A 10-year follow-up study of patients with severe traumatic brain injury and dysautonomia treated with intrathecal baclofen therapy

Heart rate variability (HRV) after traumatic brain injury (TBI): a scoping review

BACKGROUND

Heart rate variability (HRV), defined as the variability between successive heart beats, is a noninvasive measure of autonomic nervous system (ANS) function, which may be altered following traumatic brain injury (TBI). This scoping review summarizes the existing literature regarding changes in HRV after TBI as well as the association between measures of HRV and outcomes following TBI.

METHODS

A literature search for articles assessing 'heart rate variability' and 'brain injury' or 'concussion' was completed. Articles were included if HRV was measured in human subjects with TBI or concussion. Review articles, protocol papers, and studies including non-traumatic injuries were excluded.

RESULTS

Sixty-three articles were included in this review. Varied methods were used to measure HRV in the different studies. Forty articles included information about differences in HRV measures after TBI and/or longitudinal changes after TBI. Fifteen studies assessed HRV and symptoms following TBI, and 15 studies assessed HRV and either functional or cognitive outcomes after TBI.

CONCLUSIONS

HRV has been studied in the context of mortality, clinical symptoms, and medical, functional, or cognitive outcomes following TBI. Methods used to measure HRV have varied amongst the different studies, which may impact findings, standardized protocols are needed for future research.

Long-term results on the suppression of secondary brain injury by early administered low-dose baclofen in a traumatic brain injury mouse model

Secondary injury from traumatic brain injury (TBI) perpetuates cerebral damages through varied ways. Attenuating neuroinflammation, which is a key feature of TBI, is important for long-term prognosis of its patients. Baclofen, a muscle relaxant, has shown promise in reducing excessive inflammation in other neurologic disorders. However, its effectiveness in TBI remains ambiguous. Thus, our study aimed to investigate whether early administration of baclofen could elicit potential therapeutic effects by diminishing exaggerated neuroinflammation in TBI mice. In this study, 80 C57BL/6 mice were used, of which 69 mice received controlled cortical impact. The mice were divided into six groups (11-16 mice each). Baclofen, administered at dose of 0.05, 0.2 and 1 mg/kg, was injected intraperitoneally a day after TBI for 3 consecutive weeks. 3 weeks after completing the treatments, the mice were assessed histologically. The results showed that mice treated with baclofen exhibited a significantly lower volume of lesion tissue than TBI mice with normal saline. Baclofen also reduced activated glial cells with neurotoxic immune molecules and inhibited apoptotic cells. Significant recovery was observed and sustained for 6 weeks at the 0.2 mg/kg dose in the modified neurological severity score. Furthermore, memory impairment was recovered with low-doses of baclofen in the Y-maze. Our findings demonstrate that early administration of low dose baclofen can regulate neuroinflammation, prevent cell death, and improve TBI motor and cognitive abnormalities.

On the recovery of disorders of consciousness under intrathecal baclofen administration for severe spasticity-An observational study

BACKGROUND

Occasionally, patients show dramatic recovery from disorders of consciousness (DOC) under intrathecal baclofen (ITB), an established treatment option for severe supraspinal spasticity. Anecdotal explanations for ITB-related recovery of cognition include modulation of afferent impulses at the spinal level, thereby reducing spasticity-related proprioceptive information overload within cortico-thalamo-cortical connections.

OBJECTIVE

In this retrospective patient chart analysis, we assessed whether a reduction in spasticity would be associated with an increase in Coma Recovery Scale revised (CRS-R) scores in a larger sample of patients than previously published.

METHODS

From a hospital-based ITB treatment register, we extracted data from 26 patients with DOC and severe supraspinal spasticity who improved by >2 points on the Coma Recovery Scale revised (CRS-R) within 6 months after ITB treatment initiation. We assessed Modified Ashworth scale (MAS) scores and CRS-R scores on admission (PRE) and 3 and 6 months after initiation of ITB treatment (3M, 6M). We performed correlation analysis of the scores and their respective changes (PRE to 3M, 3M to 6M). We also correlated the time from acute event until ITB initiation to CRS-R scores at 3M and 6M.

