Intrathecal Baclofen for Severe Spasticity: Longitudinal Data From the Product Surveillance Registry

Complications of intrathecal baclofen therapy for spasticity: A single-centre cohort of 170 individuals

BACKGROUND

Intrathecal baclofen (ITB) therapy effectively reduces severe spasticity but is associated with complications that can be serious. The evolution of these complications over time and their predictive factors are not well known.

OBJECTIVES

The primary aim was to describe the incidence of ITB complications in adults with neurological disorders and disabling spasticity. The secondary aims were to describe the complications and the time-course of their incidence, to identify factors associated with complications, and to evaluate ITB effectiveness.

METHOD

We conducted a retrospective, single-centre, longitudinal observational study of data from people implanted with an ITB pump between 1995 and 2023. We calculated the incidence of complications overall and per category, and their evolution over the study period. Factors associated with complications were searched among demographic, clinical, device-related, and ITB dose characteristics. Effectiveness of ITB therapy was assessed using a goal-achievement scale.

RESULTS

Data from 170 individuals were included (1577 years of ITB therapy); 198 complications were reported. Complication incidence was 0.13 events per pump-year and rate was 0.63 events per implantation. 49 % of complications were device related, 31 % procedure related and 20 % drug related. Surgical intervention was required for 63 % of complications. The main risk factors were walking capacity with odds ratio (OR) 3.12 (95 % CI 1.14 to 9.10, P = 0.030), and pre-Ascenda catheters with OR 3.36 (95 % CI 1.28 to 9.10, P = 0.014). Synchromed II pumps were associated with a higher risk of procedure-related complications: OR 3.41 (95 % CI 1.14 to 12.12, P = 0.039). Complication incidence decreased continuously during the study period, mainly because of a reduction in the number of device-related complications. Goals were partially achieved in 51 % of participants and achieved in 37 %.

CONCLUSIONS

The incidence of complications associated with ITB therapy was high, and complications were mostly serious (requiring hospitalisation and/or life threatening). We recommend thorough examination of the benefits and risks of ITB therapy for each individual and systematic screening for dysfunctions at follow-up visits.

Research methodology: A bibliometric review using the spastic hand as an example

Bibliometric review involves systematically analysing the academic literature on a particular topic, enabling researchers to better understand the trajectory and future trends of a specific research field. This study uses various bibliometric tools to analyse relevant research on the spastic hand over the past two decades, aiming to identify key contributors, hotspots and emerging trends. The results show that early studies focused on cerebral palsy, stroke and botulinum toxin treatment, while recent advancements highlight surgical procedures such as neurectomy and soft tissue transfer. Future research should enhance international collaboration and the use of neuroimaging and electrophysiological techniques to gain a deeper understanding of the neural mechanisms underlying spasticity, optimize surgical procedures and explore novel treatments for spastic hand.

A Simplified Procedure for Intrathecal Baclofen Catheter Replacement Through a Granulation Tunnel Using a 16-Gauge Peripheral Vein Catheter

Intrathecal baclofen (ITB) therapy is an established surgical treatment for spasticity. Long-term management of ITB may necessitate catheter replacement, which typically requires a new dural puncture. Although rare, complications such as cerebrospinal fluid leakage, nerve injury, and hemorrhage can occur with a new dural puncture. We successfully replaced an intrathecal catheter of ITB through a granulation tunnel formed around the old catheter using a 16-gauge vein catheter, without the need for a new dural puncture. A 79-year-old man with spasticity resulting from cervical spinal cord infarction underwent ITB therapy and required intrathecal catheter replacement. During the replacement surgery, a 16-gauge indwelling peripheral vein catheter was inserted into the granulation tunnel around the old catheter, using the old catheter as a guide. After the old catheter was removed, the vein catheter remained in place, and a new intrathecal catheter was carefully introduced through the vein catheter. The catheter was successfully advanced into the subarachnoid space via the vein catheter and granulation tunnel, completing the procedure without any surgical complications. This technique can reduce the risks associated with dural puncture, lower radiation exposure, and decrease the overall surgical time.

