Intrathecally administered baclofen for treatment of children with spasticity of cerebral origin

Intrathecal baclofen efficacy for managing motor function and spasticity severity in patients with cerebral palsy: a systematic review and meta-analysis

BACKGROUND

Spasticity can significantly affect a patient's quality of life, caregiver satisfaction, and the financial burden on the healthcare system. Baclofen is one of only a few options for treating spasticity. The purpose of this study is to investigate the impact of intrathecal baclofen (ITB) therapy on severe40.23 spasticity and motor function in patients with cerebral palsy.

METHODS

We conducted a systematic review in PubMed, Scopus, Ovid, and the Cochrane Library in accordance with the PRISMA guidelines. We included studies based on eligibility criteria that included desired participants (cerebral palsy patients with spasticity), interventions (intrathecal baclofen), and outcomes (the Ashworth scales and the Gross Motor Function Measure [GMFM]). The within-group Cohen's d standardized mean differences (SMD) were analyzed using the random effect model.

RESULTS

We screened 768 papers and included 19 in the severity of spasticity section and 6 in the motor function section. The pre-intervention average spasticity score (SD) was 3.2 (0.78), and the post-intervention average score (SD) was 1.9 (0.72), showing a 40.25% reduction. The SMD for spasticity reduction was - 1.7000 (95% CI [-2.1546; -1.2454], p-value < 0.0001), involving 343 patients with a weighted average age of 15.78 years and a weighted average baclofen dose of 289 µg/day. The SMD for the MAS and Ashworth Scale subgroups were - 1.7845 (95% CI [-2.8704; -0.6986]) and - 1.4837 (95% CI [-1.8585; -1.1088]), respectively. We found no relationship between the participants' mean age, baclofen dose, measurement time, and the results. The pre-intervention average GMFM (SD) was 40.03 (26.01), and the post-intervention average score (SD) was 43.88 (26.18), showing a 9.62% increase. The SMD for motor function using GMFM was 0.1503 (95% CI [0.0784; 0.2223], p-value = 0.0030), involving 117 patients with a weighted average age of 13.63 and a weighted average baclofen dose of 203 µg/day. In 501 ITB implantations, 203 medical complications were reported, including six new-onset seizures (2.96% of medical complications), seven increased seizure frequency (3.45%), 33 infections (16.26%), eight meningitis (3.94%), and 16 cerebrospinal fluid leaks (7.88%). Delivery system complications, including 75 catheter and pump complications, were also reported.

CONCLUSION

Despite the risk of complications, ITB has a significant impact on the reduction of spasticity. A small but statistically significant improvement in motor function was also noted in a group of patients.

Utilizing combination intrathecal baclofen and analgesic medication to manage spasticity and pain in patients with pediatric-onset disability: Case series

PURPOSE

The use of intrathecal medications for the management of spasticity and various pain syndromes in the adult population has been previously reported. However, no evidence-based guidelines currently exist in the pediatric population. This case series presents patients (n = 8) with pediatric-onset disability who underwent placement of intrathecal baclofen pumps initially for management of severe spasticity. Despite titration of dose and use of oral analgesia, their uncontrolled pain persisted. Each patient was transitioned to a combination of baclofen and analgesic intrathecal therapy. The outcome in pain improvement and quality of life, as reported by patients and/or caregivers, were retrospectively reviewed.

METHODS

Retrospective review of the background and decision-making process regarding transition to combination intrathecal therapy identified patient selection characteristics. Each patient and/or their caregivers completed a survey regarding improvements in pain, spasticity, function, and quality of life following initiation of combination intrathecal medications.

RESULTS

Survey results revealed improvements in functional and pain assessments after initiation of combination baclofen and analgesic intrathecal medication. Patients and caregivers reported decreases in pain and oral spasticity medications.

CONCLUSION

Use of pumps with antispasmodic and analgesic medication for combination intrathecal medication delivery should be considered in the management of patients with childhood-onset disabilities who have both severe spasticity and pain.

Spasticity and movement disorders in cerebral palsy

PURPOSE

To review the neurosurgical treatments of children with movement disorders associated with cerebral palsy (CP) during the previous decades, up to the present day.

METHODS

An extensive literature review was undertaken to identify important publications about this subject. My experience treating children with these disorders over the past three decades was included in the individual sections.

RESULTS

Peripheral neurotomies have been developed for children with focal spasticity. For those with spastic paraparesis, selective lumbar rhizotomies were developed, and for those with spastic quadriparesis, intrathecal baclofen infusions were developed. Both effectively alleviate spasticity in the affected extremities. Generalized dystonia associated with CP has been treated with deep brain stimulation with mild improvement, but treatment with intrathecal baclofen and intraventricular baclofen improve those movements markedly. No effective treatment has been reported for children with athetoid CP. For those with choreiform CP, deep brain stimulation may be effective but intrathecal baclofen does not appear to be.

CONCLUSION

Treatment of children with movement disorders associated with CP increased slowly in the 1970s and 1980s but accelerated rapidly in the 1990s with the introduction of lumbar dorsal rhizotomies and intrathecal baclofen. In the last 30 years, tens of thousands of children with spasticity and movement disorders associated with CP have been treated by pediatric neurosurgeons, and their care has become an integral component of current pediatric neurosurgical practice.

Oculo-dento-digital Dysplasia Presenting as Spastic Paraparesis Which Was Successfully Treated by Intrathecal Baclofen Therapy

A 42-year-old man with a history of migraine and bilateral syndactyly presented with numbness of the extremities and shaking legs, which thus prevented him from working as a carpenter. A neurological examination revealed spastic paraparesis with pathological reflexes on all four extremities. Oculo-dento-digital dysplasia (ODDD) was suspected based on his medical history and characteristic facial appearance including small eye slits, thin mouth, and pinched nose with anteverted nostrils. Genetic tests revealed a gap junction alpha 1 (GJA1) gene mutation and confirmed the diagnosis of ODDD. His spastic paraparesis was resistant to oral antispastic medication, however, his symptoms successfully improved after the initiation of intrathecal baclofen therapy, which thus allowed him to return to work.

