Continuous intrathecal baclofen for children with spasticity and/or dystonia: Goal attainment and complications associated with treatment

Practice, play, repeat - individualized outcomes after the "intensity matters!"-program for children with disabilities - a descriptive multicase study

PURPOSE

To examine and categorize individual outcomes after the "Intensity matters!"-program, a new, cross-professional intensive intervention for children with disabilities across Norway.

MATERIALS AND METHODS

84 children and their parents/legal guardian were enrolled in this multicase study. Participants were active in defining goals, and hereby the content of the intervention. The pre-settled goals were grouped into the categories of body functions and structure, activities and participation inspired by the components of the International Classification of Functioning, Disability, and Health (ICF). The pre-settled goals were assessed pre- and post-intervention by using The Canadian Occupational Performance Measure (COPM). A clinically important change was predefined as a change ≥2 points.

RESULTS

1004 pre-settled goals were categorized into focus areas, where 62.4% were categorized as activity; functional mobility (n = 626). Post-intervention assessment of the COPM ratings of child performance and satisfaction showed a mean change of 3.7 (range -0.25;8.5) and 3.8 (range 0.25;10), respectively.

CONCLUSION

The majority of participants in the "Intensity Matters!"-program had a clinically important change in their individual goals after only three weeks of intervention. This study supports the use of client-centered measures in rehabilitation for children with disabilities, but a further examination of long-term outcome is warranted.

Complications of Intrathecal Baclofen Pump Therapy: An Institutional Experience from Saudi Arabia

The intrathecal baclofen pump (ITB) is one of the advanced treatment options in the management of spasticity. This retrospective cohort study was conducted to identify the complications of ITB treatment at a tertiary care rehabilitation facility. Various demographic and technical factors were analyzed, which are less often reported in the literature. All patients with ITB who had their refill at the ITB clinic between November 2019 and March 2020 were included. Of 48 patients, 17 patients had 18 (37.5%) ITB-related complications. Catheter-related complications were most common, whereas loss of efficacy (16.7%) and baclofen withdrawal (14.5%) were the most common outcomes of complications. Only catheter occlusion had a significant relationship with the pattern of spastic quadriparesis (p = 0.001). Gender, rehabilitation diagnosis, patients' residence, and facility of ITB placement did not have significant association. Similarly, age, distance from hospital, disease onset, ITB therapy duration, and baclofen dose were not statistically significant in relation to ITB-related complications.

Attainment of personal goals in the first year of intrathecal baclofen treatment in dyskinetic cerebral palsy: a prospective cohort study

PURPOSE

To assess attainment of individual treatment goals one year after intrathecal baclofen (ITB) pump implantation in individuals with dyskinetic cerebral palsy (CP).

MATERIALS AND METHODS

A multi-center prospective cohort study was conducted including 34 non-walking individuals with severe dyskinetic CP, classified as Gross Motor Function Classification System (GMFCS) IV/V, aged 4-24 years, 12 months after pump implantation. The main outcome measure was Goal Attainment Scaling (GAS). Predictors of GAS results were analyzed. Complications were registered systematically.

RESULTS

Seventy-one percent of individuals with dyskinetic CP fully achieved one or more treatment goals. One or more treatment goals were partially achieved in 97% of individuals. Two factors were found to be associated with attainment of goals: Dyskinesia Impairment Scale (DIS) score at baseline and the difference in pain score between baseline and follow-up. These two variables explain 30% of the variance in the outcome.

CONCLUSIONS

Intrathecal baclofen is effective in achieving individual treatment goals in children and young adults with dyskinetic CP after nine to 12 months of ITB treatment. A positive outcome on treatment goals is, for a small part, associated with higher severity of dystonia at baseline and with improvement of pain during treatment.

CLINICAL TRIAL REGISTRATION NUMBER

Dutch Trial Register, number NTR3642.Implications for rehabilitationIntrathecal baclofen treatment is effective in attainment of personal treatment goals, one year after pump implantation in patients with dyskinetic cerebral palsy.A positive outcome on treatment goals is, for a small part, related to higher severity of dystonia at the start and on improvement of pain during treatment.

Infectious Complications and Operative Management of Intrathecal Baclofen Pumps in the Pediatric Population: A Systematic Review and Meta-Analysis of 20 Years of Pooled Experience

BACKGROUND

Intrathecal baclofen (ITB) is a treatment modality used to improve the quality of life of patients with intractable spasticity and dystonia. Although it is an effective solution in patients failing oral interventions, it is associated with potential infectious complications. It is known that pediatric patients with ITB have significantly higher infection rates compared with adult patients. The cause of these higher rates in pediatric patients remains unclear. In the present study, we performed a meta-analysis focusing on the incidence of infection, and clarification of potential risk factors for infection in pediatric patients with ITB.

METHODS

This meta-analysis was performed in accordance with the PRISMA guidelines. An electronic database search was performed through PubMed, Web of Science, Embase, and Cochrane Library databases. Eligibility criteria and bias assessment were applied before statistical analysis.

RESULTS

The 17 studies identified yielded 2238 pediatric patients treated with implanted ITB pumps between 1994 and 2014. Infection comprised 34% of observed complications, second only to catheter malfunction. Pediatric ITB primary infection ranged between 0% and 44% among included studies (interquartile range, 4.85%-18.85%). A linear mixed-effects regression model showed that subfascial implantation had 12% lower primary infection rates compared with subcutaneous implantations across the literature. The relative risk of infection was 56% lower in pediatric patients with subfascially implanted ITB pumps.

CONCLUSIONS

Surgeons and clinicians should use these data to better assess patient risk-benefit when considering ITB pump implantation.

Surgical complications of intrathecal baclofen in children: A single centre, 20-year retrospective cohort study

INTRODUCTION

Complications of intrathecal baclofen treatment (ITB) with an implanted pump can be severe and require surgery. Surgical implantation techniques and catheter materials for continuous ITB treatment have improved over the past years with the aim to reduce complications.

OBJECTIVE

To assess: 1) the type and rate of complications of ITB that require surgical intervention, 2) which risk factors influence the occurrence of complications, and, specifically, 3) whether complication rate is influenced by type of catheter used.

METHODS

A retrospective cohort study was conducted including all children (<18 years old) in one university medical center with pump implantation between 2001 and 2017. All complications requiring surgery were recorded. Risk factors for surgical intervention were determined using multiple logistic regression analysis. Catheter related complications between two types of catheters (silicone vs coated) were compared.