Intrathecal baclofen pump in pregnancy: case report, literature review, and management considerations

BACKGROUND

Baclofen, a gamma-aminobutyric acid receptor type B agonist in the central nervous system, is the first-line medication among central nervous system modulating agents for the treatment of neurogenic muscle spasticity. While baclofen is most often administered enterally, patients with severe spasticity may be candidates for baclofen delivered by intrathecal pump. Currently, there are only nine studies reporting on the use of intrathecal baclofen (ITB) during pregnancy and childbirth.

CASE PRESENTATION

We described a female patient with a history of childhood idiopathic spasticity of the bilateral lower extremities that was controlled by ITB pump who became pregnant in her late third decade of life and delivered a healthy infant. The patient required multiple increases of her baclofen course over the course of her pregnancy.

DISCUSSION

Our case, alongside the existing literature on ITB during pregnancy, suggests that ITB therapy in pregnancy poses a low risk of teratogenicity and infant withdrawal seizures; however, larger, controlled studies are necessary to make those conclusions with confidence. Healthcare providers caring for pregnant ITB patients should be cognizant of the potential for such patients to require increased doses of ITB during pregnancy to achieve adequate symptom control.

Scar Tissue Catheter Tip Occlusion From an Intrathecal Baclofen Delivery: A Case Report and Review of the Literature

Intrathecal morphine is associated with the complication of catheter tip granuloma which causes symptoms of decreased pain control, increased required dose, and neurological deficit. Catheter tip granulomas from intrathecal baclofen are thought to never occur because of the mechanism by which intrathecal morphine causes granulomas. We present a case of an intrathecal baclofen induced scarring of a catheter tip with clinical characteristics similar to some symptoms of granuloma. A 66-year-old woman with multiple sclerosis induced spasticity was partially controlled with intrathecal baclofen delivery at an extremely high dose of 1638 micrograms per day. She presented in the hospital with symptoms of withdrawal from intrathecal baclofen and required an emergency revision of her baclofen pump. Replacement of the catheter demonstrated complete occlusion of the catheter tip by scar tissue. Following surgery, her spasticity was well-controlled at the much lower dose of 200 micrograms per day. Intrathecal baclofen delivery can cause catheter tip scarring which causes some symptoms similar to catheter tip granuloma. Early recognition of these signs of catheter tip occlusion could help prevent progression to withdrawal.

Traditional Lecture Versus Procedural Video Randomized Trial: Comparative Analysis of Instructional Methods for Teaching Baclofen Pump Management

OBJECTIVE

This study compared the effectiveness of traditional lectures and microvideos in teaching baclofen pump programming and refilling to physicians who have completed less than 10 refills for the previous 2 yrs.

DESIGN

A mixed-method approach was used with 60 participating physicians specializing in physical medicine and rehabilitation or pain management. Preintervention and postintervention assessments were conducted using a rubric, and the participants' perceptions and preferences were gathered through focus group sessions.

RESULTS

Two thirds of the participants specialized in physical medicine and rehabilitation. No significant differences in the preintervention, postintervention, or knowledge retention scores were found between the traditional lecture and microvideo groups. Both methods demonstrated comparable effectiveness in improving the baclofen pump refilling and programming skills. Qualitatively, participants perceived both approaches as equally helpful, but those in the microvideo group raised concerns because of instructors' unavailability and online platform navigation. Nevertheless, they preferred the convenience, accessibility, and time efficiency of the microvideos.

CONCLUSIONS

The study concluded that microvideos are an effective alternative to traditional lectures for acquiring knowledge on baclofen pump programming and refilling. Further research should consider learners' characteristics and investigate the benefits of blended learning in medical education.