Intrathecal baclofen, selective dorsal rhizotomy, and extracorporeal shockwave therapy for the treatment of spasticity in cerebral palsy: a systematic review

Cerebral palsy (CP) is a chronic congenital disorder as the result of abnormal brain development. Children suffering from CP often battle debilitating chronic spasticity, which has been the focus of recent academic literature. In this systematic review, the authors aim to update the current neuromodulation procedures for the treatment of spasticity associated with CP in all age groups. A systematic review following was conducted using PubMed from inception to 2020. After initial title and abstract screening, 489 articles were identified, and 48 studies met the inclusion criteria for this review. In total, a majority of the published articles of treatments for CP were reporting the use of selective dorsal rhizotomy (SDR) (54%), and the remainder were of intrathecal baclofen (ITB) pumps (29%) and extracorporeal shockwave therapy (ESWT) (17%). Each method was found to have improvement of spasticity at a rate that achieved statistical significance. ITB pump therapy is an all-encompassing method of treating spasticity in children from CP, as it allows for a less invasive treatment that can be titrated to individual patient needs; however, its disadvantages include its long-term maintenance requirements. SDR appears to be an effective method for permanent spasticity relief in young patients. ESWT is a more recent and innovative technique for offering relief of spasticity while being minimally invasiveness. Further studies are needed to establish optimal frequencies and sites of application for ESWT.

Complications After Dual Placement of a Baclofen Pump and Ventricular Shunt in Individuals With Severe Brain Injury

Objective

To assess the complications of dual placement of an intrathecal baclofen (ITB) pump and a ventriculoperitoneal shunt (VPS) in people with severe brain injury.

Design

Case series.

Setting

Referral center, ambulatory, and hospitalized care.

Participants

Referred sample (N=9) composed of 5 men and 4 women with severe brain injuries (5 traumatic brain injuries, 3 subarachnoid hemorrhages, 1 intracerebral hemorrhage) and a mean disease duration of 6±4.5 years (range, 0.5-11.4y).

Intervention

Both systems (ie, an ITB device and a VPS system) were implanted in all participants.

Main Outcome Measures

We assessed the number and type of complications that occurred after implantation of the second system, as well as subsequent interventions.

Results

The ITB delivery system was implanted after the VPS system in 5 patients (ITB group), and the VPS system was the second implanted system in 4 groups (VPS group). Seven complications occurred in 7 patients after implantation of the second system, 4 in the ITB group and 3 in the VPS group. Three of the complications were drug-related, 2 were procedure-related, and 2 were device-related. The complication occurred within 4 days after implantation of the second system in 6 patients.

Conclusions

Complications are frequent in patients who undergo implantation of both an ITB delivery device and a VPS system. Drug-related complications were more common. Complications occurred more often when an ITB device was implanted as the second system. The critical period is the first 4 days.

The use of opioids in children receiving intrathecal baclofen therapy

PURPOSE

We hypothesized that children on chronic intrathecal baclofen therapy (ITB) may require less analgesics for postoperative pain control and are at higher risk of developing opioid-induced respiratory depression postoperatively. The aims of this study are to review children on chronic intrathecal baclofen therapy receiving opioids after major surgery and to determine the incidence complications in this population.

METHOD

We conducted a retrospective cohort study comparing 13 children on ITB, who underwent posterior spinal fusion surgery, to 17 children with spina bifida that received the same surgery.

RESULTS

On postoperative day 0 (POD 0), four children (40%) had respiratory depression in the baclofen group compared to none in the control group. Desaturation was significantly more frequent in children in the ITB group compared to those of the control group on POD 0; oversedation was recorded in 8 (80%) children in the baclofen group vs. 3 (17.6%) in the control group. Desaturation, respiratory depression, and oversedation were significantly more frequent on POD 0 in children in the baclofen group compared with children in the control group.

CONCLUSIONS

The findings of the current study suggest that children on chronic intrathecal baclofen therapy require lesser amounts of opioids for postoperative pain control and are at a greater risk of developing postoperative respiratory depression and excessive sedation compared to patients without baclofen therapy.

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.

Simultaneous explantation and implantation of intrathecal pumps: a case series

OBJECTIVE

Intrathecal drug delivery devices (IDDDs) are a mainstay in the treatment of spasticity and refractory pain. While these devices have been shown to greatly improve the quality of life for patients, they also have a high perioperative complication and failure rate. A major complication of IDDD implantation is infection. The current standard of care in the treatment of IDDD infection necessitates that the pump be explanted and the infection treated prior to implantation of a new IDDD. This process leads to long hospital stays, interruptions in optimal medical management, and a high risk for dangerous drug withdrawals. The authors describe a technique that allows for the explantation of the infected pump and implantation of a new pump concurrently, which they have named the "Turner Switch" technique in honor of its inventor.

METHODS

The authors conducted a retrospective analysis of cases of infected IDDDs in which patients underwent simultaneous explantation of the infected pump and implantation of a new pump. Demographics and clinical data were collected.

RESULTS

Data from a total of 17 patients (11 male, 6 female) who underwent simultaneous IDDD explantation and implantation to treat infections were analyzed from a 3-year period. No patients experienced infection of the newly implanted pump or catheter. Of the 17 patients, 14 (82.4%) had baclofen pumps to treat spasticity and 3 (17.6%) had fentanyl pumps to treat chronic pain. The median hospital stay was 7 days, with 16 of 17 (94.1%) patients able to be discharged home or to a facility with a level of care similar to their preoperative care. All patients ultimately experienced complete resolution of their initial infections. Five patients (29.4%) required a return to the operating room within the next 5 months (for repair of a CSF leak in 2 cases, for treatment of infection at the old pump site in 2 cases, and for treatment of a CSF leak compounded with infection in 1 case). No patient experienced infection of the newly implanted pump or catheter.

CONCLUSIONS

IDDD infections represent a large portion of morbidity associated with these devices. The current standard of care for deep pump infections requires pump explantation and a course of antibiotics prior to reimplantation of the IDDD. The authors demonstrate the effectiveness of a procedure involving simultaneous explantation of an infected pump and implantation of a new pump on the contralateral side in the treatment of IDDD infections.