RESULTS

ITB led to significant improvement in spasticity based on MAS scores, which did not correlate to the improvements seen in CRS-R total and subscale scores. Daily ITB dose did neither correlate to MAS scores nor to CRS-total scores in the whole patient group, but after 3 months, ITB dose correlated to some CRS-R subscale scores in some patient subgroups. Time until ITB treatment did not correlate to CRS-R scores later on.

CONCLUSIONS

Our data confirm that ITB may exert beneficial effects in selected DOC patients with respect to improved cognitive functions, which, however, do not correlate to its antispastic effect. The lack of correlation between time to ITB and CRS-R outcome, but significant CRS-R improvements following pump implantation, renders spontaneous remissions unlikely and leaves room for alternative pharmacological mechanisms.

Neurobehavioral Symptoms and Heart Rate Variability: Feasibility of Remote Collection Using Mobile Health Technology

OBJECTIVES

To determine the covariance of heart rate variability (HRV) and self-reported neurobehavioral symptoms after traumatic brain injury (TBI) collected using mobile health (mHealth) technology.

SETTING

Community.

PARTICIPANTS

Adults with lifetime history of TBI (n = 52) and adults with no history of brain injury (n = 12).

DESIGN

Two-week prospective ecological momentary assessment study.

MAIN MEASURES

Behavioral Assessment Screening Tool (BASTmHealth) subscales (Negative Affect, Fatigue, Executive Dysfunction, Substance Abuse, and Impulsivity) measured frequency of neurobehavioral symptoms via a RedCap link sent by text message. Resting HRV (root mean square of successive R-R interval differences) was measured for 5 minutes every morning upon waking using a commercially available heart rate monitor (Polar H10, paired with Elite HRV app).

RESULTS

Data for n = 48 (n = 38 with TBI; n = 10 without TBI) participants were included in covariance analyses, with average cross-correlation coefficients (0-day lag) varying greatly across participants. We found that the presence and direction of the relationship between HRV and neurobehavioral symptoms varied from person to person. Cross-correlation coefficients r ≤ -0.30, observed in 27.1% to 29.2% of participants for Negative Affect, Executive Dysfunction, and Fatigue, 22.9% of participants for Impulsivity, and only 10.4% of participants for Substance Abuse, supported our hypothesis that lower HRV would covary with more frequent symptoms. However, we also found 2.0% to 20.8% of participants had positive cross-correlations (r ≥ 0.30) across all subscales, indicating that higher HRV may sometimes correlate with more neurobehavioral symptoms, and 54.2% to 87.5% had no significant cross-correlations.

CONCLUSIONS

It is generally feasible for community-dwelling adults with and without TBI to use a commercially available wearable device to capture daily HRV measures and to complete a short, electronic self-reported neurobehavioral symptom measure for a 2-week period. The covariance of HRV and neurobehavioral symptoms over time suggests that HRV could be used as a relevant physiological biomarker of neurobehavioral symptoms, though how it would be interpreted and used in practice would vary on a person-by-person and symptom domain basis and requires further study.

Sepsis or sympathetics? Paroxysmal sympathetic hyperactivity after pontine stroke

A 64-year-old man from nursing home with a pontine stroke 3 months ago, ventilator-dependent, presented with episodic fever, tachycardia and tachypnoea occurring several times a day. He was evaluated for sepsis and pulmonary embolism and was treated empirically with broad-spectrum antibiotics. But these episodes persisted. Due to the episodic nature and typical symptoms of sympathetic overactivity, in the setting of prior brain injury, paroxysmal sympathetic hyperactivity was considered. His antibiotics were discontinued, and he was treated symptomatically with baclofen and bromocriptine, which resulted in a partial reduction of these episodes.