Characteristics of Changes in Intrathecal Baclofen Dosage over Time due to Causative Disease

Intrathecal baclofen (ITB) therapy effectively treats spasticity caused by brain or spinal cord lesions. However, only a few studies compare the course of treatment for different diseases. We investigated the change in daily dose of baclofen per year and its associated adverse events in patients presenting with the three most common etiologies at our institute: hereditary spastic paraplegia, cerebral palsy, and spinal cord injury. The ITB pumps were implanted from July 2007 to August 2019, with a mean follow-up period of 70 months. In patients with hereditary spastic paraplegia, baclofen dosage was reduced after eight years following ITB introduction, and the treatment was terminated in one patient owing to disease progression. In patients with cerebral palsy, the dosage increased gradually, and became constant in the 11th year. Patients with spinal cord injury gradually increased their baclofen dosage throughout the entire observation period. Severity and adverse event rates were higher in patients with cerebral palsy than in others. The degree and progression of spasticity varied depending on the causative disease. Understanding the characteristics and natural history of each disease is important when continuing ITB treatment.

[Surgical procedures for treatment of spasticity]

BACKGROUND

The causes of spasticity are various and include cerebral palsy, spinal cord injury, stroke, multiple sclerosis or other congenital or acquired lesions of the central nervous system (CNS). While there is often a partial functional component, spasticity also results in varying degrees of impairment of the quality of life.

OBJECTIVE

A review of surgical treatment options for spasticity.

MATERIAL AND METHODS

A systematic PubMed review of the literature on epidemiology and treatment options with a focus on neurosurgical interventions for spasticity and developments in the last 20 years as well as inclusion of still valid older landmark papers was carried out. Illustration of indications, technique, follow-up, and possible pitfalls of the different methods for the surgical treatment of spasticity.

RESULTS

Depending on the affected region, the number of muscle groups, and the extent of spasticity, focal (selective peripheral neurotomy, nerve transfer), regional (selective dorsal rhizotomy), or generalized (baclofen pump) procedures can be performed. The indications are usually established by an interdisciplinary team. Conservative (physiotherapy, oral medications) and focally invasive (botulinum toxin injections) methods should be performed in advance. In cases of insufficient response to treatment or only short-term relief, surgical methods can be evaluated. These are usually preceded by test phases with, for example, trial injections.

CONCLUSION

Surgical methods are a useful adjunct in cases of insufficient response to conservative treatment in children and adults with spasticity.

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.

Neurosurgical management of elevated tone in childhood: interventions, indications and uncertainties

Elevated tone (hypertonia) is a common problem in children with physical disabilities. Medications intended to reduce tone often have limited efficacy, with use further limited by a significant side effect profile. Consequently, there has been growing interest in the application of Neurosurgical Interventions for the Management of Posture and Tone (NIMPTs). Three main procedures are now commonly used: selective dorsal rhizotomy (SDR), intrathecal baclofen (ITB) and deep brain stimulation (DBS). This review compares these interventions, along with discussion on the potential role of lesioning surgery. These interventions variably target spasticity and dystonia, acting at different points in the distributed motor network. SDR, an intervention for reducing spasticity, is most widely used in carefully selected ambulant children with cerebral palsy. ITB is more commonly used for children with more severe disability, typically non-ambulant, and can improve both dystonia and spasticity. DBS is an intervention which may improve dystonia. In children with certain forms of genetic dystonia DBS may dramatically improve dystonia. For other causes of dystonia, and in particular dystonia due to acquired brain injury, improvements following surgery are more modest and variable. These three interventions vary in terms of their side-effect profile and reversibility. There are currently populations of children for who it is unclear which intervention should be considered (SDR vs ITB, or ITB vs DBS). Concerns have been raised as to the equity of access to NIMPTs for children across the UK, and whether the number of surgeries performed each year meets the clinical need.

