Pump Management: Intrathecal Baclofen Pumps

Abstract

For more than three decades, intrathecal baclofen (ITB) has been used to manage severe spasticity related to cerebral palsy, multiple sclerosis, spinal cord injury, and stroke. Spasticity, defined as a velocity-dependent increase of resistance to passive muscle stretch, can be severe enough to cause debilitating pain and contractures significantly reducing quality of life. ITB should be considered for patients who fail oral medications or cannot tolerate the often sedating side effects. ITB therapy utilizes a catheter placed within the intrathecal space and delivers medication directly into the cerebral spinal fluid (CSF). This method requires a significantly lower dose of baclofen to be administered and bypasses the blood-brain barrier (BBB), avoiding many unwanted side effects of high-dose oral medications. Catheter tip placement is a crucial step in ITB therapy and determines the concentration center given CSF’s limited ability to distribute baclofen due to flow and baricity. Before the initiation of ITB therapy, patient goals and spasticity severity should be assessed. Prior to pump placement, a trial is generally performed to evaluate patient response and estimate initial dosing. After pump placement, initial dosing and titration to a steady therapeutic state should be achieved with the fewest number of adjustments and may be done outpatient or expedited in an inpatient setting. This chapter will address and define the appropriate clinical use and placement of intrathecal pumps in the management of severe spasticity as well as explore short- and long-term management of baclofen pumps including dosing adjustments, adverse events, and discontinuation of care.