Patient management of cerebral origin spasticity with intrathecal baclofen

Surgical management of spasticity of cerebral origin in children

In children, spasticity is commonly seen in the context of cerebral palsy (CP), but also following head injury, cerebral infarct or other brain insults. CP is a wide term used to describe a constellation of symptoms that characterise the physical impairment of movement due to abnormal brain development. The management of spasticity is tailored according to the clinical picture of the child. Ambulatory mild spastic diplegics tend to reach the maximum of their disability in the first few years of life, and change little after the age of 5-7 years. Such patients who are between 3-5 years and who attempt to mobilise with walking frames are often good candidates for either dorsal rhizotomy or intrathecal baclofen (ITB) administration with the implantation of an indwelling pump. Non-ambulatory mild spastic diplegics and spastic quadriplegics have more profound spasticity, painful spasms, orthopaedic deformities, and difficulties with daily care and posture. ITB has become established as the first line of surgical treatment for these patients. In the last decade, there has been a definite trend away from ablative treatments and towards reversible stimulation and infusion systems. Current pumps have practical limitations but, in the next decade, it is anticipated that technological improvements will render the pumps more patient friendly.

Cost-effectiveness of intrathecal baclofen therapy for the treatment of severe spasticity associated with cerebral palsy

Spasticity is relatively common among children with cerebral palsy. This condition can be painful, can severely impair a child's ability to perform basic tasks, and can place an enormous emotional and financial burden on the family. Intrathecal baclofen delivered via an implantable pump is an effective treatment option for children unresponsive to oral medication and needing generalized motor control. However, the initial investment for the delivery device and its surgical placement can be a barrier to access. A cost-effectiveness analysis of intrathecal baclofen for adults in the British health care system concluded that intrathecal baclofen offered good value for the money. No similar analysis of intrathecal baclofen has been conducted in the context of the US health care system, and no study has specifically examined cost-effectiveness of intrathecal baclofen in a pediatric population. The aim of this article is to assess the cost-effectiveness of intrathecal baclofen among children with severe spasticity of cerebral origin who have not responded to less invasive treatments such as oral medications relative to alternative medical and surgical therapy. The authors used mathematical modeling and computer simulation to estimate the incremental cost per quality-adjusted life-year for identical cohorts of children treated with intrathecal baclofen or alternative therapy over a 5-year episode of treatment. Data on treatment costs representative of these children were derived from a health insurance claims database that included both commercial and Medicaid data. Utility values used to construct quality-adjusted life-years were obtained from a panel of expert clinicians who used the Health Utilities Index-2 to rate health states associated with the course of treatment. On average, intrathecal baclofen therapy increased the 5-year cost of treatment by $49 000 relative to alternative treatment. However, this was accompanied by an average gain of 1.2 quality-adjusted life-years. The net result was an incremental cost-effectiveness ratio of $42 000 per quality-adjusted life-year, a figure well within the $50 000 to $100 000 range that is widely accepted as offering good value for the money.

Intrathecal baclofen for the treatment of spasticity of cerebral origin

Nurses monitoring children receiving intrathecal baclofen therapy can assist with management of these patients by being aware of possible complications related to a change in tone, medication withdrawal, or overdose. The tone management team relies on family care providers, school nurses, ambulatory clinic nurses, and outside physical and occupational therapists to provide information and updates on changes in patient status as needed. Close collaboration and communication regarding the child and his/her response to ITB is essential to providing safe and effective care for this challenging population of patients.

Management options for the child with spastic cerebral palsy

Knowledge of spasticity management for the child with cerebral palsy begins with understanding how cerebral palsy and spasticity are defined and related. The next step is learning what the treatment options are and how they can impact the child. There are many strategies for managing spasticity. This article focuses on pharmacologic and surgical approaches. Pharmacologic is further subdivided into medications taken by mouth, given through an injection (Botox) or delivered by a pump (baclofen). Surgery includes neurosurgical and orthopaedic procedures. Each treatment is reviewed using rationale, patient selection, delivery methodology, and management technique citing the advantages and disadvantages of each modality.