RESULTS

In total, 88 complications of ITB treatment requiring surgery were found in 47 (36.2%) out of 130 children. These included catheter-related complications (55.7% of all complications), infections (21.6%), cerebrospinal fluid leakage (14.8%), and pump-related complications (7.9%). The silicone catheter type, used until 2012, was found to be a significant risk factor for complications (Odds Ratio 3.75; 95% CI: 1.30-10.83). Since the introduction of the coated catheter type, in 2012, the rate of catheter-related complications decreased, from 0.15 to 0.10 complications per pump year.

CONCLUSION

The rate of surgical complications of intrathecal baclofen in children is high, and most frequently catheter-related. The number of complications decreased since the introduction of a new, coated, catheter in 2012. This study helps to inform children and their caregivers about the risk of possible complications of ITB, and to identify directions for future improvement of ITB care.

Musculoskeletal and skin considerations in children with medical complexity: Common themes and approaches to management

The term "children with medical complexity" (CMC) describes a population of heterogeneous genetic and metabolic disorders with multi-system involvement, with shared common abnormalities within the musculoskeletal system. Disorders that affect the central nervous system (CNS) result in abnormal muscular tone, ranging from dystonia and spasticity, to hypotonia, to combinations of both (axial hypotonia with appendicular hypertonia). Abnormal tone can impair movement and function and contribute to development of contractures, progressive scoliosis and hip dislocation. Impaired mobility, chronic illness and polypharmacy can result in fragile bones and increased risk of fracture, which can be difficult to diagnose and associated with pain. Additionally, CMC with impaired ability to communicate, total dependence on caregivers and frequent use of support devices can develop unintended skin injuries. There are a variety of treatments available for CMC with musculoskeletal disorders ranging from physical supports to pharmacologic treatments to surgeries. Medical and surgical treatments can promote changes in tone and support bone health to improve comfort, hygiene and proper positioning. These therapies may also carry significant risk in medically fragile patients. It is important for CMC to have a care team with a good understanding of the patient's overall health and goals of care and that can advocate for the patient to balance optimization of function and reduction of pain while also minimizing risk.

Adverse events associated with paediatric intrathecal baclofen in Australia: 5 years of data collection

AIM

This study aims to examine the adverse event (AE) rate for intrathecal baclofen (ITB) therapy in an Australian paediatric population and to clarify type and frequency of AEs.

METHODS

AE data were extracted from the Australian Paediatric ITB Research Group national database, to include the first 5 years of data collection. Raw data were collated and analysed descriptively.

RESULTS

Data were collected for 40 patients. Forty-seven AEs in 23 patients were reported. Ten (25%) patients required surgical intervention related to their AE. Five patients (12.5%) required pump removal. The most frequent ITB-related AEs were catheter dysfunction (24%), drug overdose, withdrawal or sensitivity (19%), seromas and haematomas (15%) and infections (13%).

CONCLUSIONS

The AE rate for ITB therapy is high and needs to be considered when counselling patients regarding ITB as a therapeutic option.

The Impact of Intrathecal Baclofen Therapy on Health-related Quality of Life for Children with Marked Hypertonia

Purpose: To investigate the effects of intrathecal baclofen therapy (ITB) on health-related quality of life for children with cerebral palsy and neurological conditions. Method: This study is part of a longitudinal, multicentre audit. The primary outcome measure, the Caregiver Priorities and Child Health Index of Life with Disabilities, was completed at baseline, 6 and 12 months post ITB implant. Results: Forty subjects with cerebral palsy and other neurological conditions demonstrated significant improvement in aspects of health-related quality of life following ITB therapy, mean change 42.3 (SD 14.9) at baseline to 53.3 (SD 14.7) at 12 months (p< .001). Conclusion: Evidence to demonstrate the utility of ITB in pediatric populations beyond spasticity and dystonia reduction is limited. Our findings suggest that ITB improves aspects of quality of life, comfort, and ease of caregiving in children with cerebral palsy and other neurological conditions.

Intrathecal baclofen versus selective dorsal rhizotomy for children with cerebral palsy who are nonambulant: a systematic review

OBJECTIVE

Cerebral palsy (CP) is the most common childhood physical disability. Historically, children with hypertonia who are nonambulatory (Gross Motor Function Classification System [GMFCS] level IV or V) were considered candidates for intrathecal baclofen (ITB) therapy to facilitate care and mitigate discomfort. Selective dorsal rhizotomy (SDR) was often reserved for ambulant children to improve gait. Recently, case series have suggested SDR as an alternative to ITB in selected children functioning at GMFCS level IV/V. The objective for this study was to systematically review the evidence for ITB and SDR in GMFCS level IV or V children.

METHODS

Medline, Embase, Web of Science, and Cochrane databases were systematically searched. Articles were screened using the following inclusion criteria: 1) peer-reviewed articles reporting outcomes after SDR or ITB; 2) outcomes reported using a quantifiable scale or standardized outcome measure; 3) patients were < 19 years old at the time of operation; 4) patients had a diagnosis of CP; 5) patients were GMFCS level IV/V or results were reported based on GMFCS status and included some GMFCS level IV/V patients; 6) article and/or abstract in English; and 7) primary indication for surgery was hypertonia. Included studies were assessed with the Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) tool.

RESULTS

Twenty-seven studies met inclusion criteria. The most commonly reported outcomes were spasticity (on the Mean Ashworth Scale) and gross motor function (using the Gross Motor Function Measure), although other outcomes including frequency of orthopedic procedures and complications were also reported. There is evidence from case series that suggests that both ITB and SDR can lower spasticity and improve gross motor function in this nonambulatory population. Complication rates are decidedly higher after ITB due in part to the ongoing risk of device-related complications. The heterogeneity among study design, patient selection, outcome selection, and follow-up periods was extremely high, preventing meta-analysis. There are no comparative studies, and meaningful health-related quality of life outcomes such as care and comfort are lacking. This review is limited by the high risk of bias among included studies. Studies of SDR or ITB that did not clearly describe patients as being GMFCS level IV/V or nonambulatory were excluded.

CONCLUSIONS

There is a lack of evidence comparing the outcomes of ITB and SDR in the nonambulatory CP population. This could be overcome with standardized prospective studies using more robust methodology and relevant outcome measures.

