Intrathecal baclofen for autonomic instability due to spinal cord injury

Intrathecal baclofen as emergency treatment alleviates severe intractable autonomic dysreflexia in cervical spinal cord injury

Context: Episodic attacks of autonomic dysreflexia (AD) are regularly experienced by patients with a spinal cord injury (SCI) on T6 or higher levels. The episodes can result in a pounding headache, flushing, blurred vision, anxiety, a stroke, posturing, hyperthermia, retinal bleeding, seizures, myocardial ischemia, cardiac arrhythmias, and death. The observed associated bradycardia is explained as a baroreceptor reflex response to the high blood pressure. Intrathecal baclofen (ITB) has been used to treat chronic AD. This case highlights the occurrence of intractable AD after removal of the ITB delivery system because of a pump pocket infection. We describe the benefit of ITB as an emergency treatment for intractable AD.Findings: A 53-year-old male suffered from spasticity and AD after a C5 ASI B SCI in 2002 was successfully treated with ITB for 14 years. He developed Staphylococcus aureus and Pseudomonas aeruginosa cellulitis at the orifice of his suprapubic catheter, which caused an abscess in the pump pocket. To prevent a withdrawal syndrome, the medication was reduced in three steps of 25%, and the pump was explanted. Postoperatively, he experienced severe AD and was treated with clonazepam, clonidine, and urapidil. The next day, the severely fluctuating blood pressure and pulse rate were no longer controllable with the medication. At L2-3, a temporary external intrathecal catheter for reinitiating ITB was inserted. With this treatment, the AD and the spasticity symptoms could be controlled.Conclusion/Clinical Relevance: The case demonstrated that refractory AD could be managed with ITB in an emergency.

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.

Recognition and management of autonomic dysreflexia in patients with a spinal cord injury

Autonomic dysreflexia is a potentially life-threatening condition that affects patients with a spinal cord injury at the level of T6 or above. It is characterised by uncontrolled elevation of systolic blood pressure of more than 20mmHg, which may occur alongside bradycardia. This article explains the pathophysiology of autonomic dysreflexia, alongside its causes, signs and symptoms. It also details the pharmacological and non-pharmacological management interventions that should be promptly initiated in patients who present to the emergency department with autonomic dysreflexia, to alleviate their symptoms and prevent further complications.

Attenuating Neurogenic Sympathetic Hyperreflexia Robustly Improves Antibacterial Immunity After Chronic Spinal Cord Injury

Spinal cord injury (SCI) disrupts critical physiological systems, including the cardiovascular and immune system. Plasticity of spinal circuits below the injury results in abnormal, heightened sympathetic responses, such as extreme, sudden hypertension that hallmarks life-threatening autonomic dysreflexia. Moreover, such sympathetic hyperreflexia detrimentally impacts other effector organs, including the spleen, resulting in spinal cord injury-induced immunodeficiency. Consequently, infection is a leading cause of mortality after SCI. Unfortunately, there are no current treatments that prophylactically limit sympathetic hyperreflexia to prevent subsequent effector organ dysfunction. The cytokine soluble tumor necrosis factor α (sTNFα) is upregulated in the CNS within minutes after SCI and remains elevated. Here, we report that commencing intrathecal administration of XPro1595, an inhibitor of sTNFα, at a clinically feasible, postinjury time point (i.e., 3 d after complete SCI) sufficiently diminishes maladaptive plasticity within the spinal sympathetic reflex circuit. This results in less severe autonomic dysreflexia, a real-time gauge of sympathetic hyperreflexia, for months postinjury. Remarkably, delayed delivery of the sTNFα inhibitor prevents sympathetic hyperreflexia-associated splenic atrophy and loss of leukocytes to dramatically improve the endogenous ability of chronic SCI rats to fight off pneumonia, a common cause of hospitalization after injury. The improved immune function with XPro1595 correlates with less noradrenergic fiber sprouting and normalized norepinephrine levels in the spleen, indicating that heightened, central sTNFα signaling drives peripheral, norepinephrine-mediated organ dysfunction, a novel mechanism of action. Thus, our preclinical study supports intrathecally targeting sTNFα as a viable strategy to broadly attenuate sympathetic dysregulation, thereby improving cardiovascular regulation and immunity long after SCI.SIGNIFICANCE STATEMENT Spinal cord injury (SCI) significantly disrupts immunity, thus increasing susceptibility to infection, a leading cause of morbidity in those living with SCI. Here, we report that commencing intrathecal administration of an inhibitor of the proinflammatory cytokine soluble tumor necrosis factor α days after an injury sufficiently diminishes autonomic dysreflexia, a real time gauge of sympathetic hyperreflexia, to prevent associated splenic atrophy. This dramatically improves the endogenous ability of chronically injured rats to fight off pneumonia, a common cause of hospitalization. This preclinical study could have a significant impact for broadly improving quality of life of SCI individuals.