Effect of continuous intrathecal baclofen therapy in children: a systematic review

AIM

To investigate the effects of continuous intrathecal baclofen (ITB) therapy in children with cerebral palsy (CP) and other neurological conditions.

METHOD

This systematic review was conducted using standardized methodology, searching four electronic databases (PubMed, Embase, CINAHL, Cochrane Library) for relevant literature published between inception and September 2017. Included studies involved continuous ITB as an intervention and outcome measures relating to all International Classification of Functioning, Disability and Health: Children and Youth (ICF-CY) components.

RESULTS

Thirty-three studies were identified, of which one, including 17 children with spastic CP, produced level II evidence, and the others, mainly non-controlled cohort studies, level IV and V. Outcomes at body function level were most frequently reported. Results suggest continuous ITB may be effective in reducing spasticity and dystonia in CP, as well as other neurological conditions, and may improve the ease of care and quality of life of children with CP, but the level of evidence is low.

INTERPRETATION

Despite three decades of applying ITB in children and a relatively large number of studies investigating the treatment effects, a direct link has not yet been demonstrated because of the low scientific quality of the primary studies. Further investigation into the effects of continuous ITB at all levels of the ICF-CY is warranted. Although large, controlled trials may be difficult to realize, national and international collaborations may provide opportunities. Also, multicentre prospective cohort studies with a long-term follow-up, employing harmonized outcome measures, can offer prospects to expand our knowledge of the effects of continuous ITB therapy in children.

WHAT THIS PAPER ADDS

There is low-level evidence for continuous intrathecal baclofen (ITB) in children with cerebral palsy. Continuous ITB is effective in reducing spasticity and dystonia in non-controlled cohort studies. Evaluation of individual goals and systematic assessment of long-term effects in large cohort studies are required.

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.

Pain Management in Athletes With Impairment: A Narrative Review of Management Strategies

OBJECTIVE

To review the literature related to different treatment strategies for the general population of individuals with amputation, spinal cord injury, and cerebral palsy, as well as how this may impact pain management in a correlated athlete population.

DATA SOURCES

A comprehensive literature search was performed linking pain with terms related to different impairment types.

MAIN RESULTS

There is a paucity in the literature relating to treatment of pain in athletes with impairment; however, it is possible that the treatment strategies used in the general population of individuals with impairment may be translated to the athlete population. There are a wide variety of treatment options including both pharmacological and nonpharmacological treatments which may be applicable in the athlete.

CONCLUSIONS

It is the role of the physician to determine which strategy of the possible treatment options will best facilitate the management of pain in the individual athlete in a sport-specific setting.

Eleven years' experience with Intrathecal Baclofen - Complications, risk factors

OBJECTIVE

Treatment with intrathecal baclofen (ITB) is commonly used in patients with severe spasticity. However, complications may occur after implantation of the ITB-device, albeit mainly procedure- and device-related problems. The aim of the study was to assess surgical- as well as catheter- and pump-related complications and define their risk factors.

METHODS

We retrospectively evaluated all patients with an implanted ITB-device who were treated at the Department of Neurology, Hochzirl Hospital, Zirl, Austria, between 2006 and 2016.

RESULTS

Twenty-nine of 116 (25%) patients experienced 32 complications: 5 procedure- and 27 device-related (4 pump- and 23 catheter-associated) problems occurred. Risk factors for sustaining any complication were a spinal localization of lesion (odds ratio [OR] OR 2.71, p = .021), other catheter types than an Ascenda^® catheter (OR 3.87, p = .041), a lower modified Rankin Scale (median 4 vs. 5; OR 2.86, p = .015) and a higher Barthel Index (median 53 vs. 0; OR 2.84, p = .006). The median time from the last ITB-related surgery to the first complication was 18 (IQR 1-57) months. Overall, 47% complications occurred within the first year after any surgical procedure regarding the ITB-device, thereof 25% within the first month.

CONCLUSIONS

Procedure- and device-related complications are frequent after implantation of an ITB-device with catheter-associated complications as the most frequently encountered problems. Patients with a spinal origin of spasticity, a lower modified Rankin Scale and a higher Barthel Index have a higher risk to sustain a complication.

Intrathecal Baclofen Therapy Prior to Spinal Fusion for Patients With Gross Motor Function Classification System IV-V Cerebral Palsy

BACKGROUND

Patients with Gross Motor Function Classification System (GMFCS) IV-V cerebral palsy (CP) have significant spasticity and frequently develop scoliosis. Intrathecal baclofen (ITB) pumps are effective in managing spasticity. The effect of ITB therapy on the postoperative course following spinal fusion in patients with GMFCS IV-V CP has not been described. This study sought to compare postoperative recovery, including complications, in patients using ITB therapy with those with no ITB therapy.

PURPOSE

Evaluate the effect of ITB on the postoperative recovery for patients with GMFCS IV-V CP who undergo spinal fusion for scoliosis.

METHODS

Health records for patients with GMFCS IV-V CP who underwent a spinal fusion for scoliosis at a major quaternary-care children's hospital from January 2009 to October 2015 were reviewed and relevant data were abstracted. Descriptive statistics and regression models were used to compare patients.

RESULTS

Sixty-nine patients were included-19 ITB therapy and 50 no ITB therapy. Demographic and operative characteristics were similar across groups. The mean length of stay for patients in the ITB therapy group was 11.2 days and 14.3 days for the no ITB therapy group, with no difference between groups (p = .12). Pain scores in both groups decreased at the same rate, with scores in the ITB therapy group averaging one-half point lower (p = .32). The average amount of morphine equivalents (p = .71) and benzodiazepine equivalents (p = .53) used were similar between groups. Complication rates were significantly different between groups. Four (21%) of the ITB therapy patients had 1 or more complications whereas 28 (56%, p = .01) in the no ITB therapy group had 1 or more complications. The average number of complications per patient in the ITB therapy group was 0.3 (SD: 0.075, range: 0-3) and the no ITB therapy group was 1.1 (SD: 1.1, range: 0-6, p = .01).

CONCLUSIONS

There was no significant difference in length of stay, pain scores, or pain/spasticity medication use between groups after spinal fusion, but there was a significantly lower incidence of complications in the ITB therapy group.

