Effectiveness and safety of cervical catheter tip placement in intrathecal baclofen treatment of spasticity: A systematic review.

OBJECTIVE: To evaluate the effectiveness and safety of intrathecal baclofen treatment of spasticity, administered via a cervical catheter tip. DESIGN: A review of PubMed and the Cochrane Library up to September 2020. No restriction in study design. Two reviewers independently evaluated eligibility, extracted data and evaluated risk of bias. Studies were included in which patients were treated with intrathecal baclofen for spasticity, with the catheter tip at or above the first thoracic level, independent of diagnosis and age. RESULTS: Thirteen studies were eligible, with a moderate to critical risk of bias. Improvement in spasticity was seen only in the upper extremity in 6% of subjects, only in the lower extremity in 2%, in both upper and lower extremities in 50% and without specification of location in 41%. Upper extremity function improved in 88% of cases. Neither drug-related (1%) nor technical (21%) complications occurred more often than in lower placement of the tip. Effects on respiratory function and sleep apnoea were not investigated. CONCLUSION: Cervically administered intrathecal baclofen seems to improve upper extremity spasticity and function, without causing more complications than thoracolumbar intrathecal baclofen. However, the mainly drug-related complications have not been thoroughly investigated and the available literature is of poor methodological quality. Further research is needed to confirm the efficacy and safety of this procedure.

Comparison of Programmed Intermittent Epidural Boluses With Continuous Epidural Infusion for the Maintenance of Labor Analgesia: A Randomized, Controlled, Double-Blind Study.

BACKGROUND: Programmed intermittent epidural boluses may improve the spread of local anesthetics compared to continuous epidural infusion, improving labor analgesia and obstetric outcomes. However, there are limited data from studies using commercially available pumps capable of coadministering programmed intermittent epidural boluses or continuous epidural infusion with patient-controlled epidural analgesia. Therefore, we performed this prospective, randomized, double-blind study to compare the impact of programmed intermittent epidural boluses versus continuous epidural infusion on labor analgesia and maternal/neonatal outcomes. We hypothesized that programmed intermittent epidural boluses will result in lower patient-controlled epidural analgesia consumption compared to that with continuous epidural infusion. METHODS: Following standardized initiation of epidural labor analgesia, women were randomized to receive 0.1% ropivacaine with 2 µg/mL fentanyl as 6-mL programmed intermittent epidural boluses every 45 minutes or continuous epidural infusion at 8 mL/h in a double-blind fashion with similar patient-controlled epidural analgesia settings in both groups. The primary outcome was patient-controlled epidural analgesia consumption per hour. Secondary outcomes included a need for physician interventions, patterns of patient-controlled epidural analgesia use, motor blockade, number of patients who developed hypotension, pain scores, duration of second stage of labor, mode of delivery, and maternal satisfaction. RESULTS: We included 120 patients (61 in programmed intermittent epidural boluses group and 59 in continuous epidural infusion group) in the analysis. The median (interquartile range) patient-controlled epidural analgesia volume consumed per hour was not significantly different between the groups: 4.5 mL/h (3.0-8.6 mL/h) for the continuous epidural infusion group and 4.0 mL/h (2.2-7.1 mL/h) for the programmed intermittent epidural boluses group (P = .17). The Hodges-Lehmann location shift estimate of the difference (95% CI) from the continuous epidural infusion to the programmed intermittent epidural boluses group is 0.9 mL/h (-0.4 to 2.2 mL/h). There were also no significant differences between the groups in any of the secondary outcomes except for higher median (interquartile range) patient-controlled epidural analgesia attempts per given ratio per hour in the programmed intermittent epidural bolus group (0.17 [0.10-0.30] vs 0.12 [0.08-0.18]; P = .03) and more motor block in the continuous epidural infusion group (those with Bromage score <5, 27.5% vs 50.0%; P = .03). CONCLUSIONS: Under the conditions of our study, we did not find improved outcomes with programmed intermittent epidural boluses compared to continuous epidural infusion except for less motor block with programmed intermittent epidural boluses. Future studies should assess whether smaller but clinically important differences exist and evaluate different parameters of programmed intermittent epidural boluses to optimize analgesia and outcomes with this mode of analgesia.

