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

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✓ Management of severe spasticity in children is often a difficult problem. Orally administered medications generally offer limited benefits. This study examines the value of intrathecally administered baclofen in the treatment of 19 children with severe spasticity of cerebral origin: eight of whom sustained brain injury associated with trauma, near drowning, or cardiac arrest; 10 with cerebral palsy (spastic quadriplegia); and one child with Leigh's disease. At the time of entry into the study, patients ranged from 4 to 19 years of age, and all were completely dependent on caretakers for activities of daily living.

Children who responded positively to a trial dose of intrathecal baclofen underwent insertion of a drug delivery system for continuous infusion. This was followed by a double-blind trial of baclofen or placebo and follow-up review at 3 and 6 months, and yearly thereafter. Seven children did not undergo pump implantation because of excess sedation or poor response. The 12 remaining children have been followed for a period of 1 to 5 years. Favorable responses were present in all 12 children as determined by the Ashworth Scale, with the greatest benefit being reduction of lower limb tone. Except in the case of one child who had reduction in lower limb tone that resulted in difficulty with transfers, the caretakers all reported significant benefits from intrathecal baclofen, with improvement in muscle tone, behavior, sitting, and general ease of care being most commonly noted.

Central side effects were seen in some children who received continuous intrathecal baclofen infusion and included hypotension (two patients), bradycardia (two), apnea or respiratory depression (two), and sedation (one). During a total of 568 months of pump operation there were 10 mechanical complications, including two related to pump or side port failure and eight related to catheter kinks, extrusions, or dislodgment. Pump pocket effusion occurred in five children and a cerebrospinal fluid fistula was seen in one child. Local infection occurred in three children and meningitis in two children.

The results demonstrate the potential value of continuous intrathecal baclofen infusion for treatment of severe spasticity of cerebral origin. However, this treatment can result in significant complications and more experience is required before the long-term benefits can be determined.

Article Information

Address reprint requests to: Robert Armstrong, M.D., Department of Paediatrics, University of British Columbia, 3644 Slocan Street, Vancouver, British Columbia, Canada, V5M 3E8.

© AANS, except where prohibited by US copyright law.

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References

  • 1.

    Akman MNLoubser PGDonovan WHet al: Intrathecal baclofen: does tolerance occur? Paraplegia 31:5165201993Akman MN Loubser PG Donovan WH et al: Intrathecal baclofen: does tolerance occur? Paraplegia 31:516–520 1993

    • Search Google Scholar
    • Export Citation
  • 2.

    Albright AL: Spastic cerebral palsy. Approaches to drug treatment. CNS Drugs 4:17271995Albright AL: Spastic cerebral palsy. Approaches to drug treatment. CNS Drugs 4:17–27 1995

    • Search Google Scholar
    • Export Citation
  • 3.

    Albright ALBarron WBFasick MPet al: Continuous intrathecal baclofen infusion for spasticity of cerebral origin. JAMA 270:247524771993Albright AL Barron WB Fasick MP et al: Continuous intrathecal baclofen infusion for spasticity of cerebral origin. JAMA 270:2475–2477 1993

    • Search Google Scholar
    • Export Citation
  • 4.

    Albright ALCervi ASingletary J: Intrathecal baclofen for spasticity in cerebral palsy. JAMA 265:141814221991Albright AL Cervi A Singletary J: Intrathecal baclofen for spasticity in cerebral palsy. JAMA 265:1418–1422 1991

    • Search Google Scholar
    • Export Citation
  • 5.

    Armstrong RW: Intrathecal baclofen and spasticity: what do we know and what do we need to know? Dev Med Child Neurol 34:7397451992Armstrong RW: Intrathecal baclofen and spasticity: what do we know and what do we need to know? Dev Med Child Neurol 34:739–745 1992

    • Search Google Scholar
    • Export Citation
  • 6.

    Armstrong RWSteinbok PFarrell Ket al: Continuous intrathecal baclofen treatment of severe spasms in two children with spinal-cord injury. Dev Med Child Neurol 34:7317381992Armstrong RW Steinbok P Farrell K et al: Continuous intrathecal baclofen treatment of severe spasms in two children with spinal-cord injury. Dev Med Child Neurol 34:731–738 1992

    • Search Google Scholar
    • Export Citation
  • 7.

    Ashworth B: Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 192:5405421964Ashworth B: Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 192:540–542 1964

    • Search Google Scholar
    • Export Citation
  • 8.

    Bennett MITai YMASymonds JM: Staphylococcal meningitis following Synchromed intrathecal pump implant: a case report. Pain 56:2432441994Bennett MI Tai YMA Symonds JM: Staphylococcal meningitis following Synchromed intrathecal pump implant: a case report. Pain 56:243–244 1994

    • Search Google Scholar
    • Export Citation
  • 9.

    Bohannon RWSmith MB: Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 67:2062071987Bohannon RW Smith MB: Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 67:206–207 1987

    • Search Google Scholar
    • Export Citation
  • 10.