Interventions for managing skeletal muscle spasticity following traumatic brain injury

BACKGROUND

Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI.

OBJECTIVES

To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI.

SEARCH METHODS

In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Data were synthesised narratively; meta-analysis was precluded due to the paucity and heterogeneity of data.

MAIN RESULTS

We included nine studies in this review which involved 134 participants with TBI. Only five studies reported between-group differences, yielding outcome data for 105 participants with TBI. These five studies assessed the effects of a range of pharmacological (baclofen, botulinum toxin A) and non-pharmacological (casting, physiotherapy, splints, tilt table standing and electrical stimulation) interventions, often in combination. The studies which tested the effect of baclofen and tizanidine did not report their results adequately. Where outcome data were available, spasticity and adverse events were reported, in addition to some secondary outcome measures.Of the five studies with results, three were funded by governments, charities or health services and two were funded by a pharmaceutical or medical technology company. The four studies without useable results were funded by pharmaceutical or medical technology companies.It was difficult to draw conclusions about the effectiveness of these interventions due to poor reporting, small study size and the fact that participants with TBI were usually only a proportion of the overall total. Meta-analysis was not feasible due to the paucity of data and heterogeneity of interventions and comparator groups. Some studies concluded that the intervention they tested had beneficial effects on spasticity, and others found no difference between certain treatments. The most common adverse event was minor skin damage in people who received casting. We believe it would be misleading to provide any further description of study results given the quality of the evidence was very low for all outcomes.

AUTHORS' CONCLUSIONS

The very low quality and limited amount of evidence about the management of spasticity in people with TBI means that we are uncertain about the effectiveness or harms of these interventions. Well-designed and adequately powered studies using functional outcome measures to test the interventions used in clinical practice are needed.

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.

Intrathecal baclofen pump infection treated by adjunct intrareservoir teicoplanin instillation

Background:

The delivery of intrathecal baclofen via pumps is gaining increasing use in the management of intractable spasticity. One of the rare but devastating complications of this method is infection. In the majority of cases, removal of the device is required, despite appropriate intravenous antibiotic therapy. We report a case that highlights the use of intrareservoir teicoplanin to achieve sterilization of the infected pump system in a patient in whom removal of the pump was not an easy option.

Case Description:

We describe our experience on a patient with cerebral palsy in whom Staphylococcus epidermidis pump infection developed due to contamination of the infusion reservoir during refilling procedure, which was successfully sterilized in situ by the combined use of systemic antibiotics and intrareservoir coadministration of baclofen with teicoplanin. The infection was eradicated and baclofen therapy was continued uninterrupted.

Conclusions:

Removal of intrathecal baclofen pump is not necessary as the first measure in cases with mild clinical symptomatology. In view of the fact that pumps for intrathecal drug delivery are very costly, salvage of the device may be attempted in selected cases, although it is not generally recommended. Combined infusion of baclofen and an antibiotic through the pump makes it possible to maintain treatment for spasticity, sterilize the pump reservoir and flow tubes, and effectively treat infections that develop during the use of these systems.

Baclofen in the Therapeutic of Sequele of Traumatic Brain Injury: Spasticity

Traumatic brain injury (TBI) is an alteration in brain function, caused by an external force, which may be a hit on the skull, rapid acceleration or deceleration, penetration of an object, or shock waves from an explosion. Traumatic brain injury is a major cause of morbidity and mortality worldwide, with a high prevalence rate in pediatric patients, in which treatment options are still limited, not available at present neuroprotective drugs. Although the therapeutic management of these patients is varied and dependent on the severity of the injury, general techniques of drug types are handled, as well as physical and surgical. Baclofen is a muscle relaxant used to treat spasticity and improve mobility in patients with spinal cord injuries, relieving pain and muscle stiffness. Pharmacological support with baclofen is contradictory, because disruption of its oral administration may cause increased muscle tone syndrome and muscle spasm, prolonged seizures, hyperthermia, dysesthesia, hallucinations, or even multisystem organ failure. Combined treatments must consider the pathophysiology of broader alterations than only excitation/inhibition context, allowing the patient's reintegration with the greatest functionality.

Intrathecal baclofen pumps do not accelerate progression of scoliosis in quadriplegic spastic cerebral palsy

PURPOSE

To compare scoliosis progression in quadriplegic spastic cerebral palsy with and without intrathecal baclofen (ITB) pumps.

METHODS

A retrospective matched cohort study was conducted. Patients with quadriplegic spastic cerebral palsy, GMFCS level 5, treated with ITB pumps with follow-up >1 year were matched to comparable cases by age and baseline Cobb angle without ITB pumps. Annual and peak coronal curve progression, pelvic obliquity progression and need for spinal fusion were compared.

RESULTS

ITB group: 25 patients (9 female), mean age at pump insertion 9.4 and Risser 0.9. Initial Cobb angle 25.6° and pelvic tilt 3.2°. Follow-up 4.3 (1.0-7.8) years. Cobb angle at follow-up 76.1° and pelvic tilt 18.9°. Non-ITB group: 25 patients (14 female), mean age at baseline 9.2 and Risser 1.0. Initial Cobb angle 29.7° and pelvic tilt 7.1°. Follow-up 3.5 (1.0-7.5) years. Cobb angle at follow-up 69.1° and pelvic tilt 21.0°. The two groups were statistically similar for baseline age, Cobb angle and Risser grade. Mean curve progression was 13.6°/year for the ITB group vs 12.6°/year for the non-ITB group (p = 0.39). Peak curve progression was similar between the groups. Pelvic tilt progression was comparable; ITB group 4.5°/year vs non-ITB 4.6°/year (p = 0.97). During follow-up 5 patients in the ITB group and 9 in the non-ITB group required spinal fusion surgery for curve progression (p = 0.35).

CONCLUSIONS

Patients with quadriplegic spastic cerebral palsy with and without ITB pumps showed significant curve progression over time. ITB pumps do not appear to alter the natural history of curve progression in this population.