Effectiveness of Pharmacological Agents and Validation of Diagnostic Scales for the Management of Paroxysmal Sympathetic Hyperactivity in Hispanics

The identification and treatment of paroxysmal sympathetic hyperactivity (PSH) still present a significant challenge. We assessed the efficacy of pharmacological agents in treating PSH symptoms and the validity of the diagnostic scales in a cohort of Hispanic patients. A retrospective chart review of cases from a single hospital was conducted in 464 records. Exclusion criteria included underlying conditions such as severe infection. Only nine patients remained in the cohort after examining their clinical records, corresponding to the following diagnoses: traumatic brain injury, subdural hemorrhage, anoxic or ischemic encephalopathy, pneumocephalus, and cerebral palsy. Using the PSH likelihood scale, six of the nine patients were identified with a score of 17 or higher, corresponding to a "probable" PSH, and three patients obtained a score between 8 and 16, corresponding to a "possible" PSH diagnosis. The top three classes of medications used were beta-blockers, antipyretics, and opioids. Benzodiazepines and neuromodulators were also frequently used in patients with trauma, but not in the ones with non-traumatic injuries. Interestingly, 75% of the patients have prescribed levothyroxine as a home medication after the PSH presentation. Medication administration did not follow a specific pattern, suggesting high variability in the management of PSH within our setting, requiring further research. Our results suggest that the pituitary axis might be involved in the progression of PSH. Establishing a specific medical code (e.g., ICD-10) describing PSH as a single entity is essential for appropriate identification and management.

Organic features of autonomic dysregulation in paediatric brain injury - Clinical and research implications for the management of patients with Rett syndrome

Rett Syndrome (RTT) is a complex neurodevelopmental disorder with autonomic nervous system dysfunction. The understanding of this autonomic dysregulation remains incomplete and treatment recommendations are lacking. By searching literature regarding childhood brain injury, we wanted to see whether understanding autonomic dysregulation following childhood brain injury as a prototype can help us better understand the autonomic dysregulation in RTT. Thirty-one (31) articles were identified and following thematic analysis the three main themes that emerged were (A) Recognition of Autonomic Dysregulation, (B) Possible Mechanisms & Assessment of Autonomic Dysregulation and (C) Treatment of Autonomic Dysregulation. We conclude that in patients with RTT (I) anatomically, thalamic and hypothalamic function should be explored, (II) sensory issues and medication induced side effects that can worsen autonomic function should be considered, and (III) diaphoresis and dystonia ought to be better managed. Our synthesis of data from autonomic dysregulation in paediatric brain injury has led to increased knowledge and a better understanding of its underpinnings, leading to the development of application protocols in children with RTT.

Effects of intrathecal baclofen therapy in subjects with disorders of consciousness: a reappraisal

Baclofen is a structural analogue of gamma-amino-butyric acid (GABA), which reduces spastic hypertonia of striated muscle due to a mechanism of GABA_B-ergic inhibition of mono- and polysynaptic reflexes at the spinal level. There are reports of patients with severe disorders of consciousness that presented a substantial improvement following intrathecal baclofen (ITB) administration for severe spasticity. The neural mechanisms underlying the clinical recovery after ITB have not yet been clarified. Baclofen could modulate sleep-wake cycles that may be dysregulated and thus interfere with alertness and awareness. The diminished proprioceptive and nociceptive sensory inputs may relieve thalamo-cortical neural networks involved in maintaining the consciousness of the self and the world. ITB treatment might also promote the recovery of an impaired GABAergic cortical tone, restoring the balance between excitatory and inhibitory cortical activity. Furthermore, glutamatergic synapses are directly or indirectly modulated by GABA_B-ergic receptors. Neurophysiological techniques (such as transcranial magnetic stimulation, electroencephalography, or the combination of both) can be helpful to explore the effects of intrathecal or oral baclofen on the modulation of neural cortical circuits in humans with disorders of consciousness.