Intrathecal Baclofen Infusion Pumps in the Treatment of Spasticity: A Retrospective Cohort Study in a Portuguese Centre.

INTRODUCTION: Spasticity is a complex problem in patients with neurological disorders and may distress their quality of life. Intrathecal baclofen infusion pumps reduce spasticity with low doses and minimal side effects but are not free from complications. We aimed to evaluate the efficacy and safety of intrathecal baclofen infusion pumps as well as patients' satisfaction. MATERIAL AND METHODS: Retrospective cohort study including all intrathecal baclofen infusion pumps placed up to December 2015. Demographic characteristics, clinical diagnoses, date of placement or withdrawal/replacement of intrathecal baclofen infusion pumps, baclofen dosage and complications of intrathecal baclofen infusion pumps were collected. Assessments from the Ashworth and Penn's scales, Katz index and patients' global satisfaction were analysed. RESULTS: In 19 years we placed 251 intrathecal baclofen infusion pumps in 155 patients. The mean age was 41.1 ± 15.8 years. The most frequent conditions were: trauma (34%), cerebral palsy (14%), multiple sclerosis (12%) and stroke (12%). Eighty-five patients (55%) required a second pump, and eleven (7%) a third one. The lifetime of the first pump was 72 (36 - 89) and the total follow-up time was 96 (9 - 132) months. The causes of withdrawal/replacement were: battery failure (57%), catheter migration/kinking (24%), infection (14%) and pump displacement/exteriorization (7%). The complication rate was 0.21 events/month. There was a significant improvement in the Ashworth and Penn's scales after the placemen of intrathecal baclofen infusion pumps (p < 0.001 for all diagnoses) and the patients were satisfied with the treatment. DISCUSSION: The incidence of complications was within range of other international studies despite our long follow-up time. Events per month, loss to follow-up, re-intervention rate, incidence of infection and mortality were similar to other studies. CONCLUSION: Intrathecal baclofen infusion pumps are safe and effective in the treatment of spasticity. Infusion pumps provide a high level of satisfaction regarding treatment and quality of life.

Introdução: A espasticidade é um problema complexo em doentes com distúrbios neurológicos influenciando a sua qualidade de vida. As bombas perfusoras intratecais de baclofeno reduzem a espasticidade com doses baixas e efeitos laterais mínimos, mas não estão livres de complicações. Pretendemos avaliar a eficácia, segurança e satisfação dos doentes com bombas perfusoras intratecais de baclofeno. Material e Métodos: Estudo de coorte retrospetivo, incluindo todas as bombas perfusoras intratecais de baclofeno colocadas até dezembro de 2015. Foram avaliadas as características demográficas, diagnósticos, data de colocação ou retirada/substituição e complicações das bombas perfusoras intratecais de baclofeno. Analisaram-se as escalas Ashworth, Penn, Katz e satisfação dos doentes. Resultados: Durante 19 anos colocaram-se 251 bombas perfusoras intratecais de baclofeno em 155 doentes. A idade média foi 41,1 ± 15,8 anos. As patologias mais freqüentes foram: traumatismo (34%), paralisia cerebral (14%), esclerose múltipla (12%) e acidente vascular cerebral (12%). Oitenta e cinco doentes (55%) precisaram de uma segunda e onze (7%) de uma terceira bomba. A semi-vida da primeira bomba foi 72 (36 ­ 89) e o tempo total de seguimento 96 (9 ­ 132) meses. As causas de retirada/substituição foram: falha de bateria (57%), migração/kinking do cateter (24%), infeção (14%) e deslocamento/exteriorização da bomba (7%). A taxa de complicações foi 0,21 eventos/mês. Houve uma melhoria significativa nas escalas de Ashworth e Penn após colocação das bombas perfusoras intratecais de baclofeno (p < 0,001 para todos os diagnósticos) e os doentes ficaram satisfeitos com o tratamento. Discussão: A incidência de complicações situou-se dentro do intervalo reportado por outros estudos internacionais, apesar do longo tempo de seguimento. Número de eventos por mês, perda de seguimento, taxas de re-intervenção ou infecção e mortalidade foram semelhantes a outros estudos. Conclusão: As bombas perfusoras intratecais de baclofeno são seguras e eficazes no tratamento da espasticidade e oferecem um alto nível de satisfação quanto ao tratamento e qualidade de vida.

