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Neurophysiologic evaluation of spastic hypertonia: implications for management of the patient with the intrathecal baclofen pump.

A number of techniques attempt to objectively quantify various clinical characteristics associated with spastic hypertonia and related motor disorders. These range in cost, complexity, physiologic basis of measured response, and invasiveness. With a greater range of treatment options for spasticity and an increase in the number of centers participating in studies of interventions for spasticity, published reports reflect increasing use of objective quantification techniques. We review studies that highlight the potential utility of neurophysiologic techniques, including the H-reflex, F-wave, and flexion withdrawal reflex, in the objective evaluation of response to intrathecal baclofen administration. The accumulated knowledge suggests that neurophysiologic evaluation is useful for assessing spinal cord responsiveness, and we recommend it as an adjunct to clinical evaluation when judging the overall effectiveness of intrathecal baclofen administration.

Baclofen↗

Spasticity in kids. An intrathecal option.

The painful muscle rigidity and severe spasms suffered by patients with brain and spinal injury can be managed even more successfully than in the past with intrathecal baclofen. For many, it's provided effective relief and improved levels of function.

Baclofen↗

Dose-dependent beneficial and detrimental effects of ROCK inhibitor Y27632 on axonal sprouting and functional recovery after rat spinal cord injury.

Axonal regeneration within the injured central nervous system (CNS) is hampered by multiple inhibitory molecules in the glial scar and the surrounding disrupted myelin. Many of these inhibitors stimulate, either directly or indirectly, the Rho intracellular signaling pathway, providing a strong rationale to target it following spinal cord injuries. In this study, we infused either control (PBS) or a ROCK inhibitor, Y27632 (2 mM or 20 mM, 12 microl/day for 14 days) into the intrathecal space of adult rats starting immediately after a cervical 4/5 dorsal column transection. Histological analysis revealed that high dose-treated animals displayed significantly more axon sprouts in the grey matter distal to injury compared to low dose-treated rats. Only the high dose regimen stimulated sprouting of the dorsal ascending axons along the walls of the lesion cavity. Footprint analysis revealed that the increased base of support normalized significantly faster in control and high dose-treated animals compared to low dose animals. Forepaw rotation angle, and the number of footslips on a horizontal ladder improved significantly more by 6 weeks in high dose animals compared to the other two groups. In a food pellet reaching test, high dose animals performed significantly better than low dose animals, which failed to recover. There was no evidence of mechanical allodynia in any treatment group; however, the slightly shortened heat withdrawal times normalized only with the high dose treatment. Collectively, our data support beneficial effects of high dose Y27632 treatment but indicate that low doses might be detrimental.

Actin Depolymerizing Factors↗

Continuous Intrathecal Infusion of Nivolumab in Advanced Melanoma With Concomitant Leptomeningeal Disease: Efficacy, Safety, and Pharmacokinetics.

BACKGROUND AND OBJECTIVES: Prognosis of melanoma with leptomeningeal disease (LMD) is poor (median overall survival of 5.1 months). Intrathecal (IT) nivolumab appears safe, although its efficacy remains uncertain. We investigated the feasibility, safety, and efficacy of continuous IT nivolumab. METHODS: This was a retrospective analysis of 11 melanoma patients with progressive LMD (MelBase; NCT02828202) treated as part of the patients' care with continuous IT nivolumab administered through spinal (n = 10) or ventricular catheter (n = 1). RESULTS: Patients (5 women, median age 52) with Eastern Cooperative Oncology Group &#x2264;1 (except for 1) and stable extracranial disease (except for 4) were treated over a median duration of 1.5 months and followed for 2.5 months. Seven presented symptomatic LMD. Primary tumors were mostly cutaneous (n = 8) and BRAF-mutated (n = 10). All patients had progressed on systemic immunotherapy; 7 had received brain radiotherapy (whole brain radiotherapy [n = 3]; stereotactic radiosurgery [n = 4]). Concomitant therapies included corticosteroids >10 mg (n = 5), intravenous nivolumab (first 3 months of IT therapy, n = 1), and targeted therapies (n = 7). The median overall survival was 2.5 months, with 3 patients surviving for more than a year. Reversible treatment-related adverse events occurred in 5 patients: meningoencephalitis (grade 3, n = 1), intracranial hemorrhage (grade 1, n = 1), intracranial hypotension (grade 2, n = 2; grade 1, n = 1). Baseline levels of nivolumab in the cerebrospinal fluid (CSF) were <2 &#xb5;g/mL, even among patients with plasma detection. CSF concentrations of nivolumab at steady state varied from 36 to 97 &#xb5;g/mL, with clearances of 4.3-15.7 mL/h. Next-generation sequencing identified CSF genomic profiles correlating with clinical progression in 4 patients. CONCLUSION: These findings warrant further trials on IT nivolumab.

