INTRATHECAL BACLOFEN THERAPY

SPASTICITY
Defined as a velocity-dependent resistance to passive movement of a joint and its associated musculature
Characterized by hyper excitability of the stretch reflex related to the loss of inhibition from descending supraspinal structure

 Must only be treated when excess tone leads to functional losses, impairment of locomotion, or deformities Surgical procedures must be performed so that excess of tone be reduced without suppressing useful muscular tone or impairing any residual motor/sensory functions.

Managing spasticity

Mechanism of action of main pharmacological anti-spastic treatments.

Baclofen
Binds to GABA-B receptors that are found throughout the neuroaxis Most of its action occurs at the presynaptic terminals, decreasing calcium influx and consequently reducing neurotransmitter release Main adverse effects of oral baclofen : sedation or somnolence, excessive weakness.

TECHNICAL NOTE

HISTORY
1985 1998

Pump implanted subcutaneously

Grabb & Pittman Subfascial technique

associated with poor healing and wound dehiscence

lowering the risk of skin dehiscence

Patient Positioning
Left decubitus position with flexed hips and knees A soft pillow is placed under the hips and between the knees to avoid pressure sores Upper arm is held away from the surgical field

Surgical preparation
Antibiotics are administered at the time of anesthesia induction Operating field is prepared with chlorhexidine and adhesive sterile draping

Implant Site Selection

The preferred surgical side is the right (for right handed) A transverse skin incision is made in the right hypocondrium at the level of the upper third of line running between the xyphoid process and pubic ramus Avoid contact with the lower end of the rig cage

Dissection
Incision is deepened through the subcutaneous fat
Care is made not to dissect it from the muscle fascia to avoid creating dead space

A single plane is created down to the rectus sheath, and both the lateral and medial edges of the rectus abdominis are identified.

 The fascia of the rectus sheath is incised horizontally and is continued laterally into the full thickness of the external oblique muscle.

 At the medial side of the wound, the anterior layer of the fascia of the internal oblique muscle merges with its posterior fascial layer over the lateral edge of the rectus abdominis muscle at a variable distance along the line of linea semilunaris Cutting in between these internal oblique layers help to open a natural plane between the external oblique muscle anteriorly and the internal oblique, transversus abdominis, and peritoneum posteriorly.

 In summary, a space is created starting beneath the anterior rectus sheath medially, continuing laterally under the external oblique. The internal oblique, the transversus abdominis, and the peritoneum constitute the posterior wall of this pouch

Checks
Pump will fit inside the pouch Fascia will close easily over the entire pump and connector There is sufficient place to connect the catheter No bleeding

Spinal Acces
Level of insertion: L3-4 Skin is incised 2 cm over the lumbar spine down to the supraspinous fascia in the interspinous space A 14-gauge Tuohy needle is used to access the thecal sac

Spinal Access
The entry point is made 1-1.5 cm from the midline away from the interspinous ligament to avoid fracture of the catheher after insertion Do not enter too laterally beyond the pedicle to avoid catheter migration as the thin fascial layer and increased muscle bulk laterally could potentially increase the differential motion and lead to migration of the catheter

Tunneling
Tunneling is performed from subfascial pouch in the abdomen and is directed to the lumbar incision Tunneling device leaves the pump side from inside the subfascial pouch by passing between the muscle layer and its fascia to end up in the subcutaneous tissue

Tunneling
Before attaching the catheter to the pump connector, make a check that CSF is draining and the catheter is secured with the connector with silk ties The full length of the catheter is left without shortening and remaining tube is coiled behind the pump and over the lumbar fascia

Postoperative Course
Stay in the hospital for at least 48 hours to make sure there is no wound leak or postlumbar puncture syndrome

Operation Duration
Varies between 50 and 150 minutes, with an average of 70 minutes

Pump

Photographic (A) and radiographic (B) representations of the SynchroMed model EL intrathecal baclofen pump depicting the pump rotor (red ring), reservoir port (yellow arrow ), catheter-

access port (blue arrow), and the pump connector (magenta arrow).

Outcome

Complication

Baclofen Dose
The average dose of intrathecal baclofen started at 200 mcg a day and increased over time for the first year or two and then stabilized below 400 mcg a day.
the amount of baclofen infused usually has to be increased in the first 612 months. In most patients, it stabilizes by a year to 2 years and further increases in dosage are not necessary. The range of effective dosing is quite large. Some patients are well controlled with 25 mcg per day and other patients may need over 1000 mcg a day

Baclofen Withdrawal Syndrome

MH: Malignant Hyperthermia NMS: Neuroleptic Malignant Syndrome