The Effect of Intrathecal Baclofen in Dyskinetic Cerebral Palsy: The IDYS Trial

Objective

Intrathecal baclofen treatment is used for the treatment of dystonia in patients with severe dyskinetic cerebral palsy; however, the current level of evidence for the effect is low. The primary aim of this study was to provide evidence for the effect of intrathecal baclofen treatment on individual goals in patients with severe dyskinetic cerebral palsy.

Methods

This multicenter, randomized, double‐blind, placebo‐controlled trial was performed at 2 university medical centers in the Netherlands. Patients with severe dyskinetic cerebral palsy (Gross Motor Functioning Classification System level IV–V) aged 4 to 24 years who were eligible for intrathecal baclofen were included. Patients were assigned by block randomization (2:2) for treatment with intrathecal baclofen or placebo for 3 months via an implanted microinfusion pump. The primary outcome was goal attainment scaling of individual treatment goals (GAS T score). A linear regression model was used for statistical analysis with study site as a covariate. Safety analyses were done for number and type of (serious) adverse events.

Results

Thirty‐six patients were recruited from January 1, 2013, to March 31, 2018. Data for final analysis were available for 17 patients in the intrathecal baclofen group and 16 in the placebo group. Mean (standard deviation) GAS T score at 3 months was 38.9 (13.2) for intrathecal baclofen and 21.0 (4.6) for placebo (regression coefficient = 17.8, 95% confidence interval = 10.4‐25.0, p < 0.001). Number and types of (serious) adverse events were similar between groups.

Interpretation

Intrathecal baclofen treatment is superior to placebo in achieving treatment goals in patients with severe dyskinetic cerebral palsy. ANN NEUROL 2019

Intrathecal baclofen in metachromatic leukodystrophy

Metachromatic leukodystrophy (MLD) is a rare progressive neurological disorder, often accompanied by motor impairments that are challenging to treat. In this case series, we report the course of treatment with intrathecal baclofen (ITB), aimed at improving daily care and comfort in children and young adults with MLD. All patients with MLD in our centre on ITB treatment for a minimum of 6 months were included (n=10; 4 males, 6 females; mean age 10y 8mo [range 6-24y]). Eight patients had MLD with a predominant spastic movement disorder (sMLD) and two were mainly dyskinetic. Patients with sMLD were compared with matched patients with spastic cerebral palsy (CP). Complication rates related to ITB treatment were similar in both groups. ITB treatment course in the first 6 months after pump implantation appears to show more dose increase in most patients MLD, compared to patients with spastic CP. This may be due to the progressive disease in MLD. ITB is a feasible therapy to improve daily care and comfort in patients with MLD and should therefore be considered early. WHAT THIS PAPER ADDS: Intrathecal baclofen (ITB) is a feasible therapy to improve comfort and daily care in children and young people with metachromatic leukodystrophy (MLD). In the first 6 months of ITB treatment, MLD seems to show more dose increase compared to spastic cerebral palsy.

Intrathecal baclofen therapy in children: an analysis of individualized goals

AIM

To determine whether intrathecal baclofen (ITB) therapy improves performance and performance satisfaction in goal areas identified by patients' parents.

METHOD

This study formed part of an ongoing multicentre national audit involving six paediatric ITB pump implant centres across Australia. The Canadian Occupational Performance Measure was the primary outcome measure utilized at baseline, 6 months, and 12 months after pump implants in paediatric patients receiving ITB therapy for the first time between 31st December 2009 and 31st December 2014.

RESULTS

Twenty-five children had goals identified (mean age 11y 1mo), 19 had a diagnosis of cerebral palsy and 22 were at Gross Motor Function Classification System level IV, V, or equivalent. Strong evidence for an improvement in goal performance (2.33, 95% CI 1.70, 2.96, p<0.001) and performance satisfaction scores (3.08, 95% CI 2.28, 3.88, p<0.001) were demonstrated at 6 months, compared to baseline. The differences were clinically significant and were sustained to 12 months.

INTERPRETATION

ITB therapy in paediatric patients with hypertonia results in clinically significant improvements in average performance and performance satisfaction scores.

WHAT THIS PAPER ADDS

The most commonly identified goals of parents of children treated with intrathecal (ITB) therapy were: improving ease of dressing, positioning, and transfers. ITB therapy is effective in improving performance and performance satisfaction in children with hypertonia. Score improvements are mainly evident within the first 6 months of therapy.

Hidden Medical Devices in the School Setting: What the School Nurse Needs to Know About the Safe Use of Baclofen Pumps

One of the "hidden" medical devices in the school setting is the baclofen pump, which is used for the treatment of spasticity. The goals of spasticity treatment are to decrease muscle tone, deformity, and pain in order to maximize function and ease of care for both child and caregiver. The use of an intrathecal baclofen pump, often for children with cerebral palsy, spinal cord injury, brain injury, or stroke, has been effective in spasticity treatment. It is important for school nurses to be aware of the safety implications associated with this type of device. The Specialized Health Needs Interagency Collaboration (SHNIC) program at the Kennedy Krieger Institute has complied education and materials that explain the use of baclofen pumps in children with spasticity and the role of the school nurse in providing staff training, developing emergency care plans, and creating a safe school environment for children with special health needs.

Clinical presentation and management of dyskinetic cerebral palsy

Cerebral palsy is the most frequent cause of severe physical disability in childhood. Dyskinetic cerebral palsy (DCP) is the second most common type of cerebral palsy after spastic forms. DCP is typically caused by non-progressive lesions to the basal ganglia or thalamus, or both, and is characterised by abnormal postures or movements associated with impaired tone regulation or movement coordination. In DCP, two major movement disorders, dystonia and choreoathetosis, are present together most of the time. Dystonia is often more pronounced and severe than choreoathetosis, with a major effect on daily activity, quality of life, and societal participation. The pathophysiology of both movement disorders is largely unknown. Some emerging hypotheses are an imbalance between indirect and direct basal ganglia pathways, disturbed sensory processing, and impaired plasticity in the basal ganglia. Rehabilitation strategies are typically multidisciplinary. Use of oral drugs to provide symptomatic relief of the movement disorders is limited by adverse effects and the scarcity of evidence that the drugs are effective. Neuromodulation interventions, such as intrathecal baclofen and deep brain stimulation, are promising options.

