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Masrour M, Zare A, Presedo A, Nabian MH. Intrathecal baclofen efficacy for managing motor function and spasticity severity in patients with cerebral palsy: a systematic review and meta-analysis. BMC Neurol 2024; 24:143. [PMID: 38678195 PMCID: PMC11055284 DOI: 10.1186/s12883-024-03647-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 04/19/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Spasticity can significantly affect a patient's quality of life, caregiver satisfaction, and the financial burden on the healthcare system. Baclofen is one of only a few options for treating spasticity. The purpose of this study is to investigate the impact of intrathecal baclofen (ITB) therapy on severe40.23 spasticity and motor function in patients with cerebral palsy. METHODS We conducted a systematic review in PubMed, Scopus, Ovid, and the Cochrane Library in accordance with the PRISMA guidelines. We included studies based on eligibility criteria that included desired participants (cerebral palsy patients with spasticity), interventions (intrathecal baclofen), and outcomes (the Ashworth scales and the Gross Motor Function Measure [GMFM]). The within-group Cohen's d standardized mean differences (SMD) were analyzed using the random effect model. RESULTS We screened 768 papers and included 19 in the severity of spasticity section and 6 in the motor function section. The pre-intervention average spasticity score (SD) was 3.2 (0.78), and the post-intervention average score (SD) was 1.9 (0.72), showing a 40.25% reduction. The SMD for spasticity reduction was - 1.7000 (95% CI [-2.1546; -1.2454], p-value < 0.0001), involving 343 patients with a weighted average age of 15.78 years and a weighted average baclofen dose of 289 µg/day. The SMD for the MAS and Ashworth Scale subgroups were - 1.7845 (95% CI [-2.8704; -0.6986]) and - 1.4837 (95% CI [-1.8585; -1.1088]), respectively. We found no relationship between the participants' mean age, baclofen dose, measurement time, and the results. The pre-intervention average GMFM (SD) was 40.03 (26.01), and the post-intervention average score (SD) was 43.88 (26.18), showing a 9.62% increase. The SMD for motor function using GMFM was 0.1503 (95% CI [0.0784; 0.2223], p-value = 0.0030), involving 117 patients with a weighted average age of 13.63 and a weighted average baclofen dose of 203 µg/day. In 501 ITB implantations, 203 medical complications were reported, including six new-onset seizures (2.96% of medical complications), seven increased seizure frequency (3.45%), 33 infections (16.26%), eight meningitis (3.94%), and 16 cerebrospinal fluid leaks (7.88%). Delivery system complications, including 75 catheter and pump complications, were also reported. CONCLUSION Despite the risk of complications, ITB has a significant impact on the reduction of spasticity. A small but statistically significant improvement in motor function was also noted in a group of patients.
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Affiliation(s)
- Mahdi Masrour
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Zare
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ana Presedo
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France.
| | - Mohammad Hossein Nabian
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France.
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Levy KH, Yaszay B, Abel MF, Shah SA, Samdani AF, Sponseller PD. Baclofen pumps do not increase risk of complications following spinal fusion. Spine Deform 2024; 12:473-480. [PMID: 38006455 DOI: 10.1007/s43390-023-00786-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/21/2023] [Indexed: 11/27/2023]
Abstract
PURPOSE To assess the complication risks associated with intrathecal baclofen (ITB) pumps in cerebral palsy (CP) patients undergoing posterior spinal fusion (PSF) and to determine if timing of pump implantation before or during PSF impacts the risk of complications. METHODS A prospectively collected multicenter database was retrospectively reviewed to identify CP patients undergoing PSF from 2008 to 2023. Patients were divided into 2 cohorts: those with an ITB pump (ITB cohort) and those without (non-ITB cohort). The ITB cohort was further categorized by placement of the pump prior to or during PSF. Cohorts were then compared in terms of postoperative complications, perioperative complications, and need for revision surgery. RESULTS Four hundred six patients (ITB n = 79 [53 prior to, 26 during PSF], non-ITB n = 326) were included in this analysis. At an average follow-up of 4.0 years (range 2-10 years), there were no significant differences between the ITB and non-ITB cohorts in the rate of perioperative complications (5.0% vs 6.5%, p = 0.80), revision surgeries (2.5% vs 4.6%, p = 0.54), or any complication type, regardless of whether pumps were placed prior to or during PSF, aside from longer surgical times in the latter group. CONCLUSION Complication rates are similar for ITBs placed prior to and during PSF. Patients with spastic CP may safely be treated with ITB pumps without increased risks of complication or further reoperation/revision following PSF. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kenneth H Levy
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital University, Baltimore, MD, USA
| | - Burt Yaszay
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - Mark F Abel
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Suken A Shah
- Department of Orthopaedic Surgery, Nemours Children's Clinic, Wilmington, DE, USA
| | - Amer F Samdani
- Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital University, Baltimore, MD, USA.