Long-term follow-up for lumbar intrathecal baclofen catheters placed using the paraspinal subfascial technique

OBJECT Intrathecal baclofen (ITB) is a valuable therapeutic option for patients with spasticity and dystonia. The techniques that place an ITB pump catheter into the subcutaneous fat of a lumbar incision are well described. Because patients who require ITB often have low body fat content, they may be predisposed to catheter-related complications. The senior author used a novel technique to place the catheter in a paraspinal subfascial fashion, and the short-term results were previously published. That study demonstrated no development of hardware erosions, catheter migrations, or CSF leaks within an average follow-up of 5 months. This study followed up on those initial findings by looking at the long-term outcomes since this technique was introduced. METHODS Using the institutional review board-approved protocol, the electronic medical records were reviewed retrospectively for all patients who underwent paraspinal subfascial catheter placement by the senior author. Patients received follow-up with the surgeon at 2 weeks postoperatively and were followed routinely by their physiatrist thereafter. RESULTS Of the 43 patients identified as having undergone surgery by the senior author using the paraspinal subfascial technique between July 2010 and February 2014, 12 patients (27.9%) required reoperation. There were 5 patients (11.6%) who had complications related to the catheter or lumbar incision. No hardware erosions or CSF leaks were identified. These patients received a median follow-up of 3.0 years, with 30 of 43 patients receiving follow-up over 2.0 years. CONCLUSION This follow-up study suggests that the technique of paraspinal subfascial catheter placement translates to long-term decreases in CSF leakage and complications from erosion, infection, and also catheter malfunctions. It does not seem to affect the overall rate of complications.

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.

Epidural Baclofen for the Management of Postoperative Pain in Children With Cerebral Palsy

INTRODUCTION

Children with cerebral palsy undergoing soft tissue and bony procedures often experience pain and spasticity postoperatively. Differentiation of pain from spasticity complicates management, so controlling spasticity with a continuous infusion of baclofen, an antispasmodic, through an already present indwelling epidural catheter holds interest.

METHODS

A retrospective chart review was performed of patients with cerebral palsy undergoing single event, multilevel lower extremity surgery at a single institution who received epidural analgesia with or without continuous baclofen infusion. Primary outcomes included need for supplemental narcotic analgesics and benzodiazepines postoperatively. Duration of hospitalization, pain scores, and complications were also evaluated.

RESULTS

Forty-four patients were identified, ranging in age from 3 to 17 years, 19 of whom received epidural baclofen. No differences were found in use of supplemental narcotic analgesia, benzodiazepines, or duration of hospitalization. Differences in pain scores were not statistically significant (0.82±0.95 for baclofen vs. 1.48±0.99 for controls) (P=0.391). Mean arterial pressure was lower in patients receiving baclofen (P=0.004). No potential side effects attributable to baclofen were noted.

CONCLUSIONS

Continuous epidural baclofen infusion seems unlikely to alter the pain-spasm cycle experienced by patients with cerebral palsy following orthopaedic surgery to a clinically significant degree. More effective, and cost-effective, measures at assessing and controlling pain and muscle spasm should be explored to benefit cerebral palsy patients postoperatively.

LEVEL OF EVIDENCE

Level III-therapeutic study.

The need for and provision of intrathecal baclofen therapy for the management of spasticity in England: an assessment of the Hospital Episode Statistics database

OBJECTIVES

The aim of this study was to evaluate changes in the uptake of intrathecal baclofen (ITB) following commissioning of this therapy by the National Health Service (NHS) England in April 2013. The specific objectives of this study were: (i) to explore the gap between the need for and the actual provision of ITB services; and (ii) to compare England figures with other European countries with comparable data available.

SETTING

Data for ITB -related procedures were obtained from the Hospital Episode Statistics (HES) database from 2009/2010 to 2013/2014.

PARTICIPANTS

Patients receiving ITB for the management of spasticity.

RESULTS

The available data for implantation of ITB from 2009/2010 to 2013/2014 for the treatment of spasticity due to varied aetiologies show that there has not been an increase in uptake of this therapy. The estimated need for this treatment based on the incidence and prevalence of conditions susceptible to ITB therapy is between 4.6 and 5.7 per million population. Our analysis of the data available from the HES database showed that the actual number of implants is around 3.0 per million population. The same period 2009-2014 has seen an increase in the delivery of other neuromodulation techniques including spinal cord stimulation, deep brain stimulation and sacral nerve stimulation.

CONCLUSIONS

There is a considerable gap between the need for and provision of ITB figures nationally. Additionally, within the same area, we have observed important differences in the ITB service delivery between the various trusts. The reasons for this can be multifactorial, including individual experience and opinions, organisational structures, resource and financial limitations. Further research analysing the efficacy and cost-effectiveness of this treatment in the UK might inform the development of Technology Appraisal Guidance for ITB, potentially leading to an improvement in service provision.

Although inconvenient, baclofen pumps do not complicate scoliosis surgery in patients with cerebral palsy

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To compare patients with operative cerebral palsy with and without an intrathecal baclofen pump (ITB) to determine whether an ITB increases the complexity of scoliosis surgery and/or increases the risk of wound complications.

SUMMARY OF BACKGROUND DATA

Options for baclofen pump placement include before, during, or after scoliosis surgery. There is some concern that prior placement of an ITB and catheter can further complicate cerebral palsy scoliosis surgery and increase the risk for wound complications.

METHODS

Prospectively collected cases from a multicenter cerebral palsy scoliosis database were reviewed for patients who underwent posterior spinal instrumentation and fusion for a major coronal deformity. These patients were then divided on the basis of whether they had ITB at the time of initial scoliosis surgery. The 2 groups were compared to determine differences in demographics, operative parameters, radiographical outcomes, and rates of wound complications.

RESULTS

Of 187 patients identified, 32 had an ITB previously placed (ITB group) and 155 did not (non-ITB group). Both groups were similar in regard to age, sex, Gross Motor Function Classification Scale score, and preoperative Cobb magnitude. When comparing operative parameters, there were no differences in the total operating room time (ITB = 375 ± 127 min, non-ITB = 423 ± 178 min; P = 0.149) or total estimated blood loss (ITB = 2323 ± 1489 mL, non-ITB = 2081 ± 1572 mL; P = 0.424). Postoperatively, the 2 groups had similar correction rates (71% vs. 67%, P = 0.303). As for perioperative wound complications, there were no differences in rates (P = 0.546) between the ITB (16%) and non-ITB group (15%).

