When do you consider intrathecal baclofen pump in patients with acquired spasticity?

I am a neurologist in Minneapolis and have directed a spasticity clinic for over 20 years. We typically have at least 100 intrathecal baclofen patients. It is an excellent therapy for selected patients but requires dose adjustments and refills of the Medtronic synchromed pumps. Problems may occur with catheter kinking or twisting, but for the appropriate patient, it is a very helpful therapy. Some patients do require supplemental chemodenervation for upper extremities as the dose of baclofen intrathecal is used to address overall spasticity which may leave gaps in therapy (e.g., a dose that reduces or eliminates all hypertonicity may interfere with a patient's ability to stand to transfer or ambulate). Typical patients are survivors of stro...

In general, intrathecal baclofen is helpful when the spasticity is mainly in the lower body, and the patient does not tolerate sufficient doses of oral baclofen or tizanidine.

Some patients also receive pain medications through their baclofen pump and may achieve greater pain relief than with oral pain medications.

Some neurosurgeons implant the baclofen catheter in higher locations (e.g., cervical spine) and are able to achieve a fair level of efficacy in the upper extremities, but this is not always possible. The risk of complications is also higher.

Dr. @Dr. First Last,

I am semi-retired and have not recently managed a baclofen pump patient. So, some of these thoughts may be "dated". I have considered a baclofen pump in those patients who:

1. have a high pill burden
2. may complain of sedation
3. good effect yet incomplete.

(Just to mention a few.)

From your description of this patient, she seems to be already managed (baclofen and dantrolene for the gross spasticity and botox for fine-tuning).

With that being said, you need to estimate or ask the patient and yourself how much do they need their spasticity (for walking, transfers, etc). This can be assessed when you do the baclofen IT bolus test.

If you are new to this, have PT and possibly OT help you or a PM&R and meet afterwards to hear...

I agree with the above answer.

I would add the following:

1. discuss and set expectations;
2. physical therapy and occupational therapy after placement are good rehabilitative options to maintain muscle tone and interesting can help psychologically and reduce some pain; and
3. send to a specialist that does the pump and does the pretrial of baclofen intrathecally: if they respond to the trial they are a good candidate.

It's a decent option with good teaching. It's been pretty helpful for my patients following this formula

All the best,
Nawaz