Humans↗

Epileptic seizures associated with intrathecal baclofen application.

We report the clinical and EEG findings in three patients presenting with seizures associated with intrathecal baclofen application for treatment of spasticity. All patients had a history of traumatic brain injury, while one patient also suffered a spinal cord injury. Two patients experienced their first seizure following intrathecal baclofen test bolus injection. Another patient had convulsions on two occasions: following postoperative baclofen dose adjustment, and after sleep deprivation. Structural brain disease seems prerequisite for baclofen to exert epileptogenic activity, since seizures have not occurred in patients receiving intrathecal baclofen for spasticity of solely spinal origin. Antiepileptic medication permitted the continuation of intrathecal baclofen treatment in the three patients.

Adolescent↗

[Continuous spinal analgesia in home care of oncologic pain].

The authors in this study, after a short survey of the most important therapeutic techniques for cancer pain, report their results in the treatment of 18 patients suffering from incurable disease. It was impossible to dismiss them from hospital care on account of a painful symptomatology not controllable by oral morphine or owing to excessive collateral morphinic consequences. The analgetic technique employed was continuous intrathecal infusion of morphine, clonidine, droperidol and, in 10 cases, bupivacaine. Drug delivery systems, totally internalized, except infusion pump, were always utilized. Adequate pain relief was obtained, within - 5 days, in all the patients. Family membres, in the same period, learnt the infusion circuit action. At this point the patients were dismissed and treated with home care. The average time of assistance was 140 days, and very moderate variations in posology were necessary. Hospital reentrance, really little numerous, happened only when no member of palliative care service was present. Reasons were no bodily pain, but the total suffering of cancer disease. No complication nor collateral consequences were never found.

Analgesics, Opioid↗

Can regeneration be promoted within the spinal cord?

Although regeneration in the peripheral nervous system (PNS) after injury is robust, regeneration in the central nervous system (CNS) is abortive. The results from differences in the balance of regeneration inhibiting and promoting factors, which in the CNS is skewed toward inhibition while in the PNS it is skewed towards promotion of nerve growth. In addition to lacking regeneration promoting factor the CNS has the ubiquitous distribution of factors that inhibit regeneration. PNS Schwann cells release a number of characterized and uncharacterized neurotrophic factors that exert powerful regeneration promoting influences on axons in the PNS. Thus it has been hypothesize that implantation of Schwann cells, or infusion of factors they release into the lesioned spinal cord should lead to CNS regeneration. However, Schwann cell implants alone are not very successful in promoting CNS regeneration Although still limited, improved regeneration takes place when there is the simultaneously inhibition of CNS regeneration blocking factors and the presence of Schwann cell-released factors. To further improve the extent of CNS regeneration we must determine the best combination of neurotrophic factors to infuse into the site of a CNS lesion, as well as be able to characterize and block all CNS regeneration inhibiting factors. This review examines what is known about promoting and inhibiting regeneration in both the PNS and CNS, and the approaches that may allow us to change the cellular environment of the CNS to one that is permissive to and promotes regeneration.

Axons↗

A comparative study of three different methods of administering metaraminol during spinal anaesthesia in the elderly.

We compared three methods of administering metaraminol during spinal (subarachnoid) anaesthesia. Fifty-two elderly patients with fractured hips were studied. Blood pressure was maintained by either intramuscular (i.m.) metaraminol (0.1 mg x kg(-1)), intravenous (i.v.) boluses (0.01 mg x kg(-1)) or an infusion (0.05 mg x kg(-1) x h(-1)). Non-invasive blood pressure was recorded every one-minute. Spinal anaesthesia initially decreased the systolic arterial pressure by 15 (14) % compared to 35 (15) % for diastolic pressure (P<0.001). I.m. metaraminol restored the systolic arterial pressure back to baseline values (-3%), but there was significant between-subject variability resulting in a very unpredictable effect. I.v. boluses and infusion had a more predictable effect and maintained systolic arterial pressure at about 20% below baseline. Range of effect, measured by inter-quartile range and variance, was greatest in the i.m. group and least in the infusion group (P<0.003). I.m. metaraminol during spinal anaesthesia has a very unpredictable effect. Infusions of metaraminol provided the best blood pressure control. Diastolic blood pressure fell significantly after spinal anaesthesia and this merits further investigation.