CONCLUSION

Although it may be inconvenient for the surgeon, ITBs do not increase the complexity of surgery or the risk for wound complications. When counseling patients and their caregivers on the timing of pump placement, it does not seem to compromise the care of the patient if the baclofen pump is placed first. Further study is needed to evaluate the safety of pump placement during or after scoliosis surgery.

LEVEL OF EVIDENCE

4.

Multidimensional outcome measure of selective dorsal rhizotomy in spastic cerebral palsy

BACKGROUND

One of the treatment option to reduce spasticity in cerebral palsy children is selective dorsal rhizotomy. Several studies have demonstrated short and long term improvements in gait and other activities after rhizotomy but this surgery still remains a controversial procedure and patient outcome indicators measures are not uniform.

AIMS

To describe our assessment and outcome evaluation protocol and to verify by this protocol short term results of rhizotomy.

METHODS

We recruited 9 cerebral palsy children (mean age 7.9 years ± 3.2) affected by mild to moderate spastic diplegia and operated by rhizotomy. Patients were studied preoperatively and at 12 months after surgery by the following clinical and instrumental measures correlated to the International Classification of Functioning: modified Ashworth Scale, passive Range of Motion, Medical Research Council Scale, Selective Motor Control Scale, 3D-motion analysis and energy cost of locomotion measurements (indicators of "body functions"); Gross Motor Functional Measure and Motor Functional Independence Measure (indicators of "activities and participation").

RESULTS

Our data showed, after rhizotomy, reduction of spasticity specially in plantarflexors muscles (p < 0.01), increase of strength of knee flexors/extensors and foot plantar/dorsiflexion muscles (p < 0.01), improvement of selective motor control (p < 0.05), more similar spatio-temporal parameters of gait analysis to healthy subjects, reduced equinus foot and knees hyperflexion as energy cost.

CONCLUSION

The complementary use of multiple indicators may improve the evaluation of the results of dorsal rhizotomy. A beneficial outcome measured by these indicators has been found in our spastic diplegic children one year after rhizotomy.

Surgical management of spasticity

Intractable and severe spasticity in childhood has the ability to impact on the quality of life, function and care of the child. Where medical and physical measures have proved insufficient, a surgical approach may be pursued. Irrespective of the underlying pathology, intrathecal baclofen will reduce spasticity in a controllable and reversible fashion, whereas selective dorsal rhizotomy is reserved for the management of bilateral cerebral palsy due to early birth. Owing to the potential for complications of intrathecal baclofen and the permanence of selective dorsal rhizotomy, careful selection and preparation are required to produce satisfactory results.

Infectious complications of intrathecal baclofen pump devices in a pediatric population

BACKGROUND

Intrathecal baclofen (ITB) is an effective therapy for spasticity and dystonia in pediatric populations; however, there are associated infectious complications.

METHODS

Patients who had an initial ITB device implanted at our center were followed to determine the proportion of patients with infectious and noninfectious complications, identify risk factors for infection and describe the clinical presentations, treatment and outcomes of infectious complications.

RESULTS

Over the 15-year study period, 139 patients had an initial ITB device placed. The mean age at placement was 13.6 years (range: 6 months to 41 years). In the first year of follow-up, 83% had no complications or secondary procedures, 17% had at least 1 secondary procedure and 5% had an infectious complication. The median time until infection was 14 days (mean 33 ± 42 days). Patients with secondary spasticity or dystonia were more likely to have infections than patients with cerebral palsy (86% versus 14%; P < 0.0001). In the 94 patients with a first secondary procedure, 29% had at least 1 other procedure and 8% had an infection in the 1 year follow-up. Overall, 24 patients had 27 infections; 22% superficial, 33% deep and 45% organ space. Staphylococcus aureus was isolated in 50% of those with cultures obtained. Explantation was required in 59% of patients with an infection and differed by infection type: superficial (17%), deep (44%) and organ space (92%) (P = 0.004).

CONCLUSIONS

Infectious complications were relatively uncommon; however, when present, frequently led to the explantation of the ITB pump device.

Influence of baclofen on laryngeal and spinal motor drive during cough in the anesthetized cat

OBJECTIVES/HYPOTHESIS

The antitussive properties of (±) baclofen on laryngeal muscle activities have not been determined. The hypothesis of this study was that administration of (±) baclofen would suppress upper airway muscle motor activity in a dose-dependent manner during cough.

STUDY DESIGN

This is a prospective, preclinical, hypothesis-driven, paired design.

METHODS

Electromyograms of the parasternal, rectus abdominis, thyroarytenoid, posterior cricoarytenoid, and thyrohyoid were measured, along with esophageal pressure. Cough was elicited by mechanical stimulation of the lumen of the intrathoracic trachea in spontaneously breathing cats.

RESULTS

Baclofen (±) (3-10 μg kg(-1) i.a.) induced decreases in the electromyogram amplitude of the rectus abdominis motor drive during coughing, the inspiratory and active expiratory (E1) phases of cough, and cough number per epoch. There was no effect of (±) baclofen on the EMG amplitudes of any of the laryngeal muscles, the parasternal, or the duration of the passive expiratory (E2) phase.

CONCLUSIONS

Results from the present study indicate differential control mechanisms for laryngeal and inspiratory motor drive during cough, providing evidence of a control system regulating laryngeal activity and inspiratory spinal drive that is divergent from the control of expiratory spinal motoneurons.

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.

Controlled study of the effects of continuous intrathecal baclofen infusion in non-ambulant children with cerebral palsy

AIM

To measure changes in children with severe spastic cerebral palsy (CP) after continuous intrathecal baclofen (ITB) infusion over 18 months and to compare the results with those of a comparison group awaiting treatment.

