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At least 541 records · Page 30Linked to original sources
PubMed2005

Efficacy of early use of intrathecal baclofen therapy for treating spastic hypertonia due to acquired brain injury.

OBJECTIVE: To determine the efficacy and safety of early (<1 year post-disease onset) use of intrathecal baclofen (ITB). DESIGN: Consecutive case series of 14 individuals with spastic hypertonia due to trauma (5), anoxia (6) and stroke (3). MAIN OUTCOME MEASURES: Modified Ashworth (MAS) and Disability Rating (DRS) scales. INTERVENTIONS: ITB pump placement within 1 year of onset, after inadequate response to other previous treatment modalities. RESULTS: At follow-up after ITB pump implantation (mean = 13.9 months; mean daily dose = 591.5 microg per day), mean MAS scores improved from baseline by 1.0 and 2.1 points in the upper and lower limbs, respectively. DRS scores did not change significantly. Functional gains included decreased pain and improved gait speed and motor skills. The only complication was spinal leak in one subject. CONCLUSIONS: ITB therapy within 1 year of onset of acquired brain injury appears effective and safe in decreasing spastic hypertonia and does not appear to adversely affect recovery.

Adolescent↗
PubMed1988

Implanted pump systems for treatment of spasticity.

In about one third of patients with violent spasticity due to spinal trauma, multiple sclerosis, and diffuse brain injury adequate control with oral antispastic medication cannot be achieved and successful rehabilitation is severely handicapped. In the past these patients were subjected to destructive chemical procedures or extensive surgery. The authors present the results of management of uncontrollable spasticity by means of continuous intrathecal administration of baclofen with a totally implantable gas driven pump system (Infusaid). 30 patients were treated between June 1985 and January. 1987. The main indication was incapacitating spasticity resistant to oral treatment with baclofen and caused by spinal cord injury or lesion (11 patients), multiple sclerosis (11 patients), infantile cerebral palsy (3 patients) and cerebral injury, hypoxia or ischaemia (5 patients). Clinical assessment included spasticity scores, integrated electromyography (Iemg) and motography. Effective control for spasticity with mean reduction of Iemg by 55%, decrease of Ashworth's score from 3 to 0 and improvement of life quality was obtained in all patients with daily dose of 10-800 micrograms of Baclofen. Voluntary resting motoricity was not impaired and there were no untoward central side effects. The excellent effect of intrathecal baclofen in comparison with oral therapy is explained by local, spinal GABAergic inhibitory action of the drug which is delivered directly into spinal subarachnoid space. Dose finding and dose adjustment is performed prior to pump implantation by intermittent injections into a subcutaneous port. The complications of the procedure were minor (catheter displacement, disconnection) and easily correctable.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1987

Propofol for intravenous sedation.

This study investigated the properties of propofol when given by subanaesthetic infusion to provide sedation as an adjunct to spinal anaesthesia for lower limb surgery in 40 patients. Sedation, defined as sleep with preservation of eyelash reflex and purposeful reaction to verbal or mild physical stimulation, was satisfactorily achieved and maintained with minimal complications. The mean duration of infusion was 98 minutes and a mean infusion rate of 3.0 mg/kg/hour was required in patients over 65. This was significantly less (p less than 0.005) than the 4.1 mg/kg/hour required in younger patients. Recovery was impressively rapid; patients regained full consciousness approximately 4 minutes after the end of infusion, and were free from minor postoperative sequelae. Conversion to general anaesthesia was achieved in three patients where surgery encroached outside the analgesic field of the regional block, simply by increasing the infusion rate to approximately 10 mg/kg/hour.

Adolescent↗
PubMed1990

Chronic intrathecal baclofen administration in severe spasticity.

On the basis of previous experimental and clinical studies, 14 patients with severe spasticity due to central or spinal cord damage, resistant to all conservative treatments, were selected after a percutaneous trial period for chronic intrathecal baclofen infusion by programmable pumps. The agent was delivered at C4 in quadriplegic patients or in cases with central spasticity and in the neighbouring areas on the affected segments in paraplegic patients. The daily baclofen dose varied from 25 to 260 micrograms and was infused in a bolus, continuously infused or both combined according to the results during the trial period. After a mean follow-up period of 11 months, constant decrease of rigidity, absence of spasms, improvement of bladder function, cramping pain remission, and moderate improvement in walking capacity and transfer activities were usually observed. Neither complications nor side effects were noted.