Aged↗

Transverse myelitis associated with Acinetobacter baumanii intrathecal pump catheter-related infection.

OBJECTIVE: To describe a late neurologic complication of intrathecal pump implantation and show the methods used for the diagnosis and successful treatment of transverse myelitis in this setting. CASE REPORT: A 32-year-old man with a chronic abdominal pain syndrome presented with right lower-extremity numbness 2 months after the placement of an intrathecal morphine pump. This progressed to bilateral lower extremity and ascending sensory loss to T12-L1 dermatome, significant lower-extremity weakness, constipation with overflow incontinence, and detrusor instability causing urinary incontinence in discrete episodes over the following 2 months consistent with a myelopathy. Magnetic resonance imaging (MRI) of the thoracic spine and cerebrospinal fluid (CSF) analysis were consistent with transverse myelitis. The intrathecal pump was removed and an Acinetobacter baumanii catheter-tip infection was diagnosed. Clinical course improved with the co-administration of intravenous corticosteroids and antibiotics, with significant clinical improvement within 30 days. CONCLUSIONS: Clinicians should recognize transverse myelitis as a possible late complication of intrathecal pump placement. Early medical intervention and removal of the intrathecal pump may be necessary to prevent irreversible spinal cord damage and may support good recovery.

Acinetobacter Infections↗

Central blocks with levobupivacaina in children.

Regional anesthesia has become a routine practice in paediatric anesthesia and local anaesthetics are now widely used in infants and children. Although local anaesthetics are generally quite safe and effective, they may produce systemic toxic reactions affecting the heart and brain. Because postoperative analgesia is often the primary justification for regional anesthesia in infants and children, bupivacaine, a long-acting local anaesthetic, is the most commonly used local anaesthetic for paediatric regional anesthesia. Levobupiva-caine has been used in children by caudal injection, by lumbar epidural route for anesthesia during operation, by continuous epidural infusion for pain control after operation and for spinal anesthesia. Levobupivacaine had shown comparable clinical profiles to that of bupivacaine but produced lower incidence of residual motor blockade. Efforts to minimize the risk of complications during caudal anesthesia must be directed towards measures that reduce accidental intravenous and intraosseous injections, reduce the total amount of local anaesthetic used and use drugs with lower toxic potential. In patients under general anesthesia, when using a large amount of local anaesthetic, in case of accidental intravenous infusion, patients receiving levobupivacaine may tolerate larger doses before manifestation of toxicity compared with those receiving bupivacaine. There are clinical situations including prolonged local anaesthetic infusions, use in neonates or small babies, and caudal block, where replacement of bupivacaine with levobupivacaine appears to be safer.

Anesthesia, Caudal↗

Anterior spinal artery syndrome--a complication of cervical intrathecal phenol injection.

Spinal nerve block by intrathecal phenol-glycerine infusion is commonly employed for relief of severe pain in terminal carcinomatosis and, frequently, a dramatic regional anesthetic effect is achieved. However, nerve block by this procedure may in very rare instances give rise to serious complications. We have seen a case of terminal malignant melanoma in which clinical manifestations, indicative of anterior spinal artery syndrome, developed following the injection of 0.3 ml of 10% phenol-glycerine into the cervical subarachnoid space at the C4--C5 level for the control of severe right arm pain. This report describes the clinical course of the patient over a period of 4 months after the nerve block and the post-mortem findings along with a brief review of the literature.

Adult↗

Nerve growth factor promotes regeneration of sensory axons into adult rat spinal cord.

Injured adult mammalian axons are unable to regenerate spontaneously in the central nervous tissue. This study investigated in two adult rat models the effects of nerve growth factor (NGF) on the capacity of central primary sensory axons to regenerate back into the spinal cord. Sensory fibers were conditioned by transection of the peripheral nerve 1 week prior to the experiment and identified by anterograde tracing with cholera toxin B subunit injected in the sciatic nerve. In the first model, a predegenerated autologous peripheral nerve graft was implanted as a bridge for the transected sensory fibers into a resection gap in the dorsal columns at the tenth thoracic (T10) spinal cord segment. Vehicle or vehicle with purified mouse or recombinant human NGF was continuously infused for 2 weeks directly into the dorsal column at T9, 3 mm from the rostral border of the nerve graft. With vehicle infusion many ascending sensory axons had grown across the nerve bridge, but essentially none had grown back into the rostral cord. In sharp contrast, NGF promoted the reentry into the denervated dorsal columns of 51% of the sensory axons that had reached the rostral level of the nerve graft. Twenty-six percent had grown 2 mm into the spinal tissue and 10% had reached the NGF-infusion site at 3 mm from the nerve graft. A few fibers were found circling around, but not beyond, the infusion site, perhaps due to the chemoattractant action of NGF. In a second model, the fourth lumbar (L4) dorsal root was crushed 2 mm from its insertion point into the spinal cord and the dorsal roots L2, L3, L5, and L6 were transected. Vehicle or vehicle with purified mouse NGF was infused for 2 weeks directly into the lumbar spinal cord, 2.5 mm rostral to the transition zone of the crushed L4 root. With vehicle, only 6% of the regenerating fibers at the transition zone had crossed the root-spinal cord barrier, but not farther than 0.5 mm into the spinal tissue. With NGF, 18% of the fibers at the transition zone were found at 0.5 mm, 9% at 1.5 mm, and 5% at 2.5 mm (the infusion site) from the transition zone. The present results demonstrate that NGF can promote the regeneration of adult sensory fibers into the otherwise nonpermissive spinal cord white matter.