Manejo perioperatorio de pacientes portadores de sistemas electrónicos implantables para el control del dolor crónico / Perioperative management of patients with implanted electronic devices for the treatment of chronic pain

No disponible

Slow Infusion of Recombinant Adeno-Associated Viruses into the Mouse Cerebrospinal Fluid Space.

Recombinant adeno-associated viruses (rAAVs) are the leading in vivo gene delivery platform, and have been extensively studied in gene therapy targeting various tissues, including the central nervous system (CNS). A single-bolus rAAV injection to the cerebrospinal fluid (CSF) space has been widely used to target the CNS, but it suffers from several drawbacks, such as leakage to peripheral tissues. Here, a protocol is described using an osmotic pump to infuse rAAV slowly into the mouse CSF space. Compared to the single-bolus injection technique, pump infusion can lead to higher CNS transduction and lower transduction in the peripheral tissues.

Total spinal block after local anesthetic administration through the wrong access port of a spinal infusion pump. / Bloqueo espinal total tras administración de anestésico local por el puerto de acceso equivocado de una bomba de infusión intratecal.

We present a case reported on the SENSAR database. A patient with a spinal infusion pump was admitted for reservoir refill. On administration of 22ml of 0.75% bupivacaine the patient suffered a total spinal block with widespread loss strength and respiratory arrest. The patient required emergency orotracheal intubation, mechanical ventilation and admission to ICU, where extubation was achieved within two hours without incidences. At a later stage it was stated that the local anaesthetic had been administered via the access port for bolus or contrast administration instead of via the access to the reservoir. Analysis of the incident showed up latent factors related to absence lack of personnel training and internal protocols. The following measures were taken: pain unit meeting, alert sent to SENSAR bulletin and training request for members of the service.

Neuromodulation in multiple sclerosis.

Neuromodulation, or the utilization of advanced technology for targeted electrical or chemical neuronal stimulation or inhibition, has been expanding in several neurological subspecialties. In the past decades, immune-modulating therapy has been the main focus of multiple sclerosis (MS) research with little attention to neuromodulation. However, with the recent advances in disease-modifying therapies, it is time to shift the focus of MS research to neuromodulation and restoration of function as with other neurological subspecialties. Preliminary research supports the value of intrathecal baclofen pump and functional electrical stimulation in improving spasticity and motor function in MS patients. Deep brain stimulation can improve MS-related tremor and trigeminal neuralgia. Spinal cord stimulation has been shown to be effective against MS-related pain and bladder dysfunction. Bladder overactivity also responds to sacral neuromodulation and posterior tibial nerve stimulation. Despite limited data in MS, transcranial magnetic stimulation and brain-computer interface are promising neuromodulatory techniques for symptom mitigation and neurorehabilitation of MS patients. In this review, we provide an overview of the available neuromodulatory techniques and the evidence for their use in MS.

Intrathecal baclofen withdrawal: A rare cause of reversible cardiomyopathy.

Baclofen is commonly used to treat spasticity of central etiology. Unfortunately, a potentially lethal withdrawal syndrome can complicate its use. This is especially true when the drug is administered intrathecally. There are very few cases of baclofen withdrawal leading to reversible cardiomyopathy described in the literature. The authors present a patient with a history of chronic intrathecal baclofen use who, in the setting of acute baclofen withdrawal, develops laboratory, electrocardiogram, and echocardiogram abnormalities consistent with cardiomyopathy. Upon reinstitution of intrathecal baclofen, the cardiomyopathy and associated abnormalities quickly resolve. Although rare, it is crucial to be aware of this reversible cardiomyopathy to ensure its prompt diagnosis and treatment.

Infection as a Complication of Intrathecal Baclofen Treatment in Children With Cerebral Palsy.