Intrathecal baclofen therapy in paediatrics: a study protocol for an Australian multicentre, 10-year prospective audit

INTRODUCTION

Increasing clinical use of Intrathecal baclofen (ITB) in Australian tertiary paediatric hospitals, along with the need for standardised assessment and reporting of adverse events, saw the formation of the Australian Paediatric ITB Research Group (APIRG). APIRG developed a National ITB Audit tool designed to capture clinical outcomes and adverse events data for all Australian children and adolescents receiving ITB therapy.

METHODS AND ANALYSIS

The Australian ITB Audit is a 10 year, longitudinal, prospective, clinical audit collecting all adverse events and assessment data across body functions and structure, participation and activity level domains of the ICF. Data will be collected at baseline, 6 and 12 months with ongoing capture of all adverse event data. This is the first Australian study that aims to capture clinical and adverse event data from a complete population of children with neurological impairment receiving a specific intervention between 2011 and 2021. This multi-centre study will inform ITB clinical practice in children and adolescents, direct patient selection, record and aid decision making regarding adverse events and investigate the impact of ITB therapy on family and patient quality of life.

ETHICS AND DISSEMINATION

This project was approved by the individual Human Research Ethics committees at the six Australian tertiary hospitals involved in the study. Results will be published in various peer reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ACTRN 12610000323022; Pre-results.

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.

Baclofen Pumps: Uses and Complications

Intrathecal baclofen therapy, given via an implanted pump in the abdominal wall either as a continuous infusion or bolus dosing, has been used for more than 25 years to treat the spasticity and dystonia associated with various brain and spinal cord conditions. Pediatric clinicians occasionally encounter baclofen pumps, and in the pediatric setting, significant morbidity can arise from their use. This article presents the background, mechanism of action, uses, and complications of intrathecal baclofen therapy and discusses various management strategies should complications occur.

Medical treatment of dystonia

Therapeutic strategies in dystonia have evolved considerably in the past few decades. Three major treatment modalities include oral medications, botulinum toxin injections and surgical therapies, particularly deep brain stimulation. Although there has been a tremendous interest in the later two modalities, there are relatively few recent reviews of oral treatment. We review the medical treatment of dystonia, focusing on three major neurotransmitter systems: cholinergic, GABAergic and dopaminergic. We also provide a practical guide to medication selection, therapeutic strategy and unmet needs.

Comparison between an Ascenda and a silicone catheter in intrathecal baclofen therapy in pediatric patients: analysis of complications

OBJECTIVE In this single-center study the authors investigated the complications occurring before and after the introduction of the new Ascenda intrathecal catheter (Medtronic Inc.) in pediatric patients treated with intrathecal baclofen therapy (ITB) for spasticity and/or dystonia. METHODS This was a retrospective review of 508 children who had received ITB, 416 with silicone catheters in the 13 years between September 1998 and September 2011 and 92 with Ascenda catheters in the 3 years between September 2011 and August 2014. The authors evaluated major complications such as infections, CSF leaks treated, and problems related to the catheter or pump, and they compared the 2 groups of patients who had received either a silicone catheter or an Ascenda catheter implant. RESULTS One hundred twenty patients in the silicone group (29%) and 1 patient in the Ascenda group (1.1%; p < 0.001) had a major complication. In the silicone group 23 patients (5.5%) were affected by CSF leakage and 75 patients (18%) experienced 82 catheter-related events, such as occlusion, dislodgment, disconnection, or breakage, which required catheter replacement. In the Ascenda group, only 1 patient (1.1%) was affected by CSF leakage. CONCLUSIONS To the authors' knowledge, this study is the first in the literature to compare the performance of the new Ascenda catheter, introduced in 2011, with the traditional silicone catheter for intrathecal drug infusion. In their analysis, the authors found that the Ascenda catheter can reduce major complications related to the catheter after ITB pump implantation. Further investigation is necessary to expand on and confirm their results.

The effect of intrathecal baclofen treatment on activities of daily life in children and young adults with cerebral palsy and progressive neurological disorders

INTRODUCTION

Intrathecal baclofen (ITB) treatment is applied in patients with spastic cerebral palsy (SCP), dystonic cerebral palsy (DCP) and progressive neurological disease (PND). Our aim was to investigate whether ITB treatment has a different effect on activities of daily life (ADL) in these groups.

METHOD

A retrospective and cross-sectional survey was conducted using a questionnaire to assess the qualitative effect of ITB (Likert scale) on different domains of functioning (mobility, personal care, communication, comfort) and satisfaction with the results. Groups were compared using non-parametric statistics.

RESULTS

Questionnaires were completed for 68 patients (39 SCP, 13 DCP, 16 PND). Satisfaction scores were relatively high in all groups (7-8) and the positive effect on personal care and communication was similar in all groups. The PND group had the shortest follow-up and scored significantly less favourably for the effect on mobility and comfort.

DISCUSSION

This is the first study to show that ITB treatment has similar effects on personal care and communication in stable and progressive neurological disease. The decrease in mobility in the PND group is likely due to the progressive nature of the disease. The different effect on comfort between groups is mainly due to the smaller effect on startles in the PND group.

Intrathecal baclofen for treating spasticity in children with cerebral palsy

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.

Baclofen pump catheter leakage after migration of the abdominal catheter in a pediatric patient with spasticity

The authors report an unusual case of intrathecal baclofen withdrawal due to the perforation and subsequent leakage of a baclofen pump catheter in a patient with spastic cerebral palsy. A 15-year-old boy underwent an uncomplicated placement of an intrathecal baclofen pump for the treatment of spasticity due to cerebral palsy. After excellent control of symptoms for 3 years, the patient presented to the emergency department with increasing tremors following a refill of his baclofen pump. Initial evaluation consisted of radiographs of the pump and catheter, which appeared normal, and a successful aspiration of CSF from the pump's side port. A CT dye study revealed a portion of the catheter directly overlying the refill port and extravasation of radiopaque dye into the subfascial pocket anterior to the pump. During subsequent revision surgery, a small puncture hole in the catheter was seen to be leaking the drug. The likely cause of the puncture was an inadvertent perforation of the catheter by a needle during the refilling of the pump. This case report highlights a unique complication in a patient with an intrathecal baclofen pump. Physicians caring for these patients should be aware of this rare yet potential complication in patients presenting with baclofen withdrawal symptoms.