Animals↗

Intravenous pamidronate attenuates bone density loss after acute spinal cord injury.

OBJECTIVE: To compare the effects of a 6-month treatment with intravenous pamidronate (30-mg infusion once per month) to conventional rehabilitation without pamidronate on bone density of the spine and leg bones and on the excretion rate of N-telopeptide, a urinary marker of bone catabolism, in acutely spinal cord injured patients. DESIGN: A nonrandomized control trial in which 24 spinal cord injured subjects entered the study within 6 weeks of their injury. Fourteen subjects received pamidronate; 10 did not. OUTCOME MEASURES: Bone density measurements by dual x-ray absorptiometry were performed before the initial treatment (within 6 weeks of the injury) and at 3, 6, and 12 months postinjury and was the primary efficacy parameter. Urine for N-telopeptide levels was the secondary efficacy parameter. RESULTS: After acute spinal cord injury, patients treated with intravenous pamidronate had significantly less bone density loss compared with those who did not receive pamidronate (parametric ANOVA, p<.02). Also, ambulatory subjects had significantly less bone density loss over the study period (p<.05) than nonambulatory subjects. In general, a high excretion level of the urinary bone-breakdown product N-telopeptide was found before intravenous pamidronate treatment, followed by a dramatic reduction in excretion after pamidronate treatment. Ambulatory subjects excreted significantly less N-telopeptide than motor-complete subjects at all time points. CONCLUSION: Intravenous pamidronate treatment and ambulatory ability in the first 6 months after an acute spinal cord injury prevents bone density loss.

Acute Disease↗

Postoperative epidural analgesia for pediatric spine surgery.

The safety of epidural infusion for postoperative analgesia in pediatric spine surgery continues to be established. A continuous epidural infusion of morphine sulfate and bupivacaine was used for postoperative analgesia in 12 pediatric patients undergoing spinal surgery. The epidural was placed intraoperatively by the operating surgeon, while continuous infusion was managed postoperatively by a pediatric anesthesiology pain service team. In addition to the continuous infusion, 2 of the 12 also were provided on-demand patient-controlled boluses via epidural catheter for breakthrough pain. Patients experienced analgesia as documented by a comprehensive pain scale form. No catheters failed, while side effects were minimal and easily managed. These results provide confirmation of the safety and efficacy of continuous epidural infusion for postoperative analgesia following pediatric spine surgery and evidence that patient-controlled epidural analgesia is an option.

Adolescent↗

Functional supersensitivity of CNS alpha 1-adrenoceptors following chronic antidepressant treatment.

Chronic but not acute administration (21 days) of desipramine (10 mg/kg), amitriptyline (10 mg/kg) or iprindole (5 mg/kg) enhanced the stimulatory effect of the alpha 1-adrenergic agonist phenylephrine on the acoustic startle reflex when phenylephrine was infused into the subarachnoid space of the spinal cord. Comparable supersensitivity to phenylephrine also occurred 1 week after selective depletion of norepinephrine in the spinal cord via intrathecal administration of 6-hydroxydopamine. Behavioral supersensitivity to phenylephrine was associated with an increase in the number of 3H-prazosin binding sites following denervation but not following chronic antidepressant treatments. The results indicate that chronic antidepressant treatments may enhance functional alpha 1-adrenergic transmission through mechanisms different than those following denervation.

Amitriptyline↗

The role of the sympathetic nervous system in congestive heart failure.