Early intraventricular baclofen therapy (IVB) for children with dystonic and dysautonomic storm

INTRODUCTION

Intrathecal baclofen (ITB) is an effective treatment for managing primary and secondary dystonia. Intraventricular baclofen (IVB) was first developed to allow treating patients in which the use of ITB was difficult due to anatomic anomalies. After that, several studies indicate that intraventricular administration of baclofen, is more effective than ITB in refractory dystonia.

CLINICAL MATERIAL

We report three cases of children with acute dystonic and dysautonomic storm, treated with IVB. The clinical outcome was satisfactory. The response to the treatment continued after the pump disconnection, suggesting that in this kind of cerebral dysregulations, short-term IVB is an effective treatment.

CONCLUSION

Early treatment with IVB may be an effective option in patients with post-anoxic dysautonomic and dystonic storm.

An investigation of the relationship between autonomic dysreflexia and intrathecal baclofen in patients with spinal cord injury

OBJECTIVE

To study the relationship between autonomic dysreflexia and intrathecal baclofen in patients with spinal cord injury.

DESIGN

Retrospective chart review.

SETTING

Inpatient and outpatient acute rehabilitation facility.

PARTICIPANTS

Thirty-four subjects.

INTERVENTIONS

We reviewed patients' medical records to ascertain the presence of symptomatic autonomic dysreflexia (AD) prior to and after implantation of an intrathecal baclofen (ITB) pump for spasticity in spinal cord injury patients. We recorded risk factors for autonomic dysreflexia including kidney and bladder stones, heterotopic ossification (HO), and ischial / sacral pressure ulcers.

OUTCOME MEASURES

Presence of autonomic dysreflexia pre and post-intrathecal baclofen pump placement, presence of risk factors associated with autonomic dysreflexia including (1) kidney or bladder stones, (2) heterotopic ossification, and (3) pressure ulcers.

RESULTS

Of the 34 subjects, 25 (73.5%) experienced AD prior to ITB pump placement and only 2 (5.9%) after placement. Four subjects (11.8%) had kidney or bladder stones, of which, all had AD prior to placement and none had AD afterwards. Twenty-six subjects (76.5%) had pressure ulcers, of which, all experienced AD prior to placement and only one (0.02%) afterwards. Six patients (17.6%) had HO, of which 5 (83%) had AD prior to placement and none afterwards. Additionally, three patients (8.8%) had at least 2 of the above risk factors, of which, all had AD prior to ITB placement and none afterwards.

CONCLUSION

This study showed a significant reduction of symptomatic episodes of autonomic dysreflexia after spinal cord injury, even in those with additional risk factors for development of autonomic dysreflexia.

