AJ, Fournier CM. Intrathecal baclofen bolus dosing and catheter tip placement in pediatric tone management. Phys Med Rehabil Clin N Am 2015; 26:89-93. [PMID: 25479782 DOI: 10.1016/j.pmr.2014.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Intrathecal baclofen (ITB), administered by an implanted pump, has emerged as an efficacious therapy for the treatment of hypertonicity in pediatrics. Although ITB has been used for more than 20 years clinically, much is still unknown about the most optimal dosing regimens and intrathecal catheter tip placement. Clinician experience, animal research, and advanced imaging is guiding the use of ITB. The rationale for high cervical catheter tip placement and pulsating flex dosing is described.
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Affiliation(s)
- Andrew J Skalsky
- Division of Pediatric Rehabilitation Medicine, Department of Pediatrics, Rady Children's Hospital San Diego, University of California San Diego, 3020 Children's Way MC 5096, San Diego, CA 92123, USA.
| | - Chrystal M Fournier
- Division of Pediatric Rehabilitation Medicine, Rady Children's Hospital San Diego, 3020 Children's Way, San Diego, CA 92123, USA
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Jose DA, Luciano P, Vicente V, Juan Marcos AS, Gustavo FC. Role of Catheter's Position for Final Results in Intrathecal Drug Delivery. Analysis Based on CSF Dynamics and Specific Drugs Profiles. Korean J Pain 2013; 26:336-46. [PMID: 24155999 PMCID: PMC3800705 DOI: 10.3344/kjp.2013.26.4.336] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 08/08/2013] [Accepted: 08/21/2013] [Indexed: 11/05/2022] Open
Abstract
Intrathecal drug delivery is an effective and safe option for the treatment of chronic pathology refractory to conventional pain therapies. Typical intrathecal administered drugs are opioids, baclofen, local anesthetics and adjuvant medications. Although knowledge about mechanisms of action of intrathecal drugs are every day more clear many doubt remain respect the correct location of intrathecal catheter in order to achieve the best therapeutic result. We analyze the factors that can affect drug distribution within the cerebrospinal fluid. Three categories of variables were identified: drug features, cerebrospinal fluid (CSF) dynamics and patients features. First category includes physicochemical properties and pharmacological features of intrathecal administered drugs with special attention to drug lipophilicity. In the second category, the variables in CSF flow, are considered that can modify the drug distribution within the CSF with special attention to the new theories of liquoral circulation. Last category try to explain inter-individual difference in baclofen response with difference that are specific for each patients such as the anatomical area to treat, patient posture or reaction to inflammatory stimulus. We conclude that a comprehensive evaluation of the patients, including imaging techniques to study the anatomy and physiology of intrathecal environment and CSF dynamics, could become essential in the future to the purpose of optimize the clinical outcome of intrathecal therapy.
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Affiliation(s)
- De Andres Jose
- Anesthesia, Critical Care, and Multidisciplinary Pain Management Department, Valencia University General Hospital, Valencia, Spain
| | - Perotti Luciano
- Anesthesia, Critical Care, and Multidisciplinary Pain Management Department, Valencia University General Hospital, Valencia, Spain
| | - Villanueva Vicente
- Anesthesia, Critical Care, and Multidisciplinary Pain Management Department, Valencia University General Hospital, Valencia, Spain
| | - Asensio Samper Juan Marcos
- Anesthesia, Critical Care, and Multidisciplinary Pain Management Department, Valencia University General Hospital, Valencia, Spain
| | - Fabregat-Cid Gustavo
- Anesthesia, Critical Care, and Multidisciplinary Pain Management Department, Valencia University General Hospital, Valencia, Spain
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Levy RM. The failed and future promise of intraspinal drug administration for neurologic disorders. Neuromodulation 2012; 15:165-70. [PMID: 22672049 DOI: 10.1111/j.1525-1403.2012.00468.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Intrathecal baclofen has become an invaluable tool to treat spasticity of various etiologies. Children who benefit from intrathecal baclofen are often significantly underweight due to underlying disease pathology, and they lack adequate soft-tissue mass to effectively provide cover to the pump. Thus, in this population, subfascial implantation is favored over the subcutaneous technique in view of the high frequency of wound dehiscence and subsequent explantation of the pump associated with the latter method. The authors describe and review their unit's adapted subfascial implantation technique that has been performed over a period of 10 years in 182 children. This technique provides better tissue coverage for the pump and has resulted in lowering the risk of complications as compared with the subcutaneous technique.
