An Introduction to Trialing Intrathecal Baclofen in Patients with Hemiparetic Spasticity: A Description of 3 Cases

Background: Intrathecal baclofen has been an effective therapy in the management ofspasticity. As interventional pain physicians are rapidly becoming the experts in intrathecaldrug delivery, they are now frequently asked to trial and implant intrathecal baclofen therapy.While some physicians might be very comfortable with the process of trialing and implanting,others will have next to no experience until the first consult appears on their desks. Whileuncomplicated lower extremity spasticity can usually be trialed with a single-shot bolus injection,more complicated cases of upper and lower extremities or hemiparetic spasticity need a moredelicate approach. This is the first case series in the literature reporting a trial using an indwellingtemporary catheter and inpatient admission. Moreover, while the technical aspects of intrathecaltherapy trialing and implantation might be familiar for the interventional physician, we reviewthe indications and goals of therapy, about which the physician may be less familiar.Objective: To present a technique for trialing intrathecal baclofen in patients with severeupper and lower extremities spasticity complication for which a single shot technique may beinadequate.Design: Case report of three patients.Setting: Tertiary-care referral medical center.Patients: A 30-year-old man with severe spasticity of the right upper and lower extremitieswith preserved left-sided function due to diffuse axonal injury. A 45-year-old woman withtraumatic brain injury and severe spasticity of the left upper extremity with minimal dysfunctionin the right upper extremity. A 34-year-old woman with Multiple Sclerosis and severe spasticityin the right upper extremity and bilateral lower extremities.Intervention: Placement of a temporary intrathecal catheter and an inpatient trial ofintrathecal baclofen.Results: In all patients, there was significant improvement in spasticity as documented bydecreased Modified Ashworth Scale scores while preserving motor strength and coordination inthe unaffected extremities.Limitations: Retrospective review of 3 cases in a single center.Conclusions: Trialing for baclofen is usually performed as a single shot bolus. For patientswith severe hemiparetic spasticity or in patients where weakness in the unaffected limb mightsignificantly affect quality of life, this trialing technique may be inadequate. In these patients,placement of a temporary intrathecal catheter and inpatient admission may be a more effectivetrial method.Key words: Baclofen, intrathecal drug delivery, spasticity, multiple sclerosis, traumatic braininjury