Interventional studies in childhood dystonia do not address the concerns of children and their carers

AIMS

This study aimed to determine the main concerns/priorities of the parents and carers of children with dystonia referred to our service and whether medical interventional studies addressed these concerns.

METHODS

Records of children assessed by our service from June 2005-December 2012 were reviewed and expressed parental/carer concerns at initial assessment categorized using the International Classification of Functioning (ICF) Framework. Medline, CINAHL and Embase databases were searched for outcome measures of medical and surgical interventional studies in childhood dystonia.

RESULTS

Data was collected from 273 children and young people with dystonia. The most commonly expressed concerns were: pain (104/273, 38.1%); difficulties in delivering activities of daily-living (66/273, 24.2%), difficulties with hand-use (59/273, 21.6%) and seating (41/273, 15.0%). Literature review identified 70 interventional studies, 46 neurosurgical and 24 pharmacological. The majority of neurosurgical studies (34/46) used impairment scales to measure change, with pharmacological studies typically reporting more subjective changes in motor symptoms. Only a minority of studies used assessments or scales capable of objectively addressing the concerns reported by our cohort.

INTERPRETATIONS

Existing interventional studies in childhood dystonia poorly address the main concerns of children with dystonia and their carers, limiting the conclusions which may be drawn as to true impact of these interventions in childhood.

Intrathecal baclofen therapy in children with severe spasticity: Outcome and complications

OBJECTIVE

To investigate clinical efficacy and incidence of complications regarding intrathecal baclofen (ITB) therapy in children.

METHODS

Retrospective medical chart review of 15 paediatric patients with congenital brain injuries who underwent ITB implantation for treatment of severe spasticity between 2003 and 2009.

RESULTS

Compared to the preoperative state, ITB therapy significantly reduced spasticity of lower limbs with corresponding decrease of the modified Ashworth scale (p < 0.05), while baclofen dosage increased (p = 0.001). Cobb angle of patients with scoliosis prior to ITB therapy (n = 8) increased significantly (p < 0.05) during follow-up. Overall, 10 complications (nine device related and one accidental) were found in six patients (40%), mostly emerging within the first three years after implantation.

CONCLUSION

Intrathecal baclofen is an effective therapy option for paediatric patients to significantly reduce spasticity of lower limbs. The high incidence of complications implicates the need for a close monitoring of the patients especially in the early post-operative period.

Intrathecal baclofen therapy in children with acquired brain injuries after drowning: A case series

Objective: To investigate clinical efficacy as well as the incidence and extent of complications regarding intrathecal baclofen (ITB) therapy in children.

METHODS

This is a retrospective medical chart review of three paediatric patients with acquired brain injuries (ABI) resulting from drowning who underwent ITB pump implantation for treatment of severe spasticity.

RESULTS

Compared to the pre-operative state, ITB therapy reduced spasticity with a corresponding decrease of modified Ashworth scale in upper (3.2 ± 1.4 to 1.3 ± 0.6) and lower extremities (3.5 ± 0.9 to 2.0 ± 1.0). Overall, six complications, five device-related and one accidental, were found in two out of three patients.

CONCLUSION

Intrathecal baclofen is an effective therapy option for paediatric patients with ABI after drowning to significantly reduce spasticity of upper and lower extremities. A word of caution must be addressed to the incidence and extent of complications related to ITB therapy.

Evaluation of functional goal outcomes using the Canadian Occupational Performance Measure (COPM) following Deep Brain Stimulation (DBS) in childhood dystonia

PURPOSE

To evaluate the functional goal-directed outcomes of Deep Brain Stimulation (DBS) in childhood dystonia according to aetiology and to explore relationship with a traditional impairment-based measure.

METHOD

This is a prospective case series study involving thirty children with dystonia with a 1-year follow-up post-DBS. The Canadian Occupational Performance Measure (COPM) and Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) were used as primary outcome measures. Results were analysed based on aetiology in 3 groups: 1. primary/primary plus dystonia; 2. secondary dystonia-cerebral palsy (CP); 3. secondary dystonia-non-CP group. Correlation between functional outcome using COPM and dystonia improvement as captured by BFMDRS was measured.

RESULTS

All groups demonstrated significant improvement in individualised goal attainment, measured with the COPM, at 1-year post-DBS. The secondary dystonia-CP group also achieved significant improvement at 6 months for performance and satisfaction scores. In the majority of secondary dystonias, the BFMDRS failed to demonstrate significant improvement. A linear correlation between change in BFMDRS and COPM scores was observed when the entire cohort was analysed.

INTERPRETATION/CONCLUSIONS

DBS improved functional performance, independently of the dystonic phenotype. Improvements in individualized COPM functional goal areas were seen in the absence of significant changes in BFMDRS scores, highlighting the relative insensitivity of impairment scales in this patient group.

Analysis of complications in 430 consecutive pediatric patients treated with intrathecal baclofen therapy: 14-year experience

OBJECT

This single-center study investigated adverse events that occurred in children and adolescent patients treated with intrathecal baclofen (ITB) therapy for spasticity and/or dystonia.

METHODS

In a 14-year period, 430 consecutive patients with a mean age of 13.3 ± 5.9 years received ITB over a mean follow-up period of 8.6 ± 3.8 years (range 12 months to 14 years). Eighty-nine percent of these patients had cerebral palsy. Major complications, defined as those that required a surgical intervention, were infections, CSF leaks, and device problems related to the catheter or pump. Assessing infections, the authors compared the 2 groups of patients implanted with an ITB system by either the subcutaneous or subfascial technique. The temporal distribution of events related to the catheter was also considered.

RESULTS

At least 1 complication was present in 25% of the patients: 9.3% experienced an infection, 4.9% a CSF leak, 15.1% a problem with the catheter, and 1% a problem related to the pump. Five percent of the assessed patients suffered more than 1 complication. The rate of infections was significantly lower (p < 0.001) in patients with the pump placed subfascially compared with those with the pump placed subcutaneously. A higher rate of infection was found after pump replacement compared with the first pump implantation (10.6% vs 6%, respectively). Catheter problems were the most common complication and occurred more frequently during the 1st year after the implant.