Adolescent↗
PubMed1992

"Locked-in syndrome" after intrathecal cytosine arabinoside therapy for malignant immunoblastic lymphoma.

A 22-year-old man with malignant immunoblastic lymphoma had "locked-in" syndrome within 48 hours of receiving a single (100 mg) dose of intrathecal cytosine arabinoside (ara-C) in conjunction with intravenous ara-C, cisplatin, and doxorubicin. Eight hours after therapy, the patient had central hypoventilation and blurred vision that progressed to blindness within 3 hours. During the next 10 hours, he became completely quadriplegic but remained intermittently alert and was able to respond to commands by eye or head movements. Radiographic studies showed necrosis of the medulla and swelling of the entire spinal cord. The patient persisted in a locked-in state until his death 3 weeks later, after removal of life support systems. Autopsy confirmed extensive necrosis of the lower medulla, optic chiasm, cranial nerves I and IV, and spinal cord. This case was unusual for its severity. The temporal relationship to ara-C instillation favors a toxic idiosyncratic response to chemotherapy. The authors advocate caution when bolus intrathecal and intravenous ara-C are administered to a patient within a short time of each other.

Adult↗
PubMed1996

Chronic intrathecal morphine treatment does not cause down-regulation of spinal adenosine A1 receptors in rats.

We have shown previously that systemic chronic morphine treatment causes down-regulation of spinal adenosine A1 receptors in rats. Recently, we have found that chronic supraspinal morphine treatment also causes this effect. In the present study, we investigated whether chronic spinal morphine treatment has the same effect of down-regulation of spinal adenosine A1 receptors. Adult male Sprague-Dawley rats were rendered tolerant to morphine either by multiple intrathecal (i.t.) injections or continuous i.t. infusion by osmotic pump administration for 2 or 4 days. Spinal A1-adenosine receptor binding activity was measured by using the selective A1 adenosine agonist [3H]cyclohexyladenosine. No significant decrease in [3H]cyclohexyladenosine binding was found in the spinal cord after 2 or 4 days of multiple i.t. injections of morphine. There was also no significant change in the amount of spinal [3H]cyclohexyladenosine bound after 4 days of continuous i.t. infusion of morphine by osmotic pump. From these and our previous results, it is concluded that only supraspinal chronic morphine treatment down regulates the spinal A1 adenosine receptor and this may play a role in the mechanism of supraspinal morphine tolerance but not spinal morphine tolerance.

Adenosine↗
PubMed1990

[The intraosseous administration on kavinton in treating myeloradiculoischemia].

The authors present a comparative analysis of the efficacy of their method of administration of vasoactive drugs into the peridural venous system and traditional conservative therapy in radiculomyeloischemia of different etiology. The dynamics of the disease was evaluated both by clinical manifestations and by evoked spinal cord potentials, complex examination of the acid-base balance of the blood from the involved vascular territory and blood from extremities. Results of a detailed examination of 24 patients with myeloradiculopathy carried out by means of precise electrophysiological and laboratory methods permit to recommend this treatment in clinical conditions.

Adult↗
PubMed2000

Pseudomonas aeruginosa infection in an intrathecal baclofen pump: successful treatment with adjunct intra-reservoir gentamicin.

OBJECTIVE: To describe the use of intra-reservoir gentamicin for the treatment of a Pseudomonas aeruginosa infected baclofen pump. SETTING: Regional Spinal Injuries Centre, Hexham, Northumberland, England. SUBJECT: Male patient aged 32 years with progressive multiple sclerosis and severe bilateral spasticity. RESULTS: Intra-reservoir gentamicin proved successful in treating infection with Pseudomonas aeruginosa. CONCLUSION: Intra-reservoir gentamicin may be successful in treating pump infection with Pseudomonas aeruginosa without the need for pump removal.