    Broseta JGarciá-March GSánchez-Ledesma MJet al: Chronic intrathecal baclofen administration in severe spasticity. Stereotact Funct Neurosurg 54/55:1471531990Broseta J Garciá-March G Sánchez-Ledesma MJ et al: Chronic intrathecal baclofen administration in severe spasticity. Stereotact Funct Neurosurg 54/55:147–153 1990

    • Search Google Scholar
    • Export Citation
  • 11.

    Broseta JMorales FGarcia-March Get al: Use of intrathecal baclofen administered by programmable infusion pumps in resistant spasticity. Acta Neurochir Suppl 46:39451989Broseta J Morales F Garcia-March G et al: Use of intrathecal baclofen administered by programmable infusion pumps in resistant spasticity. Acta Neurochir Suppl 46:39–45 1989

    • Search Google Scholar
    • Export Citation
  • 12.

    Ciba-Geigy: Lioresal Intrathecal. Product Monograph. Mississauga, Ontario, Canada:Ciba-Geigy Canada1994Ciba-Geigy: Lioresal Intrathecal. Product Monograph. Mississauga Ontario Canada: Ciba-Geigy Canada 1994

    • Search Google Scholar
    • Export Citation
  • 13.

    Dralle DMüller HZierski J: Lumbar intrathecal baclofen for cerebral spasticity in children. Phys India 4:1531561988Dralle D Müller H Zierski J: Lumbar intrathecal baclofen for cerebral spasticity in children. Phys India 4:153–156 1988

    • Search Google Scholar
    • Export Citation
  • 14.

    Dralle DMüller HZierski Jet al: Intrathecal baclofen for spasticity. Lancet 2:10031985 (Letter)Dralle D Müller H Zierski J et al: Intrathecal baclofen for spasticity. Lancet 2:1003 1985 (Letter)

    • Search Google Scholar
    • Export Citation
  • 15.

    Hankey GJStewart-Wynne EGPerlan D: Intrathecal baclofen for severe spasticity. Med J Aust 147:2611987 (Letter)Hankey GJ Stewart-Wynne EG Perlan D: Intrathecal baclofen for severe spasticity. Med J Aust 147:261 1987 (Letter)

    • Search Google Scholar
    • Export Citation
  • 16.

    Hattab JR: Review of European clinical trials with baclofen in Feldman RGYoung RRKoella WP (eds): Spasticity: Disordered Motor Control. Chicago: Yearbook Medical1980 pp 7185Hattab JR: Review of European clinical trials with baclofen in Feldman RG Young RR Koella WP (eds): Spasticity: Disordered Motor Control. Chicago: Yearbook Medical 1980 pp 71–85

    • Search Google Scholar
    • Export Citation
  • 17.

    Heruth KT: Medtronic SynchroMed drug administration system. Ann NY Acad Sci 531:72751988Heruth KT: Medtronic SynchroMed drug administration system. Ann NY Acad Sci 531:72–75 1988

    • Search Google Scholar
    • Export Citation
  • 18.

    Johnston JReich SBailey Aet al: Shiley INFUSAID pump technology. Ann NY Acad Sci 531:57651988Johnston J Reich S Bailey A et al: Shiley INFUSAID pump technology. Ann NY Acad Sci 531:57–65 1988

    • Search Google Scholar
    • Export Citation
  • 19.

    Khorasani APeruzzi W: Dantrolene treatment for abrupt intrathecal baclofen withdrawal. Anesth Analg 80:105410561995Khorasani A Peruzzi W: Dantrolene treatment for abrupt intrathecal baclofen withdrawal. Anesth Analg 80:1054–1056 1995

    • Search Google Scholar
    • Export Citation
  • 20.

    Kofler MKronenberg MFRifici Cet al: Epileptic seizures associated with intrathecal baclofen application. Neurology 44:25271994Kofler M Kronenberg MF Rifici C et al: Epileptic seizures associated with intrathecal baclofen application. Neurology 44:25–27 1994

    • Search Google Scholar
    • Export Citation
  • 21.

    Lazorthes YSallerine-Caute BVerdie JCet al: Chronic intrathecal baclofen administration for control of severe spasticity. J Neurosurg 72:3934031990Lazorthes Y Sallerine-Caute B Verdie JC et al: Chronic intrathecal baclofen administration for control of severe spasticity. J Neurosurg 72:393–403 1990

    • Search Google Scholar
    • Export Citation
  • 22.

    Müller HZierski JDralle Det al: Intrathecal baclofen in spasticity in Müller HZierski JPenn RD (eds): Local-Spinal Therapy of Spasticity. Berlin: Springer-Verlag1988 pp 154214Müller H Zierski J Dralle D et al: Intrathecal baclofen in spasticity in Müller H Zierski J Penn RD (eds): Local-Spinal Therapy of Spasticity. Berlin: Springer-Verlag 1988 pp 154–214

    • Search Google Scholar
    • Export Citation
  • 23.

