Intrathecal Baclofen In the Treatment of Adult Spasticity

Joseph C. Hsieh, M.D., M.B.A., M.P.H.; Richard D. Penn, M.D.


Neurosurg Focus. 2006;21(2) 

In This Article

Abstract and Introduction

Medical management of adult spasticity, a condition of increased muscle tone and deep tendon reflexes, is often challenging and complex. Oral medications such as baclofen often have unacceptable supraspinal side effects at effective doses. Intrathecal baclofen delivered by an implanted catheter and pump system provides good relief of spasticity while overcoming these limitations. In this paper the authors survey the use of oral and intrathecal baclofen therapy, detail the surgical process, and explain the risks and benefits of the procedure.

Spasticity is simply defined as a state of increasing mus cle tone with movement and associated exaggerated deep tendon reflexes.[17] The simplicity of its description, however, belies the seriousness of the condition. The excessive involuntary motor activity associated with spasticity can result from lesions of the CNS. It may manifest in forms including, but not limited to, a Babinski response; exaggerated stretch, cutaneous, or autonomic reflexes; and abnormal postures (dystonia).[39] In short, spas ticity remains a multifaceted entity, and because of this, multiple treatment modalities have been attempted.

Therapies for spasticity have run the gamut of medical and surgical innovation. Conservative options include the use of traditional oral medications and rehabilitative therapies. Oral pharmacology for spasticity has been confined to medications that limit peripheral cholinergic activity at the neuromuscular junction (for example, botulinum tox in), that inhibit the release of calcium from the sarcoplasmic reticulum (for example, dantrolene sodium), or modulate CNS activity (for example, baclofen, diazepam, and clonidine).[21,24]

When medical therapy has failed, surgery has at times resulted in success. The best-known surgery, modern se lective dorsal rhizotomy, can be traced back to operations credited to Otfried Foerster[12] in 1913. Selective dorsal rhizotomy involves the surgical sectioning of select dorsal nerve roots that exhibit abnormal activation on EMG studies. The positive results include increases in voluntary mo bility and reductions in rigidity. Never the less, risks in clude symptom recurrence and loss of sphincter control and sensation.[10,11] Other surgical lesioning op tions such as ven tral rhizotomy, cordectomy, or midline myelotomy have all met with limited success but with even more significant morbidity.[32]

In recent years, a synergistic approach including medical and surgical options has been found to be particularly effective. Perhaps the most promising and rapidly adopted surgical therapy for spasticity has been an implanted pump catheter for the delivery of ITB. In this paper we will de tail an introduction to intrathecal and oral baclofen, the surgical process, and risks and benefits associated with the procedure.


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