CONCLUSIONS

While ITB is an effective treatment to manage spasticity of different origins, adverse events may occur and need to be managed. The surgical procedure should be meticulous and different techniques may have a diverse impact on the infection rate, which is the most critical complication. Despite the adverse events that occurred in this study, the majority of patients were satisfied with the treatment received.

Change in parent-identified goals in young children with cerebral palsy receiving a context-focused intervention: associations with child, goal and intervention factors

The purpose of this study was to examine the relationship between goal achievement measured by the Canadian Occupational Performance Measure (COPM) and child, goal, and intervention factors. Participants were 41 preschool children with cerebral palsy (CP) who were in the context-focused therapy arm of a randomized controlled trial. Factors including child age, Gross Motor Function Classification System (GMFCS) level, type and complexity of goals, and intervention strategies were analyzed. Children made large, positive mean changes on the COPM over 6 months (Performance = 3.8, SD = 1.9; Satisfaction = 4.3, SD 4.3) with younger children showing greater change. The COPM scores had low to moderate correlations with change on the Pediatric Evaluation of Disability Inventory and the Gross Motor Function Measure (GMFM-66). Regression analysis indicated that age, but not GMFCS level influenced COPM change scores. Goal complexity and intervention strategies were not significantly related to COPM change scores. The results provide support for using the COPM as an individualized measure of change in young children with CP receiving intervention.

Occurrence of adverse events in long-term intrathecal baclofen infusion: a 1-year follow-up study of 158 adults

OBJECTIVE

To assess the frequency and types of adverse events (AEs) related to intrathecal baclofen (ITB) therapy in adults, and associated risk factors.

DESIGN

A prospective, observational cohort study of adults followed up from January 1 to December 31, 2010.

SETTING

A neurologic rehabilitation department in a university hospital.

PARTICIPANTS

All consecutive adult subjects (N=158) receiving ITB via a pump, either implanted or followed up during the study period.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Frequency and type of AEs.

RESULTS

In 2010, 158 subjects were followed up for ITB therapy, of whom 128 were implanted before 2010 (nonsurgical subjects), and 30 underwent implantation in 2010 (surgical subjects). Of these 30 subjects, 20 were "newly implanted" and 10 were "replacements." The most frequent pathologic disorders were spinal cord injury (42%) and multiple sclerosis (28%). Twenty-eight subjects (18%) experienced a total of 38 AEs. The rate of AEs was .023 per month of ITB treatment. AEs were related to the surgical procedure in 53% of cases, to the device in 29% (predominantly catheter dysfunctions), and to adverse effects of baclofen in 18%. AEs related to the surgical incision (scar complications and collections) were more frequent in replacement than newly implanted subjects (P=.009). No significant association between occurrence of an AE and subject characteristics (age, gait capacity, spinal vs cerebral spasticity, duration of ITB therapy follow-up) was found. Nearly half of the AEs were serious, extending admission time by a mean of 16 days. No AE induced long-term morbidity or death.

CONCLUSIONS

The AE rate was relatively low in this cohort. This has to be balanced against the clinical, functional, and quality-of-life improvements, which are expected from ITB therapy.

Intrathecal baclofen treatment in dystonic cerebral palsy: a randomized clinical trial: the IDYS trial

Background

Dystonic cerebral palsy is primarily caused by damage to the basal ganglia and central cortex. The daily care of these patients can be difficult due to dystonic movements. Intrathecal baclofen treatment is a potential treatment option for dystonia and has become common practice. Despite this widespread adoption, high quality evidence on the effects of intrathecal baclofen treatment on daily activities is lacking and prospective data are needed to judge the usefulness and indications for dystonic cerebral palsy. The primary aim of this study is to provide level one clinical evidence for the effects of intrathecal baclofen treatment on the level of activities and participation in dystonic cerebral palsy patients. Furthermore, we hope to identify clinical characteristics that will predict a beneficial effect of intrathecal baclofen in an individual patient.

Methods/Design

A double blind placebo-controlled multi-center randomized clinical trial will be performed in 30 children with dystonic cerebral palsy. Patients aged between 4 and 25 years old with a confirmed diagnosis of dystonic cerebral palsy, Gross Motor Functioning Classification System level IV or V, with lesions in the cerebral white matter, basal ganglia or central cortex and who are eligible for intrathecal baclofen treatment will be included. Group A will receive three months of continuous intrathecal baclofen treatment and group B will receive three months of placebo treatment, both via an implanted pump. After this three month period, all patients will receive intrathecal baclofen treatment, with a follow-up after nine months. The primary outcome measurement will be the effect on activities of and participation in daily life measured by Goal Attainment Scaling. Secondary outcome measurements on the level of body functions include dystonia, spasticity, pain, comfort and sleep-related breathing disorders. Side effects will be monitored and we will study whether patient characteristics influence outcome.

Discussion

The results of this study will provide data for evidence-based use of intrathecal baclofen in dystonic cerebral palsy.

Trial registration

Nederlands Trial Register, NTR3642

Improvement in upper limb function in children with dystonia following deep brain stimulation

BACKGROUND

Childhood dystonia can severely impact upper limb function. Deep brain stimulation (DBS) has been shown to be effective in reducing dystonic symptoms in childhood. Functional recovery following DBS is however not well understood.

AIMS

To explore changes in upper limb function following DBS in paediatric dystonia.

METHODS

Upper limb outcomes, using the Melbourne Assessment of Unilateral Upper Limb Function, are reported in 20 cases of childhood dystonia (unilateral n = 1, four limb n = 19) at 6 and 12 months following DBS.

RESULTS

Improvement in at least in one upper limb was seen in the majority of cases (n = 17, 85%) at 12 months following DBS. Deterioration of scores in both upper limbs was seen in 3 children with progressive disorders. Grouping the children aetiologically, a significant improvement in the dominant hand was obtained for the primary dystonia/dystonia-plus group at both six (p = 0.018) and twelve months (p = 0.012). In secondary dystonia due to a static disorder, improvement was also seen at 6 (p = 0.043) and 12 months (p = 0.046) in the non-dominant hand. No significant change was found in the group of children with progressive disorders.

CONCLUSIONS

DBS has the potential to alter upper limb function in children with primary and secondary dystonia. The dominant hand improved most in children with primary dystonias, with greater improvement in the non-dominant hand in secondary-static cases.

