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Intrathecal Baclofen Therapy: Pros and Cons
1Department of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
2Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
3Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
4Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
5Graduate Program of Biomedical Engineering, Yonsei University College of Medicine, Seoul, Korea
Corresponding author: Sung-Rae Cho Department of Rehabilitation Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea. Tel: +82-2-2228-3715, Fax: +82-2-363-2795, E-mail: srcho918@yuhs.ac
• Received: January 18, 2023 • Accepted: January 25, 2023
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Intrathecal baclofen (ITB) therapy is known to directly control spasticity in the spinal cord with fewer systemic adverse effects in a variety of neurological diseases including spinal cord injury, cerebral palsy (CP), stroke, traumatic brain injury, and hypoxic brain injury [1-4]. ITB therapy can effectively reduce severe spasticity that does not respond to oral medications or botulinum toxin treatment [5,6]. In addition, ITB therapy is reversible and continuously controls spasticity, whereas orthopedic musculoskeletal surgery and selective posterior rhizotomy are irreversible [7,8].
Previous experience with ITB screening tests (Table 1) showed beneficial effects such as spasticity reduction, improved sitting posture and sleep pattern, and decreased excessive sweating and chronic pain [8]. However, it can cause adverse effects, such as headache, dizziness, drowsiness, nausea, vomiting, dysarthria, posterior neck pain, voiding difficulty, and respiratory depression, aside from surgical or catheter-related complications [9-13].
In other issues, spasticity reduction not only induces functional improvement but also causes functional impairments due to muscle hypotonia and instability in walking and standing [9]. I actually experienced that ambulatory patients with CP showed standing impairment or gait disturbance after ITB bolus injection [8]. Therefore, confirming functional changes via ITB test trials is necessary to reduce spasticity without functional impairments before ITB pump implantation [8,14].
I also experienced reversible adverse effects, such as headache, drowsiness, and decreased sitting balance after ITB pump implantation, in which symptoms were relieved after adjusting the infusion dose and maintaining an appropriate dose to maximize the beneficial effects while minimizing the negative events [8,15]. Recent studies have suggested that early exposure to ITB therapy is appropriate to prevent musculoskeletal deformities and contracture [16] and participate in active rehabilitation programs [17] in contrast to the conventional concept that ITB pump implantation should be delayed for over 1 year post-onset. Patients with severe spasticity should consider early application of ITB therapy to decrease caregiver burden, prevent complications, and eventually improve function.
However, the impact on scoliosis after ITB pump implantation has been controversial in children with CP with further scoliosis progression [18-20] vs. no significant difference [21,22]. In their study published in current issue of Annals of Rehabilitation Medicine, Lee et al. [23] performed a systematic review and meta-analysis which showed that ITB pump implantation accelerates annual Cobb’s angle progression in children with CP. Patients with ITB pump implantation showed a faster rate of scoliosis progression probably due to paraspinal muscle hypotonia, although patients with no ITB pump implantation also showed aggravation of scoliosis. Severe scoliosis might negatively affect sitting or standing posture and activities of daily living, causing caregiver burden [24-26].
Nonetheless, spinal curvature can be managed using an inner seat system because scoliosis progression is not an unpredictable phenomenon when ITB therapy reduces paraspinal muscle spasticity and hypertonia. In contrast, ITB therapy may decrease hip adductor spasticity, pelvic obliquity, and hip subluxation or dislocation, presumably alleviating scoliosis acceleration and perineal care burden. Therefore, the results of this meta-analysis should be carefully interpreted, and advantages and disadvantages of ITB therapy should be carefully considered before ITB pump implantation.
CONFLICTS OF INTEREST
Sung-Rae Cho is a Section Editor of Annals of Rehabilitation Medicine. The author did not engage in any part of the review and decision-making process for this manuscript. Otherwise, no potential conflict of interest relevant to this article was reported.
ACKNOWLEDGMENTS
This study was supported by the Korean Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI) (HI21C1314, HI22C1588), and the Korean Fund for Regenerative Medicine (KFRM) grant (21A0202L1, 21C0715L1).
Table 1.
Outcomes of the intrathecal baclofen therapy screening tests
4. Brennan PM, Whittle IR. Intrathecal baclofen therapy for neurological disorders: a sound knowledge base but many challenges remain. Br J Neurosurg 2008;22:508-19.
7. Kan P, Gooch J, Amini A, Ploeger D, Grams B, Oberg W, et al. Surgical treatment of spasticity in children: comparison of selective dorsal rhizotomy and intrathecal baclofen pump implantation. Childs Nerv Syst 2008;24:239-43.
8. Yoon YK, Lee KC, Cho HE, Chae M, Chang JW, Chang WS, et al. Outcomes of intrathecal baclofen therapy in patients with cerebral palsy and acquired brain injury. Medicine (Baltimore) 2017;96:e7472.
9. Motta F, Buonaguro V, Stignani C. The use of intrathecal baclofen pump implants in children and adolescents: safety and complications in 200 consecutive cases. J Neurosurg 2007;107(1 Suppl): 32-5.
10. Borowski A, Littleton AG, Borkhuu B, Presedo A, Shah S, Dabney KW, et al. Complications of intrathecal baclofen pump therapy in pediatric patients. J Pediatr Orthop 2010;30:76-81.
11. Awaad Y, Rizk T, Siddiqui I, Roosen N, McIntosh K, Waines GM. Complications of intrathecal baclofen pump: prevention and cure. ISRN Neurol 2012;2012:575168.
12. Sgouros S, Charalambides C, Matsota P, Tsangaris I, Kostopanagiotou G. Malfunction of SynchroMed II baclofen pump delivers a near-lethal baclofen overdose. Pediatr Neurosurg 2010;46:62-5.
13. Vidal J, Fenollosa P, Martin E, Barberá J, Robaina FJ, Fuentes M, et al. Safety and efficacy of intrathecal baclofen infusion by implantable pump for the treatment of severe spinal spasticity: a spanish multicenter study. Neuromodulation 2000;3:175-82.
14. Phillips MM, Miljkovic N, Ramos-Lamboy M, Moossy JJ, Horton J, Buhari AM, et al. Clinical experience with continuous intrathecal baclofen trials prior to pump implantation. PM R 2015;7:1052-8.
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17. Maneyapanda MB, McCormick ZL, Marciniak C, Reger C. Long-term dosing of intrathecal baclofen in the treatment of spasticity after acquired brain injury. PM R 2017;9:556-62.
18. Sansone JM, Mann D, Noonan K, Mcleish D, Ward M, Iskandar BJ. Rapid progression of scoliosis following insertion of intrathecal baclofen pump. J Pediatr Orthop 2006;26:125-8.
22. Shilt JS, Lai LP, Cabrera MN, Frino J, Smith BP. The impact of intrathecal baclofen on the natural history of scoliosis in cerebral palsy. J Pediatr Orthop 2008;28:684-7.
23. Lee S, Hyun C, Kim K, Kwon HE, Woo M, Koh SE. Effect of intrathecal baclofen pump on scoliosis in children with cerebral palsy: a meta-analysis. Ann Rehabil Med 2023;doi: 10.5535/arm.22108 [Epub ahead of print].
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