[Pharmacological treatment of neurogenic detrusor hyperactivity: intrathecal drugs]. / Traitement pharmacologique de l'hyperactivité détrusorienne neurologique: drogues intrathécales.

Intrathecal clonidine has been tested in spinal cord injury patients not supporting or resistant to anticholinergic drugs. Although the acute effect of clonidine on urodynamic parameters was satisfactory, cardiovascular adverse effects limited the long-term efficacy of this treatment. Intrathecal baclofen has a limited effect on overactive bladder in patients with spinal spasticity, but can modify the quality of erections and induce an incapacity to trigger ejaculation by vibratory penile stimulation.

[Radiculopathy following intrathecal baclofen pump implantation]. / Radiculalgie après implantation de pompe à baclofène.

INTRODUCTION: Intrathecally delivered baclofen has been used as a treatment for severe spasticity since 1984. After a successful intrathecal baclofen trial, a programmable drug delivery system was implanted. Few early complications such as infection or hematoma are observed after this surgery. OBJECTIVE: To describe an unusual and unknown complication of intrathecal baclofen therapy. METHOD: We report 2 cases of complications of intrathecal baclofen therapy, radiculalgy, that appeared early after pump implantation. The clinical symptoms and computed tomography (CT) results are described. RESULTS: The first patient described pain, which evoked left S1 radiculopathic features. The second had left L5 radiculopathic involvement. The mean pain level was estimated on a 10-point visual analog scale as 7.5 (range 4-9). Lumbar CT scan showed a conflict between the symptomatic root and the catheter and eliminated other causes of the symptoms. Treatment with analgesic drugs was successful in 1 patient. The other presented with proximal disconnection of the catheter, which led to surgical replacement of the catheter. The pain disappeared after this surgery. CONCLUSION: Intrathecal baclofen therapy with a subcutaneously implanted progammable pump can be complicated by radiculalgy secondary to a conflict between the catheter and symptomatic root. The diagnosis is made by CT lumbar scan. If medical treatment is not sufficient, surgery could be proposed to replace the catheter.

Intrathecal baclofen for treatment of spasticity of multiple sclerosis patients.

We conducted a retrospective study of the case files of 64 multiple sclerosis (MS) patients presenting severe spasticity, who had received intrathecal (IT) baclofen test injections between 1992 and 2004 in a rehabilitation unit. In almost all cases of our series, IT baclofen was proposed to patients who were no longer able to walk. IT baclofen is a safe and effective treatment to reduce spasticity in MS patients. Despite an advanced stage of the disease at the time of pump placement, the complication rate was low and the efficacy of this treatment was maintained over time.

Post-activation depression in various group I spinal pathways in humans.

This investigation was designed to study the effects of post-activation depression in different spinal pathways fed by group I afferents available to investigation in human subjects. It was precipitated by a recent investigation in the cat showing that-contrary to the general assumption-post-activation depression is not a widespread phenomenon in the spinal cord. In 24 healthy subjects comparison was made between the effects of low and high-test stimulus rates on the monosynaptic Ia excitation, known to be subject to post-activation depression, and on oligosynaptic pathways fed by group I afferents. Both the amplitude of monosynaptic H reflexes and the amount of heteronymous monosynaptic Ia facilitation were significantly smaller at high than at low-test stimulus rates (1-2 s compared with 6-8 s between two consecutive stimuli). So was the amount of reciprocal Ia inhibition of tibialis anterior motoneurones. In contrast, the amount of other non-monosynaptic group I effects directed to the same motor nuclei (peroneal-induced excitation of quadriceps motoneurones, disynaptic non-reciprocal group I inhibition of flexor carpi radialis motoneurones, and D1 inhibition of flexor carpi radialis and soleus H reflexes) were enhanced at high stimulus rates. Results in humans confirm that post-activation depression depends on the type of group I afferents, and/or on the target neurones. The functional significance of the discrepancy between post-activation depression in pure Ia pathways and in other group I pathways is discussed with regard to the fusimotor-driven servo-assistance from Ia afferent discharges.

[Botulinum toxin and spinal cord injury]. / Toxine botulique et paraplégie.

OBJECTIVE: To realize a clarification about the interest of the use of botulinum toxin in spinal cord injured patients. METHOD: Interrogation of Medline database (crossing of botulinum toxin and spinal cord injury). We have also analyzed data from R. Poincaré Hospital in 2001. RESULTS: Three articles of the twenty-five selected, treated effectively of botulinum toxin effect in the limbs muscles of spinal cord injured patients. DISCUSSION: There are some indications of botulinum toxin in spinal cord injured patients ASIA C and D when spasticity induce focal functional discomfort. Indications are exceptional for ASIA A and B patients. No study showed improvement of functional abilities after botulinum toxin injection in spinal cord injured patients. Published studies only covered small number of patients.

[Efficacy of botulinum toxin A for the treatment of detrusor hyperreflexia]. / Effet de la toxine botulique A intradétrusorienne pour le traitement de l'hyperactivité vésicale d'origine neurologique.

OBJECTIVE: To determinate the efficacy of botulinum toxin to treat refractory urinary incontinence due to bladder hyperreflexia. METHOD: The international medical literature was reviewed from the Medline and Pubmed database. DISCUSSION: The usual first line treatment of detrusor hyperreflexia is parasympathicolytic drugs and self cathterization. In case of lack of efficacy or severe side effects, a surgical procedure (enterocystoplasty) can be performed. 300 units of Botox injected into the detrusor permit a significant increase of bladder capacity and a significant decrease of maximal detrusor pressure for at last 6 months. But we did not find any double blind controlled studies in this indication and no fundamental studies focused on the mechanism of action of botulinum toxin on the bladder muscle. It is now impossible to conclude on the long term efficacy and toxicity. CONCLUSION: Botulinum toxin injected into the detrusor muscle seems to be an efficient treatment of bladder hyperreflexia for 6 months in patients resistant to parasympathicolytic drugs. Long term efficacy and mechanism of action is actually not known.

[Clinical evaluation of spasticity]. / Evaluation clinique de la spasticité.

Spasticity is one component of the upper motor neurone syndrome. Unlike motor deficit and co-contraction, spasticity is responsive to treatment. Thus it receives more attention than the other features of the upper motor neuron syndrome. In order to treat correctly the patients, we need to know expectations of the patient and family. Detailed clinical evaluation including functional analysis is necessary to determine whether the objectives are reasonable. This evaluation is not always very easy because of complex clinical features. Simply aiming to reduce spasticity is not a final treatment goal. There must be a purpose behind it. It is actually very difficult to evaluate functional effect of spasticity treatments. Few studies show a real functional improvement. Yet patients are satisfied with the results and the goals are often achieved. One explanation is that functional scales usually used do not fit to the spasticity problem.

[Intrathecal therapy for bladder hyperreflexia]. / Traitement de la vessie hyperactive par les drogues intrathécales.

Intrathecal clonidine was tested for the control of bladder hyperreflexia resistant to pararsympathicolytic drugs in spinal cord injured patients. Urodynamic parameters were significantly improved after acute bolus of intrathecal low doses of clonidine. Unfortunately, the chronic intrathecal infusion of clonidine induced cardiovascular side-effects. Intrathecal baclofen did not modified significantly neurogenic bladder dysfunction from spinal lesion. But intrathecal baclofen modified penile erection quality and impaired the ejaculation reflex induced by penile vibratory stimulation in the same population.