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Intrathecal baclofen
- 1. Trey Rumph Mercer University 4 th year Student
- 4. Score Ashworth Scale (1964) Modified Ashworth Scale Bohannon & Smith (1987) 0 (0) No increase in tone No increase in muscle tone 1 (1) Slight increase in tone giving a catch when the limb was moved in flexion or extension Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension. 1+ (2) Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the reminder (less than half) of the ROM (range of movement). 2 (3) More marked increase in tone but limb easily flexed. More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved. 3 (4) Considerable increase in tone - passive movement difficult. Considerable increase in muscle tone passive, movement difficult. 4 (5) Limb rigid in flexion or extension. Affected part(s) rigid in flexion or extension.
- 5. Penn spasm frequency scale Score Spasm frequency score No spasms 0 No spasms Mild spasms at stimulation 1 One or fewer spasms per day Irregular strong spasms less than 1 time/[sol]/h 2 Between 1 and 5 spasms per day Spasms more often than 1 time/[sol]/h 3 Five to less than 10 spasms per day Spasms more than 10 times/[sol]/h 4 Ten or more spasms per day, or continuous contraction
- 24. Source: Data on file at Medtronic.
Hinweis der Redaktion
- A disorder characterized by velocity-dependant increase in the tonic stretch reflex (muscle tone) with exaggerated tendon jerks resulting from hyperexcitability of the stretch reflexes The stretch Reflex Arc Nerve fibers from various tract converge and synapse in the anterior horn, maintaining segmental muscle tone by modulating the stretch reflex arc, which is basically a negative feedback loop in which muscle stretch (stimulation) cause reflexive contraction (inhibition), thus maintaining muscle length and tone. Damage to certain tracts results in loss of inhibition and a disruption of the stretch reflex arc. Uninhibited muscle stretch produces exaggerated, uncontrolled muscle activity stressing the reflex arc and resulting in spasticity.
- Jagatsinh Due to increased Gamma motor neuron activity Due to impaired descending influence on segmental input or structural reorganization of the propriospinal input Resulting in increased responsiveness of alpha and gamma motor neurons to the input from muscle afferents On alpha motor cells and consequently hyperactivity of alpha motor cells
- Dystonia can manifest in many forms including adult-onset focal forms: writer's cramp is the most common form of dystonia ( a ). It is task specific and begins when the repetitive task of handwriting is undertaken. The hand, finger and forearm muscles contract into an abnormal posture making writing difficult. Torticollis refers to a condition in which the muscles around the neck contract in a sustained or intermittent manner forcing the head to turn to one side with the chin thrust upward ( b ). This condition is also referred to as wry neck or cervical dystonia. Other forms of dystonia have a childhood/adolescent-onset. For example, early-onset generalized dystonia is the most severe and common of the hereditary dystonias. Symptoms usually begin in childhood with onset in a leg or arm, manifesting as muscle contractions and twisting ( c ). It progresses to other body parts forcing them into abnormal positions, which can be painful. This condition is also referred to as dystonia musculorum deformans and Oppenheim's disease. Rapid-onset dystonia-parkinsonism is a hereditary condition with sudden onset of dystonic symptoms within hours to weeks after physical or mental stress. Symptoms can manifest as dystonic spasms in the upper limbs with facial grimacing, but can also include parkinsonian symptoms such as slowness of movement and postural instability ( d ). The pathophysiological basis of dystonias Xandra O. Breakefield, Anne J. Blood, Yuqing Li, Mark Hallett, Phyllis I. Hanson & David G. Standaert Nature Reviews Neuroscience 9 , 222-234 (March 2008) doi:10.1038/nrn2337
- Used primarily in the calf muscles to treat dynamic equinus of the ankle Injected several areas of the muscle Repeated every 3-8 months to maintain its effect Most evidence is for Equinus varus**
- CBA: range of motion, strength, assessment of selective motor control, muscle tone and function
- Serum Baclofen virtually undetectable
- Cleared at CSF clearance rates CSF elminiation t ½ = 1.5hrs CSF clearance 30ml/hr
- $70 for the initial test bolus 20ml refill ~$425 40ml Refill ~$850
- Severe spastic hemiplegia: benefits the affected area without making the unaffected area hypotonic Spastic diplegia related to Cerebral Palsy Patient (usually don’t show benefit from ITB) Use selective dorsal rhizotomy, first line Primary Dystonia’s tend not to respond well to ITB, these are associated with gene involvement
- Traditionally inserted subfascially on the right side, and catheter inserted obliquely in the lumbar region Kroin JS, Ali A, York M, Penn RD: The distribution of medication along the spinal canal after chronic intrathecal administration. Neurosurgery 33:226-230, 1993
- If child is unresponsive to 50 μ cg then increase bolus to 75 to 100 μ cg the next day. (Spasticity) **There is enough evidence to disregard these test doses, literature points out that more than 90% of patients who were screened have decrease dystonia scores after pump implantation**** Albright AL, Gilmartin R, Swift D, Krach LE, Ivanhoe CB, McLaughlin JF: Long term intrathecal baclofen therapy for severe spasticity of cerebral origin. J Neurosurg 98:291-295, 2003
- Key points of the low complication implant technique include: Paramedian oblique entry Helps stabilize the catheter against dislodgement Reduced wear on catheter compared to midline entry V-wing anchor at spinal entry point Reduces catheter dislodgements Catheter connector/primary anchor Reduces catheter dislodgements Strain-relief sleeve on catheter tubing Reduces catheter kinks and holes Loop of catheter under pump Reduces catheter kinks Slack in catheter by connector Reduces catheter kinks Thick wall proximal catheter Reduces catheter kinks and holes Pump anchor using suture loops or mesh pouch Reduces catheter kinks and dislodgements
- * Find out why
- Most commonly S. Aureus Treat by removing the pump, and IV antibiotics for 14 days 5-15% prevalence Most prevalent the first two week after implantation
- Subdural catheter placement: drug infuses into the subdural space and accumulates and then upon patient repositioning the accumulation is released into the intrathecal space Baclofen is not neurotoxic Half-life: 4-5 hours
- Occurs much more commonly than overdosage
- Mild to moderate: enteral Baclofen If NPO IV Diazepam Follow the flow of medication through the catheter in real-time
- Other Citations Anne-Berit Fjelstad, R.N., Jorunn Hommelstad, R.N., M.S., and Angelika Sorteberg, M.D., Ph.D.. (2009) Infections related to intrathecal baclofen therapy in children and adults: frequency and risk factors. Journal of Neurosurgery: Pediatrics 4 :5, 487-493 Online publication date: 1-Nov-2009.