Adult↗
PubMed1998

The effect of experimental spinal cord edema on the spinal evoked potential.

Experimental spinal cord edema was successfully produced in the cat intumescentia cervicalis by the infusion method of Marmarou. The water content around the infusion site significantly increased to 75.9% from the normal value of 69.8% of white matter in the lateral column, with the infusion of 20 microliters of autoserum. The edema was observed for a length of ca.20 mm, spreading mainly longitudinally in the lateral column. The spinal evoked potential was measured four times on the course of infusion and the N1 peak latency at the end of infusion did not show any significant difference compared to the value before infusion. This model may contribute to basic understanding of pathophysiology of spinal cord edema by changing the nature and the volume of infusate, and the location of infusion, according to the experimental purpose.

Afferent Pathways↗
PubMed1992

Vascular changes in the spinal cord in N-methyl-D-aspartate-induced excitotoxicity: morphological and permeability studies.

Our previous studies have demonstrated toxicity in spinal cord neuronal systems of middle-aged rats with continuous intrathecal infusion of N-methyl-D-aspartate (NMDA). The present study was undertaken to determine when during the course of excitotoxicity vascular changes occur. The model used was intrathecal infusion of NMDA in the region of the lumbar enlargement of the spinal cord. Horseradish peroxidase (HRP) was used as a marker of vascular permeability alterations occurring in this model. Pathological changes were observed in the cord gray matter of all rats infused with 30-60 micrograms/min NMDA for 30 or 60 min. The changes consisted of swelling of dendrites which gave the neuropil a vacuolated appearance. There was expansion of the extracellular spaces in these areas and neurons were shrunken with pyknotic nuclei. These changes were more frequently encountered in the posterior than anterior horns and were specific for NMDA since they did not occur in NMDA-infused rats pretreated with MK-801, a specific NMDA antagonist. Endothelial dysfunction manifested as increased permeability to HRP. This was a consistent finding in all rats infused with the higher dose of NMDA and was less frequent in those infused with 30 micrograms/min and no vascular changes were observed in rats infused with NMDA for 30 min despite the presence of tissue changes. Increased permeability affected all types of vessels but principally, capillaries and venules. There was no evidence of endothelial necrosis or vascular occlusion. This study demonstrates that in excitotoxin-mediated tissue damage, breakdown of the blood-brain barrier follows the development of nervous tissue damage. Thus, edema is not a significant feature of early lesions in excitotoxin-induced brain injury.

Animals↗
PubMed1995

Spread of a neurotropic coronavirus to spinal cord white matter via neurons and astrocytes.

Mouse hepatitis virus strain JHM (MHV-JHM) causes a chronic encephalomyelitis in susceptible mice, with histological evidence of demyelination in the spinal cord. After intranasal inoculation, virus spreads retrogradely to several brain structures along neuroanatomic projections to the main olfactory bulb. In the absence of experimental intervention, mice become moribund before the spinal cord is infected. In this study, infusions of anti-MHV neutralizing monoclonal antibodies were administered to protect mice from the MHV-JHM-induced acute encephalitis and to allow survival until virus spread to the spinal cord. Under these conditions, virus was observed to enter specific layers (primarily laminae V to VII) in the gray matter of the upper spinal cord, consistent with transneuronal spread. While the brain structures which are the sources for virus spread to the spinal cord cannot be determined with certainty, the ventral reticular nucleus is likely to be important since it is consistently and extensively labeled in all mice and receives projections from subsequently infected areas of the spinal cord. After initial entry into the gray matter, virus rapidly spread to the white matter of the spinal cord. During the early stages of this process, extensive infection of astrocytes was noted, suggesting that cell-to-cell spread via these glial cells is an important part of this process. Reports from other laboratories using cultured cells strongly suggested that astrocytes serve as important regulators of oligodendrocyte function and, by extrapolation, have a major role in vivo in the processes of both demyelination and remyelination. Thus, our results not only outline the probable pathway used by MHV-JHM to infect the white matter of the spinal cord but also, with the assumption that infection of astrocytes leads to subsequent dysfunction, raise the possibility that infection of these cells contributes to the demyelinating process.