METHOD

Thirty-eight children with severe spastic CP considered suitable for ITB were assessed when first seen, just before insertion of an intrathecal pump, and 9 months and 18 months later. Eighteen children waited around 9 months for a pump (group 1: nine males, nine females; mean age 9y 11mo [SD 3y 7mo], nine in Gross Motor Function Classification System [GMFCS] level IV, nine in level V). This baseline period was used as a control for comparison with the first and second 9-month periods after the pump for the remaining 20 children (group 2: 11 males, nine females; mean age 10y 2mo [SD 3y 1mo], nine in GMFCS level IV, 11 in level V). The main outcome measure was the Pediatric Evaluation of Disability Inventory (PEDI); other assessments were of function, ease of care, quality of life, and costs of new equipment.

RESULTS

No significant change was found in the PEDI between group 1 while awaiting treatment and group 2 in the two periods afterwards, nor in the Lifestyle Assessment Questionnaire or the cost of new equipment. Significant changes were found in group 2 in the first 9 months according to the modified Ashworth score (difference between mean values for groups -1.7, standard error 0.58; p=0.008), Penn Spasm score (-1.3, 0.37; p=0.001), mean joint range of movement (8.3°, 2.8; p=0.005), and Caregiver Questionnaire (-19.7, 5.1; p=0.01), and in the second 9 months for the Modified Ashworth Scale score (-0.62, 0.12; p=0.001).

INTERPRETATION

ITB in children with severe spastic CP over the first 18 months improves their quality of life in terms of comfort and ease of care. It has less effect on function, participation in society, or the overall cost of new equipment.

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 in cerebral palsy. A retrospective study of 25 wheelchair-assisted adults

OBJECTIVE

To study the efficacy and safety of intrathecal baclofen therapy (ITB) in wheelchair-dependent adults with cerebral palsy.

PATIENTS AND METHODS

A retrospective analysis and clinical examination of 25 wheelchair-assisted adults with cerebral palsy receiving ITB initiated between 1999 and 2009 in three different cities in western France.

RESULTS

ITB improves spasticity and facilitates wheelchair comfort and nursing care. The therapy has an effect on motor disorders and pain. Eighty percent of the ITB patients were satisfied. Dissatisfaction was related to complications or adverse events and not lack of efficacy. Complications occurred in 32% of the patients and transient interruption of the treatment or surgical removal of the ITB pump was necessary in 16% of cases.

DISCUSSION AND CONCLUSION

Wider use of ITB in this indication is likely and should lead to a better understanding of the drug's pharmacological effects on motor disorders and pain. Use of the Goal Attainment Assessment Scale or Caregiver Questionnaire can help us.

Infraclavicular fossa as an alternate site for placement of intrathecal infusion pumps: technical note

OBJECTIVE

Intrathecal infusion using an implantable pump is a common method of delivering medication for spasticity or chronic pain. The classic site for placement of the pump is in the abdominal wall. In some patients, there are confounding factors that make placement of an abdominal pump impractical. The purpose of this study was to report the implantation of Synchromed II pumps (Medtronic, Inc, Minneapolis, Minnesota) in the infraclavicular fossa.

METHODS

Four patients, aged 13 to 33 years, underwent infraclavicular placement of a Synchromed II infusion pump. In one patient, severe scoliosis and hip joint contractures precluded placement of the pump in the traditional position. Another patient had several ostomies on the abdominal wall, leaving no place for the pump. In a third, a combination of scoliosis and ostomy rendered the abdomen inappropriate for pump placement.

RESULTS

In 3 patients, a 20-mL pump was placed in the infraclavicular fossa. In the fourth, a 40-mL pump was placed in the left infraclavicular fossa. All patients tolerated the operation well. There were no postoperative reports of local pain or discomfort. One patient died from unrelated respiratory compromise several months after pump placement. At last follow-up (average of 11 months), the pumps were functioning well, and there were no wound-related complications. Selected pre- and postoperative photographs are presented.

CONCLUSION

The infraclavicular fossa is a viable alternative to the abdomen as the site for placement of a drug infusion pump.

Consensus on the appropriate use of intrathecal baclofen (ITB) therapy in paediatric spasticity

Among features of motor disorders in children, spasticity is associated with considerable morbidity and problems in care, particularly in severely affected patients. Intrathecal baclofen (ITB) has been increasingly used as a relatively specific treatment modality for spasticity. To date, most of the evidence for its use in paediatric patients has come from retrospective and uncontrolled studies, although randomised, controlled trials of screening ITB and ITB therapy itself have recently been published. This consensus statement on the use of ITB in paediatric patients with spasticity was developed on the basis of currently available evidence, with the aim of providing information for clinicians, promoting an expert opinion and a consistent approach to the management of these patients and emphasising the need for further prospective, large-scale studies.

Infections related to intrathecal baclofen therapy in children and adults: frequency and risk factors

OBJECT

The purpose of this study was to determine the frequency of infection and to identify risk factors for infection in connection with the implantation of an intrathecal baclofen (ITB) pump.

METHODS

This retrospective study included all pediatric and adult patients who received ITB at Rikshospitalet during the years 1999-2005. A database was created that included the following variables: patient age, sex, weight, diagnosis, surgical procedure performed, presence of a percutaneous endoscopic gastrostomy (PEG) tube, urinary as well as fecal incontinence, anesthetist's classification of patient status (American Society of Anesthesiologists grade), timing of antibiotics administration, surgeon, assisting nurse, and surgical procedure time. Moreover, the mode of intrathecal screening trial (transcutaneous vs subcutaneous catheter insertion) and any complications were registered. The authors differentiated between deep and superficial infection, and they registered the causative agent.

RESULTS

A total of 163 patients received ITB; of these, 91 were pediatric patients (median age 10 years), and 72 were adults (median age 44 years). A total of 408 surgical procedures were performed. No infections occurred in direct relation to the screening trials. When a pump was implanted subsequent to a screening trial with transcutaneous catheter insertion, the rate of infection was 9% in the pediatric patients. The corresponding infection rate for pumps implanted after a screening trial with a subcutaneous distal catheter (Albright method) was 12%. This difference was not significant. There was a significantly higher incidence of deep infections following pump implantation in the pediatric group (p = 0.028) than in the adult group. The presence of a PEG tube increased the incidence of infection (p = 0.008) and may be one of the main reasons for a higher frequency of infections in children. When the patient suffered urinary and/or fecal incontinence, there was a higher chance of infection (p = 0.021). The surgical time was significantly longer in the pediatric group than in adults; however, the length of the surgical procedure had no impact on the occurrence of infection. The most common causative agent was Staphylococcus aureus; this microbe was responsible for 69% of deep infections. Also, 69% of deep infections occurred within 1 month after surgery.