Evaluation of functional outcome and neurological recovery pattern in patients with retro-thecal tubercular epidural abscess managed at a tertiary center

We performed a retrospective observational study to analyze the neurological recovery pattern in patients with a sub-laminar retro-thecal epidural abscess managed at our tertiary apex center from 2014 to 2020. We evaluated the Maximal Spinal Cord Compression (MSCC) ratio on Magnetic Resonance Imaging (MRI), the time interval between the appearance of neurological deficit and the initiation of management, spasticity as per Modified Ashworth Scale, presence of drug resistance, and the Lower Extremity Motor Score (LEMS). All patients were given anti-tubercular chemotherapy. We surgically managed 8 patients of which 6 required decompression alone, while 2 patients required additional instrumentation. 2 patients were managed conservatively of which 1 responded favorably to conservative treatment while the other patient showed a worsening of neurology following the detection of drug resistance and abrupt discontinuation of chemotherapy. The mean LEMS on admission was 20.2, which improved to 38.5 at the end of 1 year (p-value <0.05). The patients in whom the time interval between the onset of neurological deficit and the initiation of management was fewer than 6 weeks showed better LEMS and milder or absent spasticity at follow-up (p-value <0.05). The MSCC ratio did not have a significant correlation with the LEMS (p-value >0.05).

Current Perspectives on the Diagnosis and Management of Healthcare-Associated Ventriculitis and Meningitis

Ventriculitis or post-neurosurgical meningitis or healthcare-associated ventriculitis and meningitis (VM) is a severe infection that complicates central nervous system operations or is related to the use of neurosurgical devices or drainage catheters. It can further deteriorate patients who have already presented significant neurologic injury and is associated with high morbidity, mortality, and poor functional outcome. VM can be difficult to distinguish from aseptic meningitis, inflammation that follows hemorrhagic strokes and neurosurgical operations. The associated microorganisms can be either skin flora or nosocomial pathogens, most commonly, Gram-negative bacteria. Classical microbiology can fail to isolate the culprit pathogen. Novel cerebrospinal fluid (CSF) biomarkers and molecular microbiology can fill the diagnostic gap and expedite pathogen identification and treatment. The pathogens may demonstrate significant resistant patterns and their antibiotic treatment can be difficult, as many important drug classes, including the beta-lactams and the glycopeptides, hardly penetrate to the CSF, and do not achieve therapeutic levels at the site of the infection. Treatment modifications, such as higher daily dose and prolonged or continuous administration, might increase antibiotic levels in the site of infection and facilitate pathogens clearance. However, in the case of therapeutic failure or infection due to difficult-to-treat bacteria, the direct antibiotic instillation into the CSF, in addition to the intravenous antibiotic delivery, may help in the resolution of infection. However, intraventricular antibiotic therapy may result in aseptic meningitis and seizures, concerning the administration of aminoglycosides, polymyxins, and vancomycin. Meanwhile, bacteria form biofilms on the catheter or the device that should routinely be removed. Novel neurosurgical treatment modalities comprise endoscopic evacuation of debris and irrigation of the ventricles. VM prevention includes perioperative antibiotics, antimicrobial impregnated catheters, and the implementation of standardized protocols, regarding catheter insertion and manipulation.

Targeted Drug Delivery for Chronic Nonmalignant Pain: Longitudinal Data From the Product Surveillance Registry

OBJECTIVES

To assist in assessment of therapy risks and benefits of targeted drug delivery (TDD) for chronic nonmalignant pain using registry data on product performance, adverse events, and elective device replacement.

MATERIALS AND METHODS

The Product Surveillance Registry (PSR) (NCT01524276) is an ongoing prospective, long-term, multicenter registry enrolling consented patients implanted with an intrathecal drug delivery system. Patients are followed prospectively with participating investigators providing pump and catheter performance data for events related to the device, procedure, and therapy. Event descriptions include patient symptoms and outcomes.