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Affiliation(s)
- Amr Ammar
- Department of Pediatric Neurosurgery, University of Nottingham, University Park, UK
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Deer TR, Prager J, Levy R, Rathmell J, Buchser E, Burton A, Caraway D, Cousins M, De Andrés J, Diwan S, Erdek M, Grigsby E, Huntoon M, Jacobs MS, Kim P, Kumar K, Leong M, Liem L, McDowell GC, Panchal S, Rauck R, Saulino M, Sitzman BT, Staats P, Stanton-Hicks M, Stearns L, Wallace M, Willis KD, Witt W, Yaksh T, Mekhail N. Polyanalgesic Consensus Conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation 2012; 15:436-64; discussion 464-6. [PMID: 22748024 DOI: 10.1111/j.1525-1403.2012.00476.x] [Citation(s) in RCA: 202] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The use of intrathecal (IT) infusion of analgesic medications to treat patients with chronic refractory pain has increased since its inception in the 1980s, and the need for clinical research in IT therapy is ongoing. The Polyanalgesic Consensus Conference (PACC) panel of experts convened in 2000, 2003, and 2007 to make recommendations on the rational use of IT analgesics based on preclinical and clinical literature and clinical experiences. METHODS The PACC panel convened again in 2011 to update the standard of care for IT therapies to reflect current knowledge gleaned from literature and clinical experience. A thorough literature search was performed, and information from this search was provided to panel members. Analysis of published literature was coupled with the clinical experience of panel members to form recommendations regarding the use of IT analgesics to treat chronic pain. RESULTS After a review of literature published from 2007 to 2011 and discussions of clinical experience, the panel created updated algorithms for the rational use of IT medications for the treatment of neuropathic pain and nociceptive pain. CONCLUSIONS The advent of new algorithmic tracks for neuropathic and nociceptive pain is an important step in improving patient care. The panel encourages continued research and development, including the development of new drugs, devices, and safety recommendations to improve the care of patients with chronic pain.
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Ughratdar I, Muquit S, Ingale H, Moussa A, Ammar A, Vloeberghs M. Cervical implantation of intrathecal baclofen pump catheter in children with severe scoliosis. J Neurosurg Pediatr 2012; 10:34-8. [PMID: 22702326 DOI: 10.3171/2012.3.peds11474] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intrathecal baclofen (ITB) pump catheter placement is traditionally performed through entry into the spinal sac at the lumbar spine. A minority of children with cerebral palsy have severe concomitant neuromuscular scoliosis. In these children, whether surgically treated or not, access to the intradural space via the lumbar spine may prove technically challenging. The authors report on a series of children in whom, for various reasons, an ITB catheter was implanted using a posterior cervical spine approach. METHODS The records of 20 children in whom a baclofen catheter had been placed were retrospectively reviewed to assess the demographic details, indications, and outcome of this procedure. RESULTS This approach was successful in all but one of the children in whom the procedure was abandoned given the presence of significant extradural scar tissue. Of the 20 children, 7 had previously undergone lumbar ITB catheter implantation, although the catheter was subsequently, iatrogenically transected during scoliosis surgery. Nine children had had corrective scoliosis surgery, and the fusion mass obviated access to the lumbar spinal sac. Four children had untreated scoliosis and corrective surgery was being contemplated. Complications included infection requiring explantation (2 patients), catheter migration (1 patient), intolerance to ITB (1 patient), and failure of implantation (1 patient). All patients who tolerated the ITB experienced improvement in spasticity. No complications were associated with the spinal level of catheter insertion. CONCLUSIONS Implantation of an ITB catheter via a cervical approach is safe and feasible and should be considered in children with severe corrected or uncorrected scoliosis, and thus avoiding the lumbar spinal sac.
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Affiliation(s)
- Ismail Ughratdar
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
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Muquit S, Ughratdar I, Ingale H, Vloeberghs M. Cervical catheter placement for intrathecal baclofen test dose: is it safe? Childs Nerv Syst 2012; 28:919-22. [PMID: 22327250 DOI: 10.1007/s00381-012-1711-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 01/28/2012] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Intrathecal baclofen testing is usually performed via a catheter inserted at the lumbar spine. However, in patients with scoliosis, the distorted anatomy and bone fusion from corrective spinal surgery obviates access at the lumbar spine. PATIENTS AND METHODS We report a method for inserting the intrathecal catheter via a posterior cervical approach and discuss our outcome. We describe our experience in 20 patients in whom intrathecal baclofen test catheter was inserted at the lower cervical spine. Data was collected prospectively. DISCUSSION The procedure was successful in all 20 patients. There were no complications as a result of surgery or from baclofen test dose administration via a cervical catheter. Of the 20 patients, 15 went on to have baclofen pump implantation via a cervical catheter. In one patient, subsequent pump implantation procedure was unsuccessful due to presence of extradural scar tissue. In the remaining four patients pump implantation was declined due impending corrective spinal surgery or social reasons. CONCLUSION Our experience shows that low cervical catheter insertion for administration of a test dose of intrathecal baclofen and feasible and safe to perform via the method described.
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Affiliation(s)
- Samiul Muquit
- Department of Neurosurgery, Queen's Medical Centre, Nottingham, UK.
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