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Characterization of standard work tools for intrathecal baclofen therapy. Childs Nerv Syst 2021; 37:3073-3081. [PMID: 34263339 DOI: 10.1007/s00381-021-05290-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intrathecal baclofen (ITB) has been an effective therapy since the 1980s, with widely reported revision, infection, and complication rates. Publications targeting surgical workflow have resulted in decreased infection and revision rates, but a standard workflow for the entire pathway has not been described. To present, define, and test standard work tools for patients receiving ITB to promote uniformity and standard of care in the field. METHODS A multidisciplinary approach from the movement disorder program of a tertiary care center defined all steps comprising the ITB pathway, and then developed standard work tools to decrease variability with respect to preoperative workup, day of surgery protocol, post-operative care, and also evaluation and treatment with respect to pump infection or malfunction. RESULTS Defined steps used at specific points of ITB pathway are presented with a single institution's outcome using the protocol from July 2017 to November 2020. A total of 60 procedures were performed. The overall complication rate was 14.5% at 6 months. Complications included an infection rate of 3.6% at 6 months, wound revision rate of 1.8% at 6 months, CSF leak rate of 1.7% at 6 months, and a 30-day readmission rate related to initial surgery of 6.7%. CONCLUSIONS Workflow efficiency and optimization for ITB patients can be used to obtain lower complication rates compared to historical cohorts in literature. A single-center, retrospective review highlights this.
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Bohn E, Goren K, Switzer L, Falck‐Ytter Y, Fehlings D. Pharmacological and neurosurgical interventions for individuals with cerebral palsy and dystonia: a systematic review update and meta-analysis. Dev Med Child Neurol 2021; 63:1038-1050. [PMID: 33772789 PMCID: PMC8451898 DOI: 10.1111/dmcn.14874] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 12/30/2022]
Abstract
AIM To update a systematic review of evidence published up to December 2015 for pharmacological/neurosurgical interventions among individuals with cerebral palsy (CP) and dystonia. METHOD Searches were updated (January 2016 to May 2020) for oral baclofen, trihexyphenidyl, benzodiazepines, clonidine, gabapentin, levodopa, botulinum neurotoxin (BoNT), intrathecal baclofen (ITB), and deep brain stimulation (DBS), and from database inception for medical cannabis. Eligible studies included at least five individuals with CP and dystonia and reported on dystonia, goal achievement, motor function, pain/comfort, ease of caregiving, quality of life (QoL), or adverse events. Evidence certainty was evaluated using GRADE. RESULTS Nineteen new studies met inclusion criteria (two trihexyphenidyl, one clonidine, two BoNT, nine ITB, six DBS), giving a total of 46 studies (four randomized, 42 non-randomized) comprising 915 participants when combined with those from the original systematic review. Very low certainty evidence supported improved dystonia (clonidine, ITB, DBS) and goal achievement (clonidine, BoNT, ITB, DBS). Low to very low certainty evidence supported improved motor function (DBS), pain/comfort (clonidine, BoNT, ITB, DBS), ease of caregiving (clonidine, BoNT, ITB), and QoL (ITB, DBS). Trihexyphenidyl, clonidine, BoNT, ITB, and DBS may increase adverse events. No studies were identified for benzodiazepines, gabapentin, oral baclofen, and medical cannabis. INTERPRETATION Evidence evaluating the use of pharmacological and neurosurgical management options for individuals with CP and dystonia is limited to between low and very low certainty. What this paper adds Meta-analysis suggests that intrathecal baclofen (ITB) and deep brain stimulation (DBS) may improve dystonia and pain. Meta-analysis suggests that DBS may improve motor function. Clonidine, botulinum neurotoxin, ITB, and DBS may improve achievement of individualized goals. ITB and DBS may improve quality of life. No direct evidence is available for oral baclofen, benzodiazepines, gabapentin, or medical cannabis.
