Intrathecal baclofen therapy for neurological disorders: a sound knowledge base but many challenges remain

Continuous infusion of intrathecal baclofen (ITB) via a subcutaneously implanted pump has developed over the last 20 years as a powerful tool in the management of spasticity in various adult and paediatric neurological conditions. Acting more focally on spinal GABA receptors, ITB causes fewer system...

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Bibliographic Details
Published in:British journal of neurosurgery 2008-08, Vol.22 (4), p.508-519
Main Authors: Brennan, P. M., Whittle, I. R.
Format: Article
Language:English
Subjects:
Adult
Baclofen
Baclofen - administration & dosage
Baclofen - therapeutic use
Catheterization - methods
Cerebral Palsy - drug therapy
Child
Child, Preschool
Clinical outcomes
Dose-Response Relationship, Drug
Drug therapy
Dystonia - drug therapy
Female
GABA
GABA Agonists - administration & dosage
GABA Agonists - therapeutic use
Granuloma - complications
Humans
infusion pump
Infusion Pumps, Implantable - adverse effects
intrathecal
Male
Muscle Spasticity - drug therapy
Neurological disorders
Pain - drug therapy
Pain - etiology
Personal Autonomy
Quality of Life - psychology
spasticity
Spinal cord
Surgery
Treatment Outcome
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Summary:Continuous infusion of intrathecal baclofen (ITB) via a subcutaneously implanted pump has developed over the last 20 years as a powerful tool in the management of spasticity in various adult and paediatric neurological conditions. Acting more focally on spinal GABA receptors, ITB causes fewer systemic side effects than orally administered baclofen. The result is facilitation of daily caring, and symptomatic relief from painful spasm. With increasing experience of ITB use, novel applications and indications are emerging. These include the management of dystonia and chronic neuropathic pain. However, despite some recent authoritative reviews, there is still uncertainty about optimal use and evaluation of this therapy. Many challenges remain. How can efficacy of therapy best be assessed both at primary testing and after pump implantation? What is the precise mechanism of baclofen action in different brain and spinal disorders associated with spasticity and dystonia? Does placement of the spinal catheter tip influence efficacy? What is the cranio-caudal gradient of CSF baclofen levels at given pump flow rates and does this matter? What CSF baclofen levels are efficacious in various conditions? Why do some patients with the same primary condition require large differences in ITB dose? What are the relative merits of programmable versus constant infusion rate pumps? What are the implications of setting up multidisciplinary teams for long term follow up? This review evaluates these questions and highlights other areas for further investigation.
ISSN:0268-8697
1360-046X
DOI:10.1080/02688690802233364