Advances in drug delivery systems and applications in neurosurgery.
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Adult↗
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Intraarterial management of giant-cell tumors of the spine in children.
Transcatheter arterial management of giant cell tumors of the spine was performed in two female patients aged 12 and 15 who had failed to respond to conventional therapy. Response was determined clinically by alleviation of pain and radiographically by regression and/or calcification of the tumor. Minor side effects included transient nausea, elevated body temperature, and pain.
Adolescent↗
Intrathecal morphine in the treatment of chronic intractable pain.
Fifteen patients with intractable pain received intrathecal morphine delivered via a programmable (Medtronic) device. In twelve patients the pain was due to cancer and three patients had pain of non malignant origin. All of the patients reported excellent or good relief. A total of 14 complications were reported in 7 patients. Most of these were minor and related to surgical or mechanical problems. One patient with pain of non malignant origin developed serious complications which required the removal of the infusion device. The results of this study show that chronic intrathecal infusion of morphine is superior to conventional forms of analgesia in patients with intractable pain of malignant origin. We would advise that it should remain a therapy of last resort in patients with intractable non malignant pain as the long term side effects are still unknown and the potential for serious side effects still exists.
Adult↗
Intrathecal narcotics in cancer pain--a case report.
A 61 year old female patient presented with metastatic bone pain three years post mastectomy. Standard oral analgesics and epidural morphine were ineffective in achieving pain control. Her pain was eventually controlled with morphine sulphate 48 mg daily via a self administered intrathecal pump. These devices are being used with increasing frequency and this case report highlights some of the problems encountered in this patient's management.
Breast Neoplasms↗
Labour pain management in a parturient with an implanted intrathecal pump.
PURPOSE: We report the peripartum anaesthetic management for vaginal delivery of a chronic pain patient with an implanted intrathecal pump. This is the first report describing labour analgesia in a patient with such a device. As intrathecal systems become more popular for the management of nonmalignant pain, this situation is likely to be encountered with increasing frequency in the future. CLINICAL FEATURES: The patient was a nulliparous 23-yr-old with a history of chronic hereditary pancreatitis whose intractable pain had been managed with intrathecal morphine 3 mg.day-1 via an implantable pump for four years. Inadequate time between presentation and onset of labour prevented us from using this system. Intravenous patient controlled analgesia with fentanyl using a bolus of 25 micrograms and a lockout of five minutes was ineffective and epidural analgesia using bupivacaine was initiated and resulted in satisfactory analgesia. CONCLUSION: The presence of an existing intrathecal delivery system does not preclude the use of supplemental epidural analgesia during labour.
Adult↗
Intrathecal baclofen withdrawal: a case report and review of the literature.
INTRODUCTION: Spasticity is an endpoint of a variety of neurologic disorders with upper motor neuron damage. There have been several studies demonstrating improvement in spasticity through administration of intrathecal baclofen. Withdrawal from oral baclofen has been well described. Intrathecal baclofen withdrawal has been less frequently reported. We present a case of withdrawal after intrathecal baclofen pump catheter failure. PATIENT: A 14-year-old boy presented with fevers, which were thought to be related to recent spine surgery and possible pneumonia. Eventual workup revealed evidence of intrathecal baclofen withdrawal owing to pump catheter failure. His fevers, with temperatures of up to 40 degrees C, and painful muscle spasms resolved and his clinical condition improved after pump exploration and resumption of intrathecal delivery. CONCLUSIONS: Intrathecal baclofen withdrawal can be life threatening. Prompt recognition and restoration of an adequate intrathecal baclofen dose is essential for recovery.
Adolescent↗
Time course of the effect of a bolus dose of intrathecal baclofen on severe cerebral spasticity.
Continuous intrathecal administration of baclofen with implanted programmable pump systems is recommended in the treatment of severe spasticity of cerebral origin. Prior to pump implantation, a baclofen bolus test (BBT) is used to assess the effectiveness of intrathecal baclofen using clinical scales such as the Modified Ashworth Scale (MAS). In the literature, the time and period of maximum effect of a bolus dose of intrathecally administered baclofen in patients with cerebral spasticity is variously reported. The aim of the study was, therefore, to reveal the time course of the effect of a BBT on severe cerebral spasticity by the use of a recently described spasticity measurement method. Spasticity in knee joints of 13 patients with severe cerebral spasticity was repeatedly assessed using the MAS and also continuously recorded by the measurement of force under circular fibreglass casts. Force was recorded as nettorque by multiplying the force by the distance between sensor and joint axis, thus allowing inter-individual comparison. Half-hour time integrals (TI) of net-torque were determined 9 hours before and 22 hours after intrathecal baclofen administration. Post-BBT half-hour time integrals (TI(+0), TI(+0.5), to TI(+22)) were compared with the mean of 17 pre-BBT half-hour time integrals. Significantly lower post-BBT half-hour time integrals compared with were found between TI(+2) and TI(+8) (Dunnett adjusted p < 0.05). The median lowest TI after BBT of the 13 patients was TI(+4). The lowest mean MAS scores were found 4 hours after BBT. The findings suggest that the greatest effect of BBT on cerebral spasticity occurs between 2 and 8.5 hours, with a maximal effect at 4 hours after intrathecal baclofen injection. Clinical scales used to determine the effect of BBT should thus be carried out during this period-ideally at 4 hours after baclofen injection.