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Affiliation(s)
- Emma Bohn
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Katherine Goren
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Lauren Switzer
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Yngve Falck‐Ytter
- Division of Gastroenterology and HepatologyVeteran Affairs North East Ohio Health Care SystemCase Western Reserve UniversityClevelandOHUSA
| | - Darcy Fehlings
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
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Pointon RS, Whelan H, Raza R, Lodh R. Is intrathecal baclofen an effective treatment for children with hereditary spastic paraparesis? Arch Dis Child 2020; 105:1016-1018. [PMID: 32732319 DOI: 10.1136/archdischild-2020-319878] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 11/03/2022]
Affiliation(s)
| | | | - Rushna Raza
- Paediatric Neurorehabilitation, Leeds Children's Hospital, Leeds, UK
| | - Rajib Lodh
- Paediatric Neurorehabilitation, Leeds Children's Hospital, Leeds, UK
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Abiri A, Abiri P, Goshtasbi K, Lehrich BM, Sahyouni R, Hsu FPK, Cadena G, Kuan EC. Endoscopic Anterior Skull Base Reconstruction: A Meta-Analysis and Systematic Review of Graft Type. World Neurosurg 2020; 139:460-470. [PMID: 32330621 DOI: 10.1016/j.wneu.2020.04.089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The influence of graft type (nonautologous vs. autologous) on surgical outcomes in endoscopic anterior skull base (EASB) reconstruction is not well understood. This review systematically evaluated rates of postoperative complications of EASB repairs that utilized autologous or nonautologous grafts. METHODS Original studies reporting EASB reconstruction outcomes were extracted from PubMed, Ovid, and the Cochrane Library from database inception to 2019. Risk ratios, risk differences, χ2 tests, and multivariate logistic regression were used to evaluate outcome measures: postoperative cerebrospinal fluid (CSF) leaks, meningitis, and other major complications (OMCs). RESULTS A total of 2275 patients from 29 studies were analyzed. Rates of postoperative CSF leaks, meningitis, and OMCs were 4.0%, 1.6%, and 2.3%, respectively, using autologous grafts, and 5.0%, 0.3%, and 1.0%, respectively, using nonautologous grafts. Multivariate analysis of 118 patients demonstrated no significant differences in age, CSF flow rate, single or multilayer reconstruction, and presence of intraoperative CSF leak or lumbar drain. Meta-analyses of 6 studies yielded a risk ratio of 0.64 (95% confidence interval [CI], 0.19-2.14; P = 0.47) for postoperative CSF leakage, and risk differences of -0.01 (95% CI, -0.06 to 0.05; P = 0.80) and -0.02 (95% CI, -0.09 to 0.05; P = 0.51) for postoperative meningitis and OMCs, respectively. There were no significant differences in postoperative CSF leakage (P = 0.95) and OMCs (P = 0.41) between graft types among cases with intraoperative CSF leaks. However, meningitis rates were lower (P = 0.04) in the nonautologous group. CONCLUSIONS EASB reconstructions utilizing autologous and nonautologous grafts are associated with similar rates of postoperative CSF leakage and OMCs. In cases with intraoperative CSF leakage, nonautologous grafts were associated with reduced postoperative meningitis.
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Affiliation(s)
- Arash Abiri
- School of Medicine, University of California Irvine, Irvine, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Parinaz Abiri
- School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Khodayar Goshtasbi
- School of Medicine, University of California Irvine, Irvine, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Brandon M Lehrich
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Ronald Sahyouni
- School of Medicine, University of California Irvine, Irvine, California, USA; Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Gilbert Cadena
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA; Department of Neurological Surgery, University of California Irvine, Irvine, California, USA.
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