Animals↗
PubMed1992

Effects of acute bolus and chronic continuous intrathecal baclofen on genitourinary dysfunction due to spinal cord pathology.

A prospective, blinded study was done to examine the effects of acute bolus and chronic continuous intrathecal baclofen on genitourinary function in 10 patients with severe spasticity due to spinal cord pathology. Genitourinary function was assessed by symptom questionnaires and urodynamic studies performed after a bolus dose of baclofen and 6 to 12 months after continuous intrathecal baclofen. Results were compared to placebo for acute bolus testing or to pre-continuous intrathecal baclofen values. In all patients with irritative voiding and urge incontinence uninhibited bladder contractions were eliminated. Of 3 patients with an indwelling urethral catheter for incontinence due to detrusor hyperreflexia 1 was converted to intermittent self-catheterization. Whereas bladder capacity, compliance, sensation and voiding pressures were not different after continuous intrathecal baclofen, when a mean of all patients was compiled, a 72% increase in capacity and 16% improvement in compliance were observed in subjects without cervical spinal cord pathology. Detrusor-sphincter dyssynergia was abolished in 40% of the patients. Continuous intrathecal baclofen may represent a novel approach to the management of patients with a neurogenic bladder who have decreased bladder compliance and detrusor hyperreflexia not controlled by oral medications.

Adult↗
PubMed1994

Complications of spinal opioid therapy: myoclonus, spastic muscle tone and spinal jerking.

This study was made in order to define risk factors for patients requiring spinal opioid therapy developing painful spastic muscle tone together with myoclonus and spinal jerking (MSJ). The case histories of 75 patients, all receiving morphine spinally, were retrospectively analysed and, of these, 10 suffered from the MSJ syndrome. The following were taken as evaluation criteria: age, sex, performance status, duration and dosage of previous systemic and current spinal morphine therapy, concomitant analgesic and co-analgesic medication, pretreatment of the dorsal column and neurological dysfunction due to damage either of the nerval plexus or of the medulla spinalis. As a result, high spinal morphine doses in conjunction with pathological changes within the spine were shown to be risk factors for this syndrome. Changing from spinal to systemic morphine application or reduction of spinal doses together with the addition of systemic morphine led to complete recovery from MSJ. As underlying mechanism, an imbalance between the activity of spinal and central opioid receptors and/or toxic morphine effects on the medulla spinalis are discussed. In conclusion, great care should be taken when applying morphine to the spine in patients with neurological dysfunction due to an apparent pathology of the medulla spinalis, especially if large amounts of morphine are likely to be required. Some systemic application of morphine might reduce the risk of patients developing MSJ syndrome.

Administration, Oral↗
PubMed2003

Intrathecal medication delivery.

This brief review of intrathecal pain medication delivery has emphasized the unusual but useful pharmacology of CSF drug delivery, the new study definitely showing that the method is helpful in cancer pain, and the rare complication of mass formation at the catheter tip. As new medications are developed for intrathecal delivery, this field is likely to expand, especially if a wider range of dorsal horn receptor mechanisms underlying pain processing can be modified. The changes in spinal cord signaling that are induced by chronic pain states are being investigated, and new possibilities for intervention are likely. the availability of a reliable well-understood way of delivering such new therapies by implanted drug pumps will speed the process. Intrathecal morphine for chronic pain has an important role in helping many patients with a wide variety of pain conditions and, as with all pain treatment, is woefully underused.

Analgesics↗
PubMed1990

[Antibiotic treatment for diabetic foot. Advantages of intravenous regional route as alternative for systemic route].