CONCLUSIONS

The rate of infection is significantly higher in children undergoing ITB pump implantation than it is in adults. Screening trials applying the Albright method fail to reduce the frequency of infection subsequent to pump implantation. The presence of a PEG tube has the greatest significance as a predictor of infection.

GMFM 1 year after continuous intrathecal baclofen infusion

The purpose of this study was to assess whether there is an improvement in motor function in persons with cerebral palsy (CP) who have had a reduction of muscle tone by continuous intrathecal baclofen infusion. This was a prospective, open label, non-blinded case series without a control group, conducted at multiple centres. There were 31 subjects, aged 4-29 years. All had a pre-treatment mean lower extremity Ashworth scores of >or= 3 and a significant reduction in tone after a bolus injection of intrathecal baclofen (ITB) and received an implanted pump for continuous delivery of ITB. Motor function was assessed by the Gross Motor Function Measure (GMFM) prior to and 1 year following pump implantation. Significant improvement (p < 0.05) in mean GMFM scores was seen in subjects < 8 years (mean change 4.1) and in those from 8-18 years (mean change 3.7) and in subjects with CP Classes 2 and 5 (mean changes 6.2 and 2.9). There was a statistically significant decrease (p < 0.05) in Ashworth scores in CP classes 2-5. Subjects or their caregivers that completed a survey about perceived changes stated that motor control, positioning and endurance improved.

Intrathecal baclofen in the management of spasticity due to cerebral palsy

Intrathecal baclofen is a cornerstone in the treatment of spasticity in children. However, further research is required to set criteria for treatment. This paper offers insight into the national act on baclofen and the experience at the Nottingham University Hospital.

Treatment of childhood spasticity of cerebral origin with intrathecal baclofen: a series of 52 cases

Continuous intrathecal baclofen infusion (CIBI) for spasticity of spinal and cerebral origin has been practised for over two decades. More recently, it has been used for severe spasticity of cerebral origin in children. Intrathecal baclofen (ITB) appears most beneficial in severe spastic tetraparetics or tetraplegics, but the evaluation of the outcome of ITB and the benefit of the treatment are largely subjective. The evidence base for this treatment has been questioned, in particular for ambulant children, mainly because of the lack of objective outcome measures. Fifty-two spastic tetraparetic children have been treated by this method in Nottingham, from 1998 to 2003. This represents a large homogeneous series of CIBI in children with severe spasticity of cerebral origin. We carried out a prospective audit of our experience, morbidity and observations during that period. We identified that the lack of a suitable scoring system for the evaluation of effectiveness and benefit is a drawback. As a result of these observations a multicentre randomized controlled trial on ITB in tetraplegia-paresis and ambulant children is advocated.

Baclofen pump implantation and spinal fusion in children: techniques and complications

STUDY DESIGN

Retrospective clinical and radiographic review of complications related to intrathecal baclofen therapy (ITB) and posterior spine fusion (PSF) in patients with cerebral palsy.

OBJECTIVE

To report the technical considerations and complications associated with ITB in patients undergoing PSF.

SUMMARY OF BACKGROUND DATA

A common treatment for spasticity in children with cerebral palsy is ITB. This population also has a high incidence of severe spinal deformities requiring PSF.

METHODS

There were 4 groups: A, 26 patients with PSF before ITB; B, 11 patients who underwent PSF and ITB concurrently; C, 25 patients with PSF after ITB; and D, the control group: 103 patients with ITB only. Complications and infections were tabulated from a retrospective chart review and ongoing surveillance data. Multiple chi analyses were used to compare the number of patients who experienced complications and infections among the groups. The operative sequence and catheter management techniques for the various scenarios are described in detail in the text.

RESULTS

The outcome by group was as follows: group A had 5 catheter malfunctions and 2 infections at the pump site, group B had 2 catheter malfunctions, 1 hypermobile pump and 1 infection at the spinal site, group C had 3 catheter malfunctions, 1 infection at the pump site and 1 infection at the spinal site. The control group had 23 catheter malfunctions, 5 pump failures, 8 infections at the pump site, and 1 infection at the spinal site. Multiple chi analyses showed no difference in the number of infection or device/catheter complications among any of the groups.

CONCLUSION

The rate of ITB therapy complications is not increased despite PSF in any order of the procedures. There are technical details in each situation that require attention. With understanding of the appropriate techniques of catheter management, ITB pumps can be implanted and managed without an increased complication rate before, during or after spinal fusion surgery.

Discriminative stimulus effects of tiagabine and related GABAergic drugs in rats

RATIONALE

Tiagabine is an anticonvulsant drug which may also have sleep-enhancing properties. It acts by inhibiting reuptake at the gamma-aminobutyric acid (GABA) transporter (GAT-1).

OBJECTIVES

The aim of the study was to determine whether tiagabine acted as a discriminative stimulus and, if so, whether other GABAergic compounds would generalise to it.

MATERIALS AND METHODS

Rats were trained to discriminate tiagabine (30 mg/kg p.o.) from vehicle, and generalisation to drugs that modulate GABA was assessed.

RESULTS

Gaboxadol (5-20 mg/kg p.o.), a selective extrasynaptic GABA A agonist, generalised to tiagabine, although the extent of the generalisation was inconclusive. Indiplon (1 mg/kg p.o.), a benzodiazepine-like hypnotic, also partially generalised to tiagabine, although zolpidem and S-zopiclone did not. Baclofen, a GABA B receptor agonist, and gabapentin, which increases synaptic GABA, did not generalise to tiagabine. (+)-Bicuculline (3 mg/kg i.p.), a GABA A receptor antagonist, blocked the tiagabine cue, but the less brain-penetrant salt form, bicuculline methochloride, had no effect.

CONCLUSIONS

These data suggest that tiagabine generates a discriminative stimulus in rats, and provides a central GABA-mediated cue, but is distinct from the other GABAergic compounds tested.