Adult↗
Long-term intrathecal baclofen therapy in ambulatory patients with spasticity.
BACKGROUND: Intrathecal baclofen (ITB) is an effective treatment for severe spasticity. In ambulatory patients with spasticity, it is possible that ITB treatment may compromise ambulatory function by unmasking underlying muscle weakness. This retrospective study is designed to determine the long-term ambulatory function in patients receiving ITB. METHODS: Thirty-six patients with severe spasticity previously screened for response to ITB were implanted with programmable pumps that allowed for continuous infusion of ITB. Patients were followed after implantation from 1 to 13 years. RESULTS: All 36 patients had decreased spasticity and retained ambulatory function. Three of the 36 patients eventually became paraplegic related to underlying disease progression. CONCLUSION: ITB therapy may be used in selected ambulatory patients with spasticity and is not associated with loss of ambulatory function.
Adult↗
Efficacy of methylprednisolone in acute experimental cauda equina injury.
In this experimental study the efficacy of methylprednisolone was investigated by neurophysiological and histopathological evaluation in a rabbit cauda equina model where injury was produced with an aneurysm clip (closed pressure 192 gr). High dose methylprednisolone (kg/30 mg) was administered by intravenous infusion in the 8th, 16th and 24th hours after injury followed by infusion of the same dosage every 6 hours for 24 hours. Nerve conduction velocity was measured before and early after trauma and 3 weeks after injury. Both neurophysiological and histopathological investigations demonstrated the neuroprotective effectiveness of methylprednisolone if it was given in the 8th hour after trauma. Although recovery was observed its efficacy was less pronounced when it was given in the 16th and 24th hours.
Animals↗
Late bacterial granuloma at an intrathecal drug delivery catheter.
In the case reported, neurological complaints were pain and dysaesthesiae in the lower back and thigh, as well as paresis of the ileopsoas muscle. MRI of the lumbar spine showed an intradural-extramedullary mass at the level of L1 homogeneously enhancing with gadolinium. This mass was situated at the tip of an intrathecal catheter implanted 11 years before for a morphine trial infusion as therapy for phantom pain after amputation of the right arm. Now, removal of the catheter was performed. Cultures of lumbar CSF and the catheter tip demonstrated coagulase negative staphylococcus. Antibiotic medication with cephalosporines was given for 6 weeks. After removal of the catheter, the patient was free of pain and he progressively regained full neurological function. Although most catheter-associated granulomas reported so far were sterile in nature, bacterial infection should still be considered even years after catheter placement.
Adult↗
Intrathecal octreotide for cancer pain.
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Aged↗
Loin pain hematuria syndrome: pain relief with intrathecal morphine.
Loin pain hematuria syndrome (LPHS) is characterized by hematuria and incapacitating loin pain. The pain experienced with LPHS is, in general, extremely difficult to treat. Many surgical and pharmacologic therapies have been directed at LPHS pain without success. This report documents successful pain control in a patient with LPHS using long-term intrathecal morphine delivered via an implantable pump. Intrathecal narcotic therapy may provide pain relief for the chronic pain of LPHS.
Adult↗
Staphylococcal meningitis following Synchromed intrathecal pump implant: a case report.
Staphylococcal meningitis associated with implantation of an intrathecal drug pump for spasticity was successfully treated by intrathecal vancomycin delivered by the same pump. This produced high CSF antibiotic levels, and the pump and catheter system did not have to be removed. We are unable to identify a similar case reported in the literature to date.
Adolescent↗
Continuous infusion with implantable pumps: expanding the radiologist's role.
Drug infusion systems attract increasing attention as biomedical technology offers miniaturized devices for targeted delivery of therapeutic substances on an outpatient basis. We have used a totally implantable, subcutaneous pump, externally programmable by radiofrequency link, learning the technique of implantation and management and using various imaging modalities for the diagnosis and control of complications. The procedure for implanting systems for continuous intrathecal analgesia and systemic intravenous chemotherapy is described. Our experience of the latter is made up of 296 implants in 290 patients. The selected infusion pump proved reliable and acceptable to patients and the quality of life, given the reduced drug toxicity, more than good. The complications were few both in frequency and in severity. The setting-up of a long-term infusion system, when major surgery is not needed, can fall within the interventional radiologist's field, partly because of a good cost-benefit ratio.