[Intrathecal baclofen therapy in brain injury and recovery of persistent vegetative state. Apropos of a case]

Patients with brain injury and spasticity are candidates for intrathecal baclofen therapy (ITB) when maximal doses of oral antispastic drugs fail. Some authors have described an improvement in the level of consciousness in patients with brain injury and disorder of consciousness treated with ITB for spasticity. We present the case of a 43-year-old patient with brain injury, spasticity, and permanent vegetative state (PVS) who showed an improvement in the level of consciousness after ITB for spasticity. We performed an ITB infusion test, assessing the spasticity with the Modified Ashworth Scale (MAS) and level of consciousness with the Coma Recovery Scale-Revised (CRS-R) and observed an improvement in the spasticity and the level of consciousness. Consequently, the ITB pump was implanted and the patient recovered from PVS to minimal conscious state (MCS). We conclude that ITB is indicated in patients with brain injury and spasticity. We suggest the improvement in the level of consciousness as a possible additional benefit. There is a lack of evidence to recommend ITB in patients with altered level of consciousness.

Intrathecal Drug Delivery

Targeted intrathecal (IT) drug delivery systems (IDDS) are well established as an effective treatment of patients with chronic nonmalignant or malignant pain, and as a tool for management of patients with severe spasticity. The risk to benefit ratio of IDD makes it a relatively safe therapy for both cancer- and noncancer-related pain, but it is not free of risks, so it should be managed at specific centers. Recent technological advances, new therapeutic applications, reported complications, and the costs as well as maintenance required for this therapy require the need to stay up to date about new recommendations that may improve outcomes. This chapter reviews all technological issues regarding IDDS implantation with follow-up and pharmacological recommendations published during recent years that provide evidence-based decision-making process in the management of chronic pain and spasticity in patients.

Intrathecal Baclofen Trial Before Device Implantation: 12-Year Experience With Continuous Administration

OBJECTIVE

To report our experience using continuous intrathecal baclofen (ITB) administration prior to a possible ITB device implantation.

DESIGN

Retrospective open label study. Mean duration of follow-up 64 months.

SETTING

Primary-care and referral center, ambulatory and hospitalized care.

PARTICIPANTS

Patients (N=116) undergoing continuous ITB trials between 2006 and 2017.

INTERVENTIONS

Continuous application of baclofen via a temporary intrathecal catheter connected to an external pump.

MAIN OUTCOME MEASURES

Assessment of the modified Ashworth Scale and range of movement prior versus end of ITB trial. According to the Barthel Index, definition of high-level patients (60-100 scoring points) and low-level patients (0-55 scoring points). Calculation of the Rivermead Mobility Index in high-level patients prior versus end of ITB trial. Evaluation of occurring adverse events.

RESULTS

A total of 119 ITB trials were performed in 116 patients (78 men, mean age 41±16), 113 patients completed the trials (31 of 113 high level, 82 of 113 low level). The median modified Ashworth scale improved from 4 (interquartile range [IQR] 3-4) to 2 (IQR 1-2; P≤.001), the range of movement from 2 (IQR 1-3) to 3 (IQR 3-3; P≤.001). The Rivermead Mobility Index increased from 9 (IQR 6-12) to 10 (IQR 7-12.5; P=.004) in high-level patients. Eighty-eight out of 113 patients (78%) were appropriate candidates for ITB device surgery, 75 of 88 (85%) proceeded to an implantation. A total of 69 adverse events occurred in 57 of 119 trials (48%), 37 of 69 (54%) were drug related, 32 of 69 (46%) were procedure related, and 42 of 69 (61%) were minor. The ITB device was implanted in 69 of 75 patients (92%) at last follow-up.

CONCLUSIONS

Continuous administration of ITB is an effective and useful alternative to ITB bolus application during ITB screening period. Half of the patients experienced adverse events; the majority were minor events.

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.

Intrathecal baclofen in paroxysmal sympathetic hyperactivity: Impact on oral treatment

INTRODUCTION

Intrathecal baclofen (ITB) is a commonly used treatment in severe spasticity. The main objective of this study was to assess the impact of ITB on reduction or withdrawal of oral drugs in patients with paroxysmal sympathetic hyperactivity (PSH) after severe traumatic brain injury.