BACKGROUND: Children with cerebral palsy (CP) and spasticity are often managed with intrathecal baclofen treatment (ITB). Complications of ITB include infection at the pump or catheter site and late complications as well as revisions of the pump and catheter because of events such as battery expiration or implant malfunction. The goal of this study is to report the short-term and long-term incidence, risk factors, and treatment outcomes of ITB infections in children. METHODS: This was a retrospective review of 294 children with CP. The number of ITB surgeries per patient, risk of infection for primary and secondary ITB-related procedures, microorganisms responsible, and associated factors, such as concurrent orthopaedic interventions, medical comorbidities, and subsequent management of ITB-related infections, were evaluated. RESULTS: Infection occurred in 28/294 patients (9.5%) with a 4.9% rate per procedure. There were 14 acute (within 90 d of surgery) and 14 late infections. The infection risk per ITB procedure was 2.4%. Risk of late infection over 5-year mean follow-up was 0.95% per year. Pump removal with acute contralateral implantation was the most successful treatment of infections. Gross Motor Function Classification System level V and G-tube were the main risk factors for infection. A total of 133 concurrent orthopaedic procedures were performed during 277 ITB procedures with no increased risk of infection. CONCLUSIONS: ITB in children with CP has a relatively low and manageable risk of infection. It is important to always consider infection as a complication with ITB because with prompt treatment the positive impact of ITB is still possible. It is safe to perform concurrent orthopaedic procedures with ITB procedures. LEVELS OF EVIDENCE: Level III-therapeutic study.

Spasticity and the use of intrathecal baclofen in patients with spinal cord injury.

Muscle spasms and spasticity constitute a significant problem in patients with spinal cord injury, interfering with rehabilitation and leading to impairments in quality of life in addition to medical complications. Administration of intrathecal baclofen (ITB) is indicated when spasticity continues to produce a clinical disability despite trials of oral treatments and other alternatives in patients who have functional goals and/or pain without contractures. Severe spasticity of spinal origin has been shown to respond dramatically to long-term ITB when used in appropriate patients with spasticity.

Aberrant intrathecal pump refill: ultrasound-guided aspiration of a substantial quantity of subcutaneous hydromorphone.

Intrathecal drug delivery systems are an effective and increasingly common pain treatment modality for certain patient populations. Pumps are surgically inserted in a subcutaneous abdominal pocket and refilled with highly concentrated medication at regular intervals. Inadvertent injection of medication outside the pump is a known complication of the refill procedure. We describe the injection of hydromorphone into the pump's surrounding subcutaneous pocket, subsequent opioid overdose, and the novel application of ultrasound to visualize and aspirate the subcutaneous drug. Ultrasonography can be used as an effective modality for rapid diagnosis and treatment of an accidental pocket fill.

Increasing back and radicular pain 2 years following intrathecal pump implantation with review of arachnoiditis.

BACKGROUND: Implanted intrathecal drug delivery pumps are now regularly used for the treatment of chronic benign and cancer-related pain that is refractory to conservative treatment methods. In most cases, the pumps are successful at reducing the intensity of pain and improving function and quality of life for pain patients. Limited studies have discussed the complications associated with intrathecal pump placement. SETTING: Academic tertiary care center. SUMMARY: We describe an unusual case of a patient who presented with progressive weakness and worsening lumbar and lower extremity pain following implantation of an intrathecal drug delivery system (IDDS). Work-up for the patient's symptoms includes a magnetic resonance imaging, which revealed lumbar arachnoiditis. Patient underwent a laminectomy and detethering of spinal cord and nerve roots below level of catheter insertion. There was transient improvement in her pain and weakness. Subsequent surgery for pump explantation revealed a retained Touhy introducer needle from her pump placement procedure. CONCLUSION: The entire IDDS was removed including the retained Touhy introducer needle. The patient later went on to receive a successful spinal cord stimulator trial and implantation with moderate relief of her chronic pain.

Cerebrospinal fluid-compensated medication reservoir for an implantable infusion device: concept and preliminary evaluation.