Cost-Benefit Analysis↗
[Severe hyperthermia caused by sudden withdrawal of continuous intrathecal administration of baclofen].
Baclofen is used for the treatment of post-traumatic spasticity. It carries a risk of overdose as well as of an acute withdrawal syndrome. We report two cases of severe hypertonia and hyperthermia (> 42 degrees C), occurring after accidental discontinuation of intrathecal infusion of baclofen. Both hypertonia and hyperthermia ceased when administration of baclofen was resumed. In parallel, the patients developed transient life-threatening alterations of hepatic (cytolysis), haematologic (coagulopathy) and cardiorespiratory functions for some days. It is concluded that the occurrence of such a withdrawal syndrome should be prevented, especially in patients with chronic intrathecal administration and first symptoms should be recognized without delay. Relationships with other malignant hyperthermias are discussed.
Adult↗
[Management of increase in spasticity in patients with intrathecal baclofen pumps].
INTRODUCTION: The incidence of complications after baclofen pump implantation is relatively high. Diagnosis of these complications can be difficult. A diagnostic tree would be a useful tool in cases of suspected malfunctioning of the intrathecal bacolfen infusion system and would standardise the diagnostic procedure. METHOD: From results in the literature and the experience of our department, we designed a diagnostic tree to aid in finding the cause of a recrudescence of spasticity in patients with implanted baclofen pumps. RESULTS: The potential causes of recrudescence of spasticity are described and a diagnostic pathway is proposed. DISCUSSION: The aim of a standardised hierarchical method of diagnosis of the cause of increased spasticity in patients with intrathecal baclofen pumps is to gain time in the diagnosis and treatment. Such diagnosis should improve patient care by permitting rapid restoration of an adequate level of baclofen infusion as well as decreasing the length of hospital stay and, as a consequence, the cost relating to malfunctioning pumps.
Baclofen↗
[Efficacy of intrathecal baclofen in the treatment of spasticity in stroke].
OBJECTIVE: To determine whether intrathecal administration of baclofen reduced spastic hypertonia in a hemiplegic patient after hemorrhagic stroke. METHODS: A trial of intrathecal administration of baclofen was carried out with bolus injections of 50 and 75 microg baclofen and clinical and functional evaluation (Aschworth, articular amplitude) before and after injection in a patient with hemorrhagic stroke. After these trials, the placement of a pump was proposed to the patient. RESULTS: Aschworth score improved from 4 to 3 on triceps, quadriceps and adductus, with functional improvement of gait quality and perimeter and position in the wheelchair. Cephalgia, present before the treatment, increased after the implantation of the pump. The patient had some ejaculation trouble with the treatment, as well as some neurological pains after the pump implantation but experienced no effect on upper limbs. DISCUSSION: The intrathecal administration of baclofen has been used in some studies of hemiplegic patients, with reduced spasticity and improved the kinematic parameters of gait. The intrathecal baclofen administration could complement other treatment to control spasticity after stroke. CONCLUSION: Intrathecal baclofen administration could be an interesting complementary therapeutic among patients with important spasticity not controlled by the usual treatments.
Baclofen↗
Weight gain in children with hypertonia of cerebral origin receiving intrathecal baclofen therapy.
OBJECTIVE: To identify the pattern of weight change in children receiving intrathecal baclofen (ITB) therapy. DESIGN: A retrospective medical chart review was conducted to identify weight status before and after ITB pump implantation. SETTING: Tertiary care children's hospital and academic medical center. PARTICIPANTS: All children and adolescents with hypertonia of cerebral origin who were younger than 19 years of age at the time of pump placement and followed in our pediatric baclofen pump program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A linear mixed model was used to examine the rate of change in weight (weight-gain velocity) before and after surgery. Weight change was adjusted for age, sex, functional level determined by the Gross Motor Functional Classification System, tube feeding, dystonia, and other comorbidities. RESULTS: The average weight-gain velocity was 2.32 kg/y presurgery and 2.93 kg/y postsurgery, adjusted for potential confounders. The 0.61 kg/y increase in weight-gain velocity attained statistical significance (P = .028). CONCLUSIONS: Although excessive weight gain is not a common problem in children with cerebral origin spasticity, increased weight-gain velocity is prevalent in children receiving ITB therapy. Health care providers may anticipate a welcome weight gain in the underweight child. This consequence should be considered when managing children receiving ITB therapy, and health care providers must appropriately intervene to prevent excessive weight gain. Further studies exploring the reasons for the increased weight-gain velocity are warranted.
Adolescent↗