Complications of intrathecal baclofen pumps in children: experience from a tertiary care center

BACKGROUND/AIMS

Intrathecal baclofen (ITB) therapy is useful in treating spasticity and dystonia but it has many complications, more so in children. The main aim of the study was to look at the complications of ITB pumps in children with the goal of future prevention.

METHODS

Charts of all patients ≤21 years with an ITB pump, implanted by a single pediatric neurosurgeon, at a single center, between 1996 and 2011 were reviewed retrospectively. Data regarding an ITB test trial were also recorded.

RESULTS

During 1996-2011, 119 children (mean age 13.2 years) underwent ITB pump placement; 84% had spastic quadriplegic cerebral palsy. The gross motor function classification system level was ≥4 for most. The pump was removed in 5 (4.2%) patients due to inefficacy. The mean follow-up was 38 months. Mechanical complications requiring pump and/or catheter revision occurred in 19.3% and infections in an additional 21.8%. Seven patients (6%) had meningitis. No complication was noted after 72 months of initial pump insertion, even after pump reinsertion.

CONCLUSION

There is a need for better infection control as well as better pump, catheter and surgical technology to lower the complications of ITB pumps in children.

Functional neurosurgery for secondary dystonia: indications and long-term results

Dystonia is a movement disorder characterized by patterned, repetitive, phasic, or tonic sustained muscle contractions that produce abnormal, often twisting, postures or repetitive movements. When the disorder is genetic or the cause is unknown and dystonia is the sole feature, the disease is called primary or idiopathic, conversely secondary dystonia (SD) may be caused by various brain insults. Both primary dystonia and SD have been notorious for their poor response to medical treatment. Today, stereotactic neurosurgical procedures are offered to improve the disability and quality of life of patients who do not respond to medical therapy. However, SD shows less and more variable results than primary dystonia to neurosurgical procedures, the benefits of ablative or deep brain stimulation (DBS) procedures in basal structures being still subject to debate and much harder to fully appreciate. In this work, the authors show a 33-patient series with secondary dystonia, separating the statistic and clinical analysis into several etiology groups: perinatal insults, tardive syndromes, genetic syndromes, and posttraumatic. In these groups, we show the mean BFM score improvement in the different patient series, comparing our results with world literature, and finally propose a classification system for bettering the clinical approach in surgery decision when this is indicated.

Evaluation of salvage techniques for infected baclofen pumps in pediatric patients with cerebral palsy

OBJECT

Intrathecal baclofen therapy has been used successfully for intractable spasticity in children with cerebral palsy. Infections are rare, but they are potentially life threatening if complicated by bacteremia or meningitis. Treatment without removal of the system is desirable if it can be done safely and effectively.

METHODS

The Authors reviewed the records of 207 patients ranging from 3 to 18 years of age with cerebral palsy who underwent placement or revision of a baclofen pump. They identified 38 patients with suspected or documented infectious complications. Initial attempts were made to eradicate infection with the devices in situ in all patients. Methods and effectiveness of pump salvage were evaluated.

RESULTS

Of the 38 patients identified, 13 (34.2%) had documented infections; 11 had deep wound/pocket empyemas and 2 had meningitis. Eight patients with deep wound infections received intravenous antibiotics alone. All required pump explantation. The remaining 3 patients underwent a washout procedure as well; the infection was cured in 1 patient. Both patients with meningitis received intravenous and intrathecal antibiotics, and both required device explantation. In addition, 25 patients (65.8%) had excessive or increasing wound erythema. No objective criteria to document a superficial infection were present. The wounds were considered suspicious and were managed with serial examinations and oral antibiotics. The erythema resolved in 24 of the 25 patients.

CONCLUSIONS

In general, observation, wound care, and oral antibiotics are sufficient for wounds that are suspicious for superficial infection. For deep-seated infection, antibiotic therapy alone is generally insufficient and explantation is required. Washout procedures can be considered, but failures are common.

Intrathecal baclofen therapy--how we do it

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.

Intraventricular baclofen as an alternative to intrathecal baclofen for intractable spasticity or dystonia: outcomes and technical considerations

OBJECT

The aim of this study was to identify the benefits of intraventricular baclofen (IVB) therapy for the treatment of intractable spasticity or dystonia in a subset of patients who had experienced multiple revisions while receiving intrathecal baclofen (ITB) therapy.

METHODS

The authors reviewed the charts of 22 consecutive patients with intractable spasticity or dystonia who initially underwent ITB therapy, subsequently suffered multiple revisions during ITB therapy, and ultimately received IVB therapy, all during a 12-year period from November 1998 to October 2010. The intraventricular catheters were positioned in the lateral ventricle, aided by stereonavigation.

RESULTS

The surgical revision rate (the average number of surgical revisions per average number of follow-up years) during ITB therapy was 0.84, and was 0.50 during IVB therapy. The most frequent complication requiring surgical revision during ITB therapy was catheter occlusion, followed by pump malfunction/pump pocket issues, and infection. The most frequent complication requiring surgical revision during IVB therapy was infection, followed by catheter misplacement/migration. Four patients suffered infection that required removal of their intraventricular catheter, and currently have no baclofen system.

CONCLUSIONS

Some of these patients had a history of increasing revisions with increasing frequency during ITB therapy. Such a history puts them at risk for spinal arachnoiditis, a condition that complicates further ITB therapy. For such patients, the authors believe that IVB therapy may be a beneficial therapeutic option, given that the surgical revision rate was lower for IVB than for ITB. Intraventricular baclofen may be a cost-effective option for patients with mounting revisions during ITB therapy.

Polyanalgesic Consensus Conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel

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.

Cervical implantation of intrathecal baclofen pump catheter in children with severe scoliosis

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.

Stereotactic endoscopic placement of third ventricle catheter for long-term infusion of baclofen in patients with secondary generalized dystonia

Continuous infusion of baclofen is a treatment option for severe generalized dystonia. Catheter insertion within the third ventricle has been described as an alternative to standard intrathecal placement to maximize intracranial concentrations of baclofen. The authors describe their experience with a novel technique for stereotactic endoscopic insertion of baclofen infusion catheters in the third ventricle in 3 patients with severe secondary generalized dystonia. Insertion was successful in all 3 patients, and all of them experienced significant improvement in dystonia scores on the Barry-Albright Dystonia Scale. Follow-up ranged from 5.5 to 7 months (mean 6 months), and no mechanical complications or CSF leaks were observed. The stereotactic endoscopic insertion of a baclofen infusion catheter into the third ventricle appears to be a safe method for continuous intraventricular baclofen infusion in patients with generalized secondary dystonia.

