Intrathecal baclofen infusion in patients with spasticity and neurogenic bladder disease

Abstract

Summary.Nine severely spastic men suffering from neurogenic bladder disease secondary to spinal cord lesion or multiple sclerosis were treated with continuous intrathecal infusion of baclofen using an implanted programmable pump. Bladder function improved in all patients. Significant improvements consisted of an increase in bladder capacity, a decrease in residual volume and a diminution of pelvic floor spasms. Three patients became continent. Intermittent self-catheterization was no longer impeded by adductor spasms. In three cases complete bladder emptying could be achieved. Maximal bladder pressure decreased two subjects, whereas it increased in two others; however for the whole group the changes were not significant. Gamma-aminobutyric acid (GABA) acts as an inhibitory neurotransmitter in the central nervous system. However, the hydrophilicity of the substance prevents its crossing the blood-brain barrier in sufficient amounts and consequently makes GABA unsuitable for therapeutic use. A more lipophilic analogue, baclofen [beta-(4-chlorophenyl)-GABA], was developed for oral administration. However, the passage of baclofen through the blood-brain barrier is limited [3,13]. The low therapeutic index of the substance limits dose increments and due to the resulting low levels in the CNS, severe somatic muscle spasticity as well as micturition disorders in neurogenic bladder disease are insufficiently controlled by oral administration of baclofen. Similarly, combination with other antispastic drugs offers little benefit [15]. When baclofen is infused intrathecally, the blood-brain barrier is bypassed. Even at very low doses, such treatment has proved to be effective against previously intractable spasticity and is associated with an extremely low incidence of side effects [12, 15, 161. * To whom correspondence should be addressedThe purpose of the present study was to evaluate the subjective improvements in voiding experienced by patients during continuous intrathecal baclofen infusion. Our subjects reported not only a marked improvement in the spasticity of skeletal muscles but also an amelioration of the lower urinary tract dysfunction. Subjects and methodsNine paraplegic or quadruplegic men who were primarily treated with continuous intrathecal baclofen for intractable muscle spasticity were studied. All patients had displayed an established pattern of spasticity for at least 1 year. Previous oral treatment with baclofen (max. 100 mg/ 24 h), tizanidine (max 32 mg/24 h), dantrolene (max. 400 mg/24 h) or combinations had only insufficiently managed the spastic features. A clinical test was therefore carried out to determine the beneficial effects of intrathecal treatment with baclofen on spasticity. An intrathecal baclofen bolus (25, 50, 75 or 100 gg) [16] was injected daily via a temporary external indwelling catheter. Prophylactically patients were also given oral trimoxazole (2x960mg). After a successful test period, a programmable drug delivery system (Synchromed; Medtronic Inc. Minneapolis, Minn., USA) co...

Normalization of Central Cord Syndrome Spinal Cord Injury Urodynamics After Intrathecal Baclofen Therapy: A Case Report

“…Kums and Delhaas reported nine cases (three multiple sclerosis [MS] and six SCI) with increased bladder capacity, a decrease in residual volume, and diminished pelvic floor spasm after ITB therapy. Three patients become continent (5). Steers et al reported ten patients (SCI, MS, syrinx, hereditary spastic paraplegia [HSP]), after ITB therapy, had resolution of "irritative" voiding and urge incontinence of the uninhibited bladder.…”

Functional Outcome and Clinical Significance of Long-term Intrathecal Baclofen Therapy for Severe Spasticity

“…Preliminary studies have indicated therapeutic effects on bladder function (20)(21)(22)(23)(24)(25) and activities II daily living (26). Bacl<>t'cn is rapidly becoming the drug of choice for intraspinal antispastic therapy and has recently been approved in several coun, tries for treatment of severe spinal spasticity.…”