Diabetic angiopathy prevents adequate access of antibiotic agents to septic areas of the diabetic foot. We treated 22 such patients with antibiotics infused through a superficial vein associated to tourniquet occlusion of the limb (Group A). A control group of 47 patients, similar in age, sex and severity of diabetes received conventional systemic therapy (Group B). 45% of the patients exhibited occlusive arterial disease. Surgery was performed by the same team in both groups. Group A received regional anesthesia at the same time of the first antibiotic infusion. Group B received general or spinal anesthesia. Amputation was required in 5% of patients in Group A compared to 30% of patients in Group B (p < 0.02). Hospital stay was also significantly shorter in patients from Group A. No complications of this form of therapy were observed. Thus, regional antibiotic therapy may improve prognosis and facilitate management in patients with septic diabetic foot.

Adult↗
PubMed2003

[Intrathecal baclofen in the treatment of severe spastic tetraplegia and dystonia in children and adolescents].

INTRODUCTION: Continuous intrathecal baclofen has been used over the past years especially in adult patients with spasticity of spinal origin. Children and young adults with severe spasticity and dystonia of cerebral origin are difficult to treat in spite of optimal systemic antispasmotic therapy with baclofen, tizanidine, dantrolene and/or diazepam. Intrathecal baclofen has therefore been applied in a group of young patients. MATERIAL AND METHODS: Eight children and young adults from East Denmark with spasticity and 12 with dystonia aged 3-18 years (median 10.9 years) were tested, operated and treated with continuous intrathecal baclofen for a period of 2-64 months (median 22.2 months). Registration of efficacy, fillings, adjustments of baclofen and other therapies were performed in an out patient setting since 1995. RESULTS: Spasticity in lower extremities was reduced from Ashworth score 3.5-4.5 (median 4.2) to Ashworth score 2.5-4.0 (median 2.9; p < 0.001) during infusion with baclofen 5-33 micrograms/kg/24 hours (median 19 micrograms/kg/24 hours). The infusion catheter tip was placed at levels Th1-Th12 (median Th7.5). Peroral baclofen was reduced from an average of 5.0 to 0.44 mg/kg/24 hours, tizanidine from 0.4 to 0.1 mg/kg/24 hours, and dantrolene from 4.0 to 0.4 mg/kg/24 hours. After initial adjustments successively increased dosages of average 0.46 microgram/kg/month were needed to maintain the same level of efficacy. In questionnaires parents or guardians rated less spasticity in lower extremities in 15 out of 19 patients, and less pain in 13 out of 19 patients. CONCLUSION: Continuous intrathecal baclofen was effective in treating severe spasticity and dystonia of cerebral origin with major effect on muscles of the lower extremities, pelvis, and back and in particular opisthotonus was relieved. Efficacy on upper extremities was far less pronounced.

Adolescent↗
PubMed2002

Comparative effect of 6% hydroxyethyl starch (containing 1% dextrose) and lactated Ringer's solution for cesarean section under spinal anesthesia.

PURPOSE: This study aimed to compare low-molecular weight hydroxyethyl starch containing 1% dextrose (HES) infusion and lactated Ringer's solution (LR) in the prevention of hypotension associated with spinal anesthesia for cesarean section. METHODS: Sixty-seven patients scheduled for cesarean section under spinal anesthesia were randomly allocated to receive either LR ( n= 35) or HES ( n= 32) infusion before cesarean delivery. Infusion of the fluid was started immediately after arrival at the operating room, through two fully open i.v. routes of 18 or 16 gauge. The two groups were compared in terms of the incidence of hypotension; ephedrine dose; cord and maternal blood gas, hemoglobin, and glucose; and Apgar scores. RESULTS: Intravenous fluid volume until delivery in the LR group was significantly greater than that in the HES group (1298 +/- 503 and 973 +/- 339 ml, respectively) in spite of the similar periods of intravenous infusion (18.1 +/- 3.9 and 18.2 +/- 4.1 min). The incidence of hypotension, and the ephedrine dose, blood gas analyses, and Apgar scores were not significantly different between the groups. The ephedrine dose correlated with the anesthesia level by spinal anesthesia (P < 0.05). CONCLUSION: This study did not show an advantage of HES compared with LR in the prevention of hypotension or in the reduction of ephedrine dose during cesarean section under spinal anesthesia. The anesthesia level, rather than the choice of intravenous fluid solution, might be related to the ephedrine dose.

Clinical Trial↗