RESULTS

Registry data from the 4646 patients (59.7% female) treated with TDD for chronic, nonmalignant pain at 59 registry sites between August 2003 and October 2019, with over 17,000 patient-years (4646 patients with 44 months average follow-up), were analyzed. Registry discontinuation was largely (46.2% of discontinued patients) due to study site closure and patient death; exit due to an adverse or device event was limited to 10.2%.

CONCLUSIONS

Treating chronic pain with escalating doses of strong systemic opioids often leads to inconsistent pain control, impaired function, untenable side effects, and reduced quality of life and this practice has contributed to the current opioid crisis in the United States. TDD has been an available therapy for these patients for greater than 30 years, and data from this real-world registry offer supporting evidence to the long-term safety of this therapy as an alternative to systemic opioids, as well as insights into patient acceptance and satisfaction.

Characterization of standard work tools for intrathecal baclofen therapy

PURPOSE

Intrathecal baclofen (ITB) has been an effective therapy since the 1980s, with widely reported revision, infection, and complication rates. Publications targeting surgical workflow have resulted in decreased infection and revision rates, but a standard workflow for the entire pathway has not been described. To present, define, and test standard work tools for patients receiving ITB to promote uniformity and standard of care in the field.

METHODS

A multidisciplinary approach from the movement disorder program of a tertiary care center defined all steps comprising the ITB pathway, and then developed standard work tools to decrease variability with respect to preoperative workup, day of surgery protocol, post-operative care, and also evaluation and treatment with respect to pump infection or malfunction.

RESULTS

Defined steps used at specific points of ITB pathway are presented with a single institution's outcome using the protocol from July 2017 to November 2020. A total of 60 procedures were performed. The overall complication rate was 14.5% at 6 months. Complications included an infection rate of 3.6% at 6 months, wound revision rate of 1.8% at 6 months, CSF leak rate of 1.7% at 6 months, and a 30-day readmission rate related to initial surgery of 6.7%.

CONCLUSIONS

Workflow efficiency and optimization for ITB patients can be used to obtain lower complication rates compared to historical cohorts in literature. A single-center, retrospective review highlights this.

Spinal cord injury: A multisystem physiological impairment/dysfunction

Spinal cord injury (SCI) is a complex disease that affects not only sensory and motor pathways below the neurological level of injury (NLI) but also all the organs and systems situated below this NLI. This multisystem impairment implies comprehensive management in dedicated SCI specialized centers, by interdisciplinary and multidisciplinary teams, able to treat not only the neurological impairment, but also all the systems and organs affected. After a brief history of the Spinal Cord Medicine, the author describes how to determine the level and severity of a SCI based on the International Standards for Neurological Classification of Spinal Cord Injury and the prognosis factors of recovery. This article provides also a review of the numerous SCI-related impairments (except for urinary, sexual problems and pain treated separately in this issue), their principles of management and related complications.

Classifying Device-Related Complications Associated With Intrathecal Baclofen Pumps: A MAUDE Study

BACKGROUND

Intrathecal baclofen (ITB) is an effective treatment for spasticity, and therapeutic levels may be optimized using surgically implanted pumps. Though these devices are effective, complications can pose significant challenges to patients, decreasing the therapeutic effect and potentially requiring reoperation. As such, it is critical that complications associated with ITB be effectively characterized.

METHODS

We queried the Manufacturer and User Facility Device Experience (MAUDE) database for cases reported during the past 3 years documenting adverse events specifically related to ITB pumps. We identified 1935 adverse events that were individually analyzed and categorized by type of complication.

RESULTS

Out of the 1935 unique adverse events identified from the MAUDE database, 25.7% were device-related complications (n = 497). Of those, 50.3% were catheter-specific (n = 250), 21.3% (n = 106) were pump-specific, and 28.3% (n = 141) were included, more generally, in catheter or device erosion.

CONCLUSIONS

The MAUDE database may be a useful resource for evaluating ITB pump complications across a larger data set. By characterizing the complications and providing values for their total occurrences, patients and physicians may have more realistic expectations for the outcomes and morbidity of this device.