Effects of high frequency repetitive transcranial magnetic stimulation on KCC2 expression in rats with spasticity following spinal cord injury

The effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) on potassium- chloride cotransporter-2 (KCC2) protein expression following spinal cord injury (SCI) and the action mechanism were investigated. SCI models were established in SD rats. Five groups were set up randomly: normal control group, SCI 7-day (7D) model group, SCI 14-day (14D) model group, SCI-7D rTMS group and SCI-14D rTMS group (n=5 each). The rats in SCI rTMS groups were treated with 10 Hz rTMS from 8th day and 15th day after SCI respectively, once every day, 5 days every week, a total of 4 weeks. After the model establishment, motor recovery and spasticity alleviation were evaluated with BBB scale once a week till the end of treatment. Finally, different parts of tissues were dissected out for detection of variations of KCC2 protein using Western blotting and polymerase chain reaction (PCR) technique. The results showed that the BBS scores after treatment were significantly higher in SCI-7D rTMS group than in SCI-14D rTMS group (P<0.05). As compared with normal control groups, The KCC2 protein in SCI model groups was down-regulated after SCI, and the decrease was much more significant in SCI-14D model group than in SCI-7D group (P<0.05). As compared with SCI model groups, KCC2 protein in rTMS groups was up-regulated after the treatment (P<0.05). The up-regulation of KCC2 protein content and expression was more obvious in SCI-7D rTMS group than in SCI-14D rTMS group (P<0.05). It was concluded that 10 Hz rTMS can alleviate spasticity in rats with SCI, which might be attributed to the up-regulation of KCC2 protein. It was also suggested that the high-frequency rTMS treatment after SCI at early stage might achieve more satisfactory curative effectiveness.

Severe, Protracted Spasm of Urinary Bladder and Autonomic Dysreflexia Caused by Changing the Suprapubic Catheter in a Cervical Spinal Cord Injury Patient: Treatment by a Bolus Dose and Increased Total Daily Dose of Intrathecal Baclofen

BACKGROUND

Intrathecal administration of baclofen by implanted pump reduces rigidity and muscle spasms. Its use specifically to control bladder spasms has not been reported.

CASE REPORT

A tetraplegic patient developed severe, protracted, bladder spasms, abdominal muscles spasms, and high blood pressure after change of suprapubic catheter; nifedipine, diazepam, and paracetamol did not control spasms; bolus dose of baclofen intrathecally produced prompt relief via baclofen pump.

CONCLUSION

Severe, protracted bladder spasms, abdominal muscles spasms, and autonomic dysreflexia, induced by change of suprapubic catheter in a spinal cord injury patient, were treated successfully by a bolus dose and increased total daily dose of intrathecal baclofen.

Prevention of recurrent autonomic dysreflexia: a survey of current practice

OBJECTIVE

There is a dearth of literature on the treatment of chronic recurrent autonomic dysreflexia (AD), a well-known complication of spinal cord injury that can have life-threatening implications. This study sought to identify clinical practices regarding the treatment of AD, both acute and recurrent, in patients with spinal cord injury (SCI).

METHODS

Online survey regarding AD management in SCI composed of 11 questions designed to obtain information on respondent characteristics, AD treatment options, and causes of AD.

SETTING

Veterans Administration health care system.

PARTICIPANTS

Veterans Health Administration National SCI Staff Physicians were sent an electronic email to participate in the anonymous web-based survey.

INTERVENTION

None applicable.

RESULTS

The response rate was 52%. The most commonly prescribed medications for minor and severe acute manifestations of AD were nitrates. For recurrent AD, clonidine was the most commonly prescribed medication.

INTERPRETATION

Anti-hypertensive medications continue to be the mainstay in the management of both acute and chronic recurrent AD. Current literature is lacking in prospective randomized controlled trials investigating the relative efficacy of AD interventions. Evidence-based practice guidelines are necessary to improve clinical care.