    Nance PSchryvers OSchmidt Bet al: Intrathecal baclofen therapy for adults with spinal spasticity: therapeutic efficacy and effect on hospital admissions. Can J Neurol Sci 22:22291995Nance P Schryvers O Schmidt B et al: Intrathecal baclofen therapy for adults with spinal spasticity: therapeutic efficacy and effect on hospital admissions. Can J Neurol Sci 22:22–29 1995

    • Search Google Scholar
    • Export Citation
  • 24.

    Ochs GStruppler AMeyerson BAet al: Intrathecal baclofen for long-term treatment of spasticity: a multi-centre study. J Neurol Neurosurg Psychiatry 52:9339391989Ochs G Struppler A Meyerson BA et al: Intrathecal baclofen for long-term treatment of spasticity: a multi-centre study. J Neurol Neurosurg Psychiatry 52:933–939 1989

    • Search Google Scholar
    • Export Citation
  • 25.

    Parke BPenn RDSavoy SMet al: Functional outcome after delivery of intrathecal baclofen. Arch Phys Med Rehabil 70:30321989Parke B Penn RD Savoy SM et al: Functional outcome after delivery of intrathecal baclofen. Arch Phys Med Rehabil 70:30–32 1989

    • Search Google Scholar
    • Export Citation
  • 26.

    Penn RD: Intrathecal baclofen for severe spasticity. Ann NY Acad Sci 531:1571661988Penn RD: Intrathecal baclofen for severe spasticity. Ann NY Acad Sci 531:157–166 1988

    • Search Google Scholar
    • Export Citation
  • 27.

    Penn RDKroin JS: Continuous intrathecal baclofen for severe spasticity. Lancet 2:1251271985Penn RD Kroin JS: Continuous intrathecal baclofen for severe spasticity. Lancet 2:125–127 1985

    • Search Google Scholar
    • Export Citation
  • 28.

    Penn RDKroin JS: Intrathecal baclofen alleviates spinal cord spasticity. Lancet 1:10781984 (Letter)Penn RD Kroin JS: Intrathecal baclofen alleviates spinal cord spasticity. Lancet 1:1078 1984 (Letter)

    • Search Google Scholar
    • Export Citation
  • 29.

    Penn RDKroin JS: Long-term intrathecal baclofen infusion for treatment of spasticity. J Neurosurg 66:1811851987Penn RD Kroin JS: Long-term intrathecal baclofen infusion for treatment of spasticity. J Neurosurg 66:181–185 1987

    • Search Google Scholar
    • Export Citation
  • 30.

    Penn RDSavoy SMCorcos Det al: Intrathecal baclofen for severe spinal spasticity. N Engl J Med 320:151715211989Penn RD Savoy SM Corcos D et al: Intrathecal baclofen for severe spinal spasticity. N Engl J Med 320:1517–1521 1989

    • Search Google Scholar
    • Export Citation
  • 31.

    Price GWWilkin GPTurnbull MJet al: Are baclofen-sensitive GABAB receptors present on primary afferent terminals of the spinal cord? Nature 307:71741984Price GW Wilkin GP Turnbull MJ et al: Are baclofen-sensitive GABAB receptors present on primary afferent terminals of the spinal cord? Nature 307:71–74 1984

    • Search Google Scholar
    • Export Citation
  • 32.

    Rifici CKofler MKronenberg Met al: Intrathecal baclofen application in patients with supraspinal spasticity secondary to severe traumatic brain injury. Funct Neurol 9:29341994Rifici C Kofler M Kronenberg M et al: Intrathecal baclofen application in patients with supraspinal spasticity secondary to severe traumatic brain injury. Funct Neurol 9:29–34 1994

    • Search Google Scholar
    • Export Citation
  • 33.

    Saltuari LMarosi MJKofler Met al: Status epilepticus complicating intrathecal baclofen overdose. Lancet 339:3733741992Saltuari L Marosi MJ Kofler M et al: Status epilepticus complicating intrathecal baclofen overdose. Lancet 339:373–374 1992

    • Search Google Scholar
    • Export Citation
  • 34.

    Siegfried JRea GL: Intrathecal application of baclofen in the treatment of spasticity. Acta Neurochir Suppl 39:1211231987Siegfried J Rea GL: Intrathecal application of baclofen in the treatment of spasticity. Acta Neurochir Suppl 39:121–123 1987

    • Search Google Scholar
    • Export Citation
  • 35.

    Steinbok PDaneshvar HEvans Det al: Cost analysis of continuous intrathecal baclofen versus selective functional posterior rhizotomy in the treatment of spastic quadriplegia associated with cerebral palsy. Pediatr Neurosurg 22:2552641995Steinbok P Daneshvar H Evans D et al: Cost analysis of continuous intrathecal baclofen versus selective functional posterior rhizotomy in the treatment of spastic quadriplegia associated with cerebral palsy. Pediatr Neurosurg 22:255–264 1995

    • Search Google Scholar
    • Export Citation

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