A. Krebs W.M. Strobl R. Cumlivski Intrathecal Baclofen Therapy for Children with spastic cerebral palsy and total body involvement. A. Krebs W.M. Strobl R. Cumlivski

Introduction Continuous intrathecal application of baclofen is a quite new indication for patients with cerebral palsy. Because of possible complications indication is very strict for these patients. A preoperative evaluation with an external pump is necessary for every patient. The muscle tone often varies during the day, so that evaluation with bolus doesn‘t show sufficient results. Baclofen is a GABAb – receptor agonist. Baclofen makes a reduction of the mono and polysynaptic reflexes. This leads to a reduction of muscle tone in patients with spastic cerebral palsy. The oral application of Baclofen needs high doses and tends to result in side effects. The advantage of intrathecal application is a very low dose, a low rate of side effects and improved muscle relaxation. Side effects are reduced trunk and head control, sitting problems because of the pump in small children, nausea and swallowing problems.

Testing procedure Inserting the intrathecal catheter through the guiding-canula Making a subcutaneous tunnel for the catheter Patient with the external pump

Material and Methods During the last five years we had an evaluation in nine patients and an implantation of a programmable pump in six patients at the Orthopaedic Hospital Vienna Speising. Six patients had spastic cerebral palsy, three patients had a near drowning. Three patients did not respond to intrathecal baclofen. The evaluation of muscle tone was done with modified ashworth scale and video documentation before and during evaluation of every patient. The evaluation period was for an average of 5 days with slow increasing of dosage using an intrathecal catheter and an external pump. For the evaluation of quality of life we used a self designed questionnair. The questionnair included maximum sitting time, visual analogue scales for pain while sitting, comfort while sitting, problems with positioning and care giving.

13 y old girl with spastic cerebral palsy. 5 days after implantation. 5 year old girl with spasticity after near drowning accident. 7 days after implantation

X-ray of implanted pump and catheter with tip of catheter at 1st lumbar vertebral body. Programmming of the pump after implantation

Material and Methods The mean follow-up time was 1 year and 4 month. The parents or attendants of all six patients with an intrathecal pump answered to the questionnair. The parents or attendants reported a very good reduction of spasticity in all of our patients who had a positive response during evaluation period. The comfort when sitting was much better and care giving was easier for parents and nurses. The spasticity according to ashworth was reduced from 3,38 to 2. Four patients (of six) had an increased attention. Two patients showed better swallowing and two patients had improvement of head-control. We had complications only in one patient with a disconnection of the catheter from the pump.

Results – Functional Improvements 3,2 0,6 5,8 6,7 4,2 3,3 2 4 6 8 Comfort while sitting (VAS 0-10) before implantation with continious application of intrathecal baclofen Maximal sitting-time (hours) Pain while sitting (VAS 0-10) Results for sitting for patients with continious intrathecal application of Baclofen. VAS: Visual analogue scale. Pain while sitting: 0= no pain, 10 = very severe pain. Comfort while sitting: 0 = good comfort, 10 = severe problems while sitting 3,4 7,5 4,2 5,6 2 4 6 8 Positioning problems (VAS 0-10) before implantation with continious application of intrathecal baclofen Care giving problems (VAS 0-10) VAS: Visual analogue scale, 0 = no problems, 10 = severe problems

Results – Reduciton of Spasticity 2,0 3,38 1 2 3 4 before implantation with continious application of intrathecal baclofen Modification of the muscle tone (Modified ashworth scale)

Discussion Continuous intrathecal baclofen is very effective and safe for patients with severe cerebral palsy with whole body involvement. The indication is severe spasticity which does not respond to oral applicaton of baclofen or spasticity after near drowning accidents. The increasement of infusion rate of baclofen during test period should be slow and the blood pressure, heart rate and oxygen saturation of the patient must be monitored. You need good compliance of these patients because of frequent controls and fillings of the pump. The evaluation will show good results only with continuous application of baclofen with an intrathecal catheter. Testing with single bolus is not very reliable in patients with cerebral palsy or after near drowning accidents.