Mechanism of GABA receptors involved in spasticity inhibition induced by transcranial magnetic stimulation following spinal cord injury

The effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) on spasticity following spinal cord injury (SCI) and the action mechanism were investigated. SCI models were established in Sprague-Dawley rats. Five groups were set up: normal control group, SCI-7 day (7D) model group, SCI-14D model group, SCI-7D rTMS group and SCI-14D rTMS group (n=10 each). The rats in SCI rTMS groups were treated with 10 Hz rTMS at 8th day and 15th day after SCI respectively. Motor recovery and spasticity alleviation were evaluated by BBB scale once a week till the end of treatment. Finally, different parts of tissues were dissected out for detection of GABA receptors using Western blotting and polymerase chain reaction (PCR) technique. The results showed that the BBB scores after treatment were significantly higher in SCI-7D rTMS group than in SCI-14D rTMS group (P<0.05). The GABA receptors were down-regulated more significantly in SCI-14D model group than in SCI-7D model group (P<0.05). At different time points, rTMS treatment could affect the up-regulation of GABA receptors: The up-regulation of GABA receptors was more obvious in SCI-7D rTMS group than in SCI-14D rTMS treatment group (P<0.05). It was concluded that 10-Hz rTMS could alleviate spasticity following SCI and promote the motor recovery in rats, which might be attributed to the up-regulation of GABA receptors. It was also suggested that early high-frequency rTMS treatment after SCI may achieve more satisfactory curative effectiveness.

Novel medical bathing with traditional Chinese herb formula alleviates paraplegia spasticity

Paraplegia spasm is a kind of chronic disease which lacks effective treatment; the patients have to endure long-term pain, which is a tough problem for nursing practice. Lots of potential candidate medicines are under investigation, and a new Chinese herb formula is introduced in the current study. In the present study, we chose six different well-known Chinese herbs to form a formula, and boiled them into the water with an optimized ratio to make bath water; 80 paraplegic patients received this medicinal bath, and 80 patients received perfume water bath as placebo group. Compared with placebo control patients, the herb-treated patients have significant reduction in paraplegia spasm, visual analogue scale score, clinician global impression and sleep disorder. This novel six-combined formula traditional medicine could be beneficial for alleviating paraplegia spasm, but the underlying action mechanism deserves further study.

Neurogenic bowel dysfunction in patients with spinal cord injury, myelomeningocele, multiple sclerosis and Parkinson’s disease

Exciting new features have been described concerning neurogenic bowel dysfunction, including interactions between the central nervous system, the enteric nervous system, axonal injury, neuronal loss, neurotransmission of noxious and non-noxious stimuli, and the fields of gastroenterology and neurology. Patients with spinal cord injury, myelomeningocele, multiple sclerosis and Parkinson’s disease present with serious upper and lower bowel dysfunctions characterized by constipation, incontinence, gastrointestinal motor dysfunction and altered visceral sensitivity. Spinal cord injury is associated with severe autonomic dysfunction, and bowel dysfunction is a major physical and psychological burden for these patients. An adult myelomeningocele patient commonly has multiple problems reflecting the multisystemic nature of the disease. Multiple sclerosis is a neurodegenerative disorder in which axonal injury, neuronal loss, and atrophy of the central nervous system can lead to permanent neurological damage and clinical disability. Parkinson's disease is a multisystem disorder involving dopaminergic, noradrenergic, serotoninergic and cholinergic systems, characterized by motor and non-motor symptoms. Parkinson's disease affects several neuronal structures outside the substantia nigra, among which is the enteric nervous system. Recent reports have shown that the lesions in the enteric nervous system occur in very early stages of the disease, even before the involvement of the central nervous system. This has led to the postulation that the enteric nervous system could be critical in the pathophysiology of Parkinson's disease, as it could represent the point of entry for a putative environmental factor to initiate the pathological process. This review covers the data related to the etiology, epidemiology, clinical expression, pathophysiology, genetic aspects, gastrointestinal motor dysfunction, visceral sensitivity, management, prevention and prognosis of neurogenic bowel dysfunction patients with these neurological diseases. Embryological, morphological and experimental studies on animal models and humans are also taken into account.

Unusual blood pressure response during standing therapy in tetraplegic man

We report a case of an individual with cervical spinal cord injury who showed a unique blood pressure response during passive standing and passive walking-like leg movement, i.e., hypertension with standing and hypotension with leg movement.