Conventional gas-compensated medication reservoirs used for implantable infusion devices require perfect sealing of the gas chamber, because the gases used are generally toxic. In addition, the physical properties of selected gas critically affect the performance of infusion devices and hydraulic performance of the infusion device can be affected by the amount of medication discharged.
In this study, we suggest a new medication reservoir that adopts a cerebrospinal fluid (CSF)-compensating mechanism, such that when a medication is released from the reservoir by a mechanical actuator, native CSF enters into the reservoir to minimize the build-up of pressure drop. We evaluated in vitro performance and conducted in vivo feasibility tests by using an intrathecal infusion device developed at the Korean National Cancer Center. Experimental results showed that the proposed CSF-compensated infusion pump was essentially less affected by ambient temperature or pressure conditions compared to the gas-compensated infusion pump. Moreover, it showed moderate implant feasibility and operating stability during an animal experiment performed for 12 days. We believe that the proposed volume-compensating mechanism could be applied in various medical fields that use implantable devices.

Ultrasound-guided refilling of an intrathecal baclofen pump--a case report.

INTRODUCTION: Refilling intrathecal baclofen (ITB) pumps can be difficult because many patients gain excessive weight after implantation due to their reduced expenditure of energy on muscle spasticity. METHODS: We report a case of a 12-year-old girl with spastic quadriplegia who gained 20 lbs after pump implantation. It was necessary to identify the access port of her pump by ultrasonography during drug refilling so as to avoid multiple needle punctures. RESULTS: The access port of the pump was readily visible by ultrasonography and stood out from other parts of the pump. CONCLUSION: Localisation of the access ports of ITB pumps by ultrasonography proved to be a feasible and easy technique for refilling the drug reservoir in patients with excessive weight gain and abundant subcutaneous fat after ITB therapy.

Estado actual del uso de la fenilefrina en la paciente gestante sometida a cesárea con anestesia espinal / No disponible

La placenta es el órgano a través del cual el feto recibe oxígeno y nutrientes y elimina productos de desecho mientras está en el útero. Este órgano tiene diversas funciones: transferencia de sustancias, respiración, función endocrina y función barrera. El flujo uterino es el principal determinante del transporte de oxigeno entre el feto y la madre. Los objetivos a cumplir cuando se utiliza un fármaco con el fin de prevenir o tratar la hipotensión arterial son: la reducción de las náuseas y vómitos maternos, el efecto sobre el gasto cardiaco y la frecuencia cardiaca materna durante el intraoperatorio y los resultados neonatales, en cuanto a evaluación precoz del recién nacido. La efedrina se asocia con un pH más ácido y un menor exceso de base en el neonato. Hay un riesgo significativamente mayor de acidosis fetal con efedrina que con fenilefrina. Comparando los efectos maternos, la fenilefrina tiene mayor riesgo de bradicardia y los hallazgos hasta ahora apuntan a un perfil más favorable en el abordaje de la hipotensión arterial materna en las cesáreas electivas con anestesia espinal con la fenilefrina. Si la paciente tiene hipotensión y bradicardia, lo cual es menos frecuente, entonces debe ser tratada con efedrina y /o anticolinérgicos(AU)

The placenta is the organ through which the fetus receives oxygen and nutrients and removes waste products while in the uterus. This body has various functions: transfer of substances, respiration, endocrine function and barrier function. Uterine blood flow is the main determinant of oxygen transport between fetus and mother. The objectives to be met when using a drug to prevent or treat low blood pressure are: reducing maternal nausea and vomiting, the effect on cardiac output and heart rate during surgery, maternal and neonatal outcomes, measured as early assessment of the newborn. Ephedrine is associated with amore acidic pH and lower base excess in the neonate. There is a significantly increased risk of fetal acidosis with ephedrine than with phenylephrine. Comparing maternal effects, phenylephrine at higher risk of bradycardia and the findings so far point to a more favorable approach to maternal hypotension during elective cesarean section under spinal anesthesia with phenylephrine. If the patient has hypotension and bradycardia, which is less frequent, then it must be treated with ephedrine and/or anticholinergic drugs(AU)