Effects of intrathecal baclofen on daily care in children with secondary generalized dystonia: a pilot study

AIM

Treatment options for dystonic cerebral palsy (CP) are limited. Our aims were to determine whether intrathecal baclofen (ITB) improves daily care, decreases dystonia and decreases pain in patients with dystonic CP.

METHODS

Patients received randomized blinded treatment with ITB or placebo. Scores on problems of daily care were recorded and dystonia, pain and comfort were assessed.

RESULTS

Four patients (three males, average age 12 years 6 months) were included (all Gross Motor Function Classification System level V). During the trial period problem scores and dystonia scores decreased in all four patients.

CONCLUSION

In this pilot study we report positive functional effects of ITB trial treatment in four patients with dystonic CP. A randomized trial with a larger cohort is needed to verify these results.

Intrathecal baclofen therapy: benefits and complications

BACKGROUND

Spasticity and dystonia in children with cerebral palsy has been treated with intrathecal baclofen therapy (ITB) at the Royal Children's Hospital, Melbourne, Australia (RCH) since 1999.

METHODS

The records of children having received or still receiving ITB during the period September 1999 until August 2005 were studied to evaluate complications and side effects. Parents answered a questionnaire focused on the health and functional impact in the children.

RESULTS

There were 18 first insertions of pumps, 6 removals, and 4 reinsertions. The longest treatment was 5 years and 11 months and was still ongoing. Seventeen complications occurred in 14 out of 18 children. Despite the high complication rate and the lack of significant functional improvement, 11 out of 12 parents agreed that ITB was beneficial.

CONCLUSION

ITB treatment at RCH over the years has resulted in some complications, mostly occurring shortly after pump insertion. For the majority of children there are substantial benefits.

Does loss of spasticity matter? A 10-year follow-up after selective dorsal rhizotomy in cerebral palsy

AIM

The aim of this study was to evaluate the long-term effects of selective dorsal rhizotomy (SDR) in children with cerebral palsy (CP).

METHOD

Nineteen children (four females, 15 males; mean age 4y 7mo, SD 1y 7mo) with bilateral spastic CP, were prospectively assessed at baseline and 18 months, 3 years, and 10 years after SDR. Assessments included the Modified Ashworth Scale for spasticity, the Gross Motor Function Measure 88 (GMFM-88) and the Wilson gait scale for ambulation, neurological investigations, and passive joint range of motion assessment. A 10-year retrospective chart review was added for orthopaedic surgery after SDR.

RESULTS

Baseline muscle tone at the hip, knee, and ankle level displayed a high degree of spasticity that normalized after SDR. After 10 years there was a slight recurrence of spasticity at the knee and ankle. Joint range of motion declined from a maximum at 3 years after SDR to the 10-year follow-up. Median ambulatory status was best 3 years after SDR and then declined. The GMFM-88 score increased from the median baseline value of 51 to 66 (p=0.002) and 76 (p<0.001) at the initial follow-ups. After 10 years there was a decline in gross motor function with a reduction in the GMFM-88 score to 62 (p=0.022). Within 10 years, 16 out of 19 patients had a mean of three orthopaedic surgeries (SD 2.8), soft tissue surgery being the most common.

INTERPRETATION

The spasticity-reducing effect of SDR, although pronounced, did not seem to improve long-term functioning or prevent contractures. This suggests that contracture development in CP is not mediated by spasticity alone.

Intrathecal baclofen therapy: complication avoidance and management

PURPOSE

Intrathecal baclofen (ITB) therapy is an accepted treatment modality for spasticity and dystonia. Several complications related to ITB have been described, including mechanical malfunctions, infections, cerebrospinal fluid fistula, and baclofen withdrawal or overdose. In this study, we present our institutional experience with ITB therapy, emphasizing complication avoidance and lessons learned.

METHODS

The charts of 87 patients treated with ITB therapy were retrospectively reviewed. The primary surgical technique, complication type and timing, method of treatment, and outcome were analyzed.

RESULTS

Thirteen out of 76 (17.1%) patients primarily treated at our department had 25 complications. The first complication occurred 17.5-30.9 months (mean 24.2±6.7) after the pump implantation. Additional four patients with pumps placed elsewhere had six complications and were subsequently treated by our group. The main complications were: catheter fracture (11), subcutaneous fluid collection (5), lumbar wound/CSF infection (3), lumbar catheter or connector protrusion (3), pump malfunction (3), distal catheter migration outside the thecal sac (2), and baclofen withdrawal (1). Of the patients in the NYULMC group, six were treated by a single surgical procedure, six underwent multiple surgical procedures, and one was managed conservatively. In retrospect, changing the surgical technique, or adding an abdominal binder may have prevented 17 complications (54.8%). There were two deaths that were unrelated to the ITB therapy.

CONCLUSION

ITB therapy is associated with complications, many of which require additional surgery. Some of these complications are avoidable by adhering to a strict surgical technique and a proper criterion for patient selection.

Intrathecal baclofen therapy for spasticity of cerebral origin--does the position of the intrathecal catheter matter?

OBJECTIVE

To assess the correlation between the position of the intrathecal baclofen therapy catheter with the clinical outcome and response to the spasticity.

METHODS AND RESULTS

A prospective cohort study was done by reviewing the paediatric group of patients with spasticity of cerebral origin who had insertion of a programmable baclofen pump for intrathecal administration in the last 10 years (August 1998 to September 2007). A total of 190 procedures were carried out in 166 patients, under a single paediatric neurosurgeon, with an age range of 18 months-16 years (mean 8.75 years) with follow up of 1-10 years (mean 5 years). The routine post-operative X-rays, which were done as per protocol, were reviewed, and the position of the intrathecal catheter tip was documented in relation to the vertebral bodies. The maintenance intrathecal baclofen dose was 25 microgms to 1,000 microgms (mean 255.8 microgms) based on the clinical response to spasticity. Statistical analysis was carried out to assess the correlation of the position of the tip of the intrathecal catheter with the outcome in spasticity based on GMFCS (Gross Motor Function Classification System) and Ashworth score.

CONCLUSION

In our series, there was no statistically significant correlation between the position of the intrathecal catheter and the clinical response to the spasticity.