METHODS

We retrospectively evaluated 20 patients with PSH due to severe traumatic brain injury who were treated with ITB in a primary care and referral center of neurology. Rates of and time until complete withdrawal or possible reduction in oral baclofen and oral propranolol after ITB treatment were calculated. Moreover, vegetative parameters (heart rate and blood pressure) as well as hypertonic attacks were assessed.

RESULTS

The median time of complete oral baclofen disposal was 5 ± 3.7 (CI 95% [2.9-7.1], range 0-14) days after ITB pump implantation in 20 of 20 patients, and the median time of complete oral propranolol disposal was 24 ± 62.97 (CI 95% [-7.87-55.87], range 5-191) in 15 of 20 patients. With ITB treatment, PSH improved promptly in all patients with alleviation of heart rate and blood pressure as well as reduction in attacks with motor phenomena. ITB treatment was safe and without complications.

CONCLUSIONS

ITB might facilitate cutting back or dispensing with other conventional oral drugs, such as oral baclofen and oral propranolol. Our study provides further evidence that ITB treatment should be considered in patients with otherwise medically refractory PSH in severe traumatic brain injury. Further prospective multicenter studies are needed to confirm the findings of this study.

Disorders of consciousness after severe brain injury: therapeutic options

PURPOSE OF REVIEW

Very few options exist for patients who survive severe traumatic brain injury but fail to fully recover and develop a disorder of consciousness (e.g. vegetative state, minimally conscious state).

RECENT FINDINGS

Among pharmacological approaches, Amantadine has shown the ability to accelerate functional recovery. Although with very low frequency, Zolpidem has shown the ability to improve the level of consciousness transiently and, possibly, also in a sustained fashion. Among neuromodulatory approaches, transcranial direct current stimulation has been shown to transiently improve behavioral responsiveness, but mostly in minimally conscious patients. New evidence for thalamic deep brain stimulation calls into question its cost/benefit trade-off.

SUMMARY

The growing understanding of the biology of disorders of consciousness has led to a renaissance in the development of therapeutic interventions for patients with disorders of consciousness. High-quality evidence is emerging for pharmacological (i.e. Amantadine) and neurostimulatory (i.e. transcranial direct current stimulation) interventions, although further studies are needed to delineate preconditions, optimal dosages, and timing of administration. Other exciting new approaches (e.g. low intensity focused ultrasound) still await systematic assessment. A crucial future direction should be the use of neuroimaging measures of functional and structural impairment as a means of tailoring patient-specific interventions.

Paroxysmal sympathetic hyperactivity: the storm after acute brain injury

A substantial minority of patients who survive an acquired brain injury develop a state of sympathetic hyperactivity that can persist for weeks or months, consisting of periodic episodes of increased heart rate and blood pressure, sweating, hyperthermia, and motor posturing, often in response to external stimuli. The unifying term for the syndrome-paroxysmal sympathetic hyperactivity (PSH)-and clear diagnostic criteria defined by expert consensus were only recently established. PSH has predominantly been described after traumatic brain injury (TBI), in which it is associated with worse outcomes. The pathophysiology of the condition is not completely understood, although most researchers consider it to be a disconnection syndrome with paroxysms driven by a loss of inhibitory control over excitatory autonomic centres. Although therapeutic strategies to alleviate sympathetic outbursts have been proposed, their effects on PSH are inconsistent between patients and their influence on outcome is unknown. Combinations of drugs are frequently used and are chosen on the basis of local custom, rather than on objective evidence. New rigorous tools for diagnosis could allow better characterisation of PSH to enable stratification of patients for future therapeutic trials.

