Intrathecal baclofen therapy

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When general or regional spasticity is severe and cannot be managed by physical or oral pharmacological means, continuous delivery of intrathecal medication should be considered. Intrathecal baclofen (ITB) therapy follows the same principles as intrathecal therapy for chronic pain as discussed elsewhere in this volume. Baclofen does not easily cross the blood-brain barrier.36 Administering this medication directly into the subarachnoid space means that very low doses of medication can be delivered directly to the spinal cord at high local concentrations. This results in good clinical effects with very low systemic absorption and hence a low incidence of side effects. A typical dose of oral baclofen is 60-80 mg/ day in divided doses. A typical intrathecal baclofen dose is 350 mg/day (1/2000th of the oral dose) as a continuous infusion. Some patients like a bolus dose in the early hours of the morning to assist them when getting out of bed.

ITB therapy has been shown to be effective in both cerebral origin17, 28,37,38[i] and in spinal origin spasticity.15,18,39[I] ITB is much more useful for trunk and lower limb spasticity than for upper limb spasticity. ITB is

Figure 33.5 Severe traumatic brain injury. (a) The patient has had botulinum toxin injections to left biceps and brachialis. (b) The patient has had botulinum toxin to biceps and brachialis of both arms plus musculocutaneous nerve phenolization.

particularly effective for the management of flexor and extensor spasms which are a frequent cause of pain, as well as for hypertonus. Some authors have recorded better upper limb effects with a higher placement of the catheter in the cervical or upper thoracic spine. However, these reports are inconsistent, and there are theoretical reasons why high placement of the catheter does not improve upper limb effects.40

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