Congestive heart failure is usually accompanied by cardiovascular signs of an increased sympathetic and a decreased parasympathetic efferent activity. A current hypothesis for these autonomic changes holds the baroreceptor mechanisms mainly responsible for this complex neural reflex pattern together with a decreased responsiveness of cardiac vagal afferent ffibers. An alternative hypothesis is proposed here. Afferent sympathetic fibers with sensory endings in the atria and in the pulmonary veins are progressively excited by volume load. In cats with a chronic spinal section at C8, breathing spontaneously, an infusion of saline induces a reflex tachycardia through a sympatho-sympathetic neural circuit. In chronic dogs with intact cardiovascular innervation, the stimulation of aortic or cardiac sympathetic afferent fibers elicits an excitatory sympathetic reflex leading to hypertension and tachycardia; in addition, the sensitivity of baroreflexes is markedly reduced. Therefore, in congestive heart failure, especially in the absence of hypotension, the reflex excitation of the sympathetic outflow and the inhibition of the vagal efferent activity directed to the heart could be due to reflex mechanisms mediated by sympathetic cardiovascular afferents.

Animals↗

The effects of epidural fentanyl on hemodynamic responses during emergence from isoflurane anesthesia and tracheal extubation: a comparison with intravenous fentanyl.

To investigate the effects of epidural fentanyl infusion on hemodynamic responses to recovery of consciousness and tracheal extubation, we studied 50 unpremedicated patients scheduled for abdominal hysterectomy. All patients underwent epidural catheterization and blind infusion of placebo and study drug. Patients were assigned randomly to three groups: Group I received epidural and intravenous (i.v.) bolus injections and infusion of saline at the rate of 0.2 mL x kg(-1) x h(-1); Group II received an i.v. injection of fentanyl 2 microg/kg for 30 s followed by 25 ng x kg(-1) x min(-1), and Group III received epidural injection and infusion using the same administration regimen as Group II. Anesthesia was induced with and maintained by isoflurane alone in an air-oxygen mixture. The study drug was administered at the start of retroperitoneal suturing. Hemodynamic variables, including systolic and diastolic arterial pressures (SAP and DAP, respectively) and heart rate (HR), were recorded every minute between the start of administration of the study and 5 min after tracheal extubation. During emergence from anesthesia and tracheal extubation, the increases in SAP, DAP, and HR in Groups II and III were significantly diminished (P < 0.05) compared with those in Group I. Arterial pressures, but not HR, were attenuated more significantly in Group III than in Group II during and after tracheal extubation, although the plasma fentanyl concentration was significantly lower (P < 0.01) in Group III (0.64 +/- 0.03 ng/ mL, [mean +/- SD]) than in Group II (1.15 +/- 0.09 ng/mL). The incidence of coughing during and after extubation was also lower with Group III. Suppression of respiratory rate prior to tracheal extubation was similar in the two groups receiving fentanyl. These findings suggest that the significant reduction in arterial pressures responses to tracheal extubation due to epidural fentanyl infusion may arise from more suppression of cough reflex than i.v. fentanyl infusion, which could be provided by the spinal action of epidural fentanyl as well as the supraspinal action.

Adjuvants, Anesthesia↗

Zoledronic acid prevents bone loss after allogeneic haemopoietic stem cell transplantation.

Allogeneic haemopoietic stem cell transplant (alloHSCT) patients are at increased risk of osteoporosis. Zoledronic acid (ZA) is a potent i.v. bisphosphonate; however, there are few data on ZA use after alloHSCT. The aim of this study is to examine the effect of a single 4 mg ZA infusion in alloHSCT patients with either osteoporosis (T-score < -2.5) or rapid bone loss post-alloHSCT. An uncontrolled, prospective study of 12 consecutive patients receiving ZA, predominantly within the first year post-HSCT. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the spine and proximal femur pretransplant, pre-ZA and post-ZA. The median annualized percentage change in total hip BMD between the pretransplant scan and the scan immediately before ZA was -13% (range, -51 to +3.6%). After ZA treatment, the total hip BMD increased by a median of +3.3% (range, -20.4 to +14.8%) in 75% of patients. The median annualized percentage change in femoral neck BMD between the pretransplant scan and the scan immediately before ZA was -13.2% (range, -40 to +1.0%). Post-ZA, femoral neck BMD increased by a median of +1.4% (range, -22.2 to +33.6%). Only one patient continued to lose bone from the femoral neck post-ZA infusion. The median annualized percentage change in spinal BMD pretransplant was -12.5% (range, -38 to +6.9%). Post-ZA, spinal BMD decreased by a median of -2.8% (range, -27.6 to +24.4%). Four patients continued to lose bone from the spine post-ZA. ZA reduces bone loss in most patients after alloHSCT. Our data require confirmation in a larger prospective, randomized study.

Adult↗