Management of intrathecal baclofen therapy for severe acquired brain injury: consensus and recommendations for good clinical practice

Although widespread in the treatment of generalised spasticity due to severe acquired brain injury, clinical use of intrathecal baclofen administered through an implanted catheter is not yet supported by full scientific evidence. The aim of the study is to provide recommendations for good clinical practice regarding intrathecal baclofen therapy. We used a modified RAND Delphi method to develop consensus-based medical guidelines, involving clinicians who use intrathecal baclofen therapy throughout Italy. The clinicians were asked 38 questions grouped in six areas (patient selection, contraindications for implant, tests prior to implant, method of implant and management of therapy, efficacy evaluation and goal setting, and management of complications). To establish consensus, 75% agreement was required in answers to every question. Consensus was reached on the second round of the Delphi process on 27/38 questions (71%), specifically those regarding identification of objectives, efficacy evaluation, and method of implant and management of therapy, whereas management of complications and contraindications for implant remained critical areas. Despite the limits of our method, a set of recommendations was drawn up for clinical practice in this sector. The study also revealed residual critical areas and indicated future lines of research necessary to reach evidence-based consensus.

Paroxysmal sympathetic hyperactivity: Autonomic instability and muscle over-activity following severe brain injury

BACKGROUND

Children who suffer from moderate-to-severe brain injury can develop a complicating phenomenon known as paroxysmal sympathetic hyperactivity (PSH), characterized by autonomic instability and identified clinically as a cluster of symptoms that can include recurrent fever without a source of infection, hypertension, tachycardia, tachypnea, agitation, diaphoresis and dystonia. Studies with adults have demonstrated that this cluster of symptoms is associated with poorer clinical outcomes (prolonged hospitalizations, poorer cognitive and motor function). However, there have been limited studies in children with PSH.

OBJECTIVE

To present a literature review regarding PSH following severe brain injury and highlight research needs in children with PSH.

METHODOLOGY

Electronic databases (CINAHL, Ovid Medline, Web of Science and Google Scholar) were searched.

RESULTS

Thirty-one research articles met the criteria for inclusion. Several themes emerged regarding the phenomenon of interest during the review: nomenclature, symptoms, management and differences between children and adults.

IMPLICATIONS

The majority of the research regarding PSH following severe brain injury has been descriptive in nature. Few studies, however, have explored PSH in children with brain injury; therefore, little is known about whether the outcomes of children with PSH are different and, if so, in what ways.

Advances in intrathecal drug delivery

PURPOSE OF REVIEW

Targeted intrathecal drug delivery systems (IDDS) are an option in algorithms for the treatment of patients with moderate-to-severe chronic refractory pain. This article is intended to review the literature regarding IDDS published over the last year, with special attention to the Polyanalgesic Consensus Conference 2012.

RECENT FINDINGS

The recommendations made by the Polyanalgesic Consensus Conference 2012 are reviewed. Separate considerations of intrathecal drug therapy for neuropathic and nociceptive pain syndromes and the new concept of 'microdosing' are discussed in this article.

SUMMARY

This review includes the recommendations for the use of IDDS, trialing, and recent reports of complications (especially, the occurrence of granulomas). In addition, the latest documents on cerebrospinal fluid and potential lines of future development are discussed.

Treatment of severe, disabling spasticity with continuous intrathecal baclofen therapy following acquired brain injury: the experience of a tertiary institution in Singapore

INTRODUCTION

Intrathecal baclofen (ITB) therapy is a proven, effective treatment for disabling cortical spasticity. We describe the first local series of five patients with acquired brain injury (ABI) who received ITB and were followed up for 63.8 months.

METHODS

A retrospective review of medical and rehabilitation records of patients who received ITB therapy was carried out. Data studied included baseline demographic and injury variables, implantation data, spasticity and function, ITB dosage over time and complications.

RESULTS

From 2006 to 2010, a total of five patients received ITB therapy via implanted pumps about 39.4 months after ABI. Four out of five patients experienced significant reductions in their lower limb spasticity scores and improvements in global function and dependency. One patient had minor adverse events associated with baclofen-related sedation. The mean ITB dose at one year was 182.7 ± 65.6 mcg/day.

CONCLUSION

Our preliminary study showed encouraging long-term outcomes and safety for ITB therapy after ABI-related intractable spasticity. Individual ITB responses over time were variable, with gender differences. The outcomes experienced by our centre were comparable to those in the general ABI population, supporting the efficacy of ITB therapy for chronic disabling spasticity.

Treatment Progress of Paroxysmal Sympathetic Hyperactivity after Acquired Brain Injury

Paroxysmal sympathetic hyperactivity (PSH) is a common complication of various acquired brain injuries such as traumatic brain injury, subarachnoid hemorrhage, anoxic brain injury, intracerebral hemorrhage, and others. It is manifested by tachycardia, hypertension, tachypnea, diaphoresis, and dystonic posturing. The development of PSH can prolong hospitalization and lead to secondary brain injury and even death. Despite the awareness of the serious clinical impact, there is no consensus on diagnostic criteria. Thus, misdiagnosis and delayed recognition is very common. Most of the current treatment programs come from case reports and small case series; there are very few large-scale randomized controlled trials. Generally accepted medications are opioids, β-blockers and gabapentin (usually used in combination). However, the efficacy of these drugs has not been systematically assessed. The purpose of this review is to determine the treatment strategies and drugs commonly used for PSH at the overall level.

Intrathecal delivery of analgesics

Targeted intrathecal (IT) drug delivery systems (IDDS) are an option in algorithms for the treatment of patients with moderate to severe chronic refractory pain when more conservative options fail. This therapy is well established and supported by several publications. It has shown efficacy and is an important tool for the treatment of spasticity, and both cancer and nonmalignant pain. Recent technological advances, new therapeutic applications, reported complications, and the costs as well as maintenance required for this therapy require the need to stay up-to-date about new recommendations that may improve outcomes. This chapter reviews all technological issues regarding IDDS implantation with follow-up, and pharmacological recommendations published during recent years that provide evidence-based decision making process in the management of chronic pain and spasticity in patients.

Intrathecal baclofen associated with improvement of consciousness disorders in spasticity patients

OBJECTIVE

Intrathecal baclofen (ITB) pump is a therapeutic option for persistent vegetative state and minimal conscious state patients that have associated spasticity. We investigated whether this treatment modality can affect their level of consciousness.

METHOD

In this prospective, open label, observational study, we implanted ITB pumps for the treatment of spasticity in eight patients with disorders of consciousness (vegetative state and minimally conscious state) and we followed them with the Coma Recovery Scale-Revised, the Eastern Cooperative Oncology Group (ECOG) performance scale, and the Modified Ashworth spasticity scale. Baclofen dose and complications also were noted.

RESULTS

The offending pathologies were traumatic brain injury in six, anoxia due to cardiac arrest in one, acute obstructive hydrocephalus in one. Two of the patients showed a marked, persistent improvement that fulfilled the criteria of emergence from minimally conscious state. Two of patients had their ITB pumps prematurely removed because of complications. The ECOG score was 4 for all patients and did not change during the study.

CONCLUSION

ITB might be associated with a significant improvement in the disorder of consciousness of two patients from a total of six that had a chronic ITB treatment.

Role of Catheter's Position for Final Results in Intrathecal Drug Delivery. Analysis Based on CSF Dynamics and Specific Drugs Profiles

Intrathecal drug delivery is an effective and safe option for the treatment of chronic pathology refractory to conventional pain therapies. Typical intrathecal administered drugs are opioids, baclofen, local anesthetics and adjuvant medications. Although knowledge about mechanisms of action of intrathecal drugs are every day more clear many doubt remain respect the correct location of intrathecal catheter in order to achieve the best therapeutic result. We analyze the factors that can affect drug distribution within the cerebrospinal fluid. Three categories of variables were identified: drug features, cerebrospinal fluid (CSF) dynamics and patients features. First category includes physicochemical properties and pharmacological features of intrathecal administered drugs with special attention to drug lipophilicity. In the second category, the variables in CSF flow, are considered that can modify the drug distribution within the CSF with special attention to the new theories of liquoral circulation. Last category try to explain inter-individual difference in baclofen response with difference that are specific for each patients such as the anatomical area to treat, patient posture or reaction to inflammatory stimulus. We conclude that a comprehensive evaluation of the patients, including imaging techniques to study the anatomy and physiology of intrathecal environment and CSF dynamics, could become essential in the future to the purpose of optimize the clinical outcome of intrathecal therapy.