Intrathecal Baclofen for Spasticity

Published in Panorama


Intrathecal Baclofen for Spasticity

Suhail, all of 25 years, is a victim of a road accident with a spinal cord injury that has left him extremely severely disabled! Bound to a wheelchair, he has no control over his bowel or bladder. On a 0 – 5 scale, he has practically Grade zero power in his lower limbs and Grade 1-2 power in his upper limbs. In short, Suhail is affected by severe spasticity in all his four limbs which have become completely stiff and rigid, so much so, it is impossible to move them even an inch unless 2-3 people put all their effort to do so!

Getting him out of the wheelchair and into his bed is a Herculean task since he cannot flex his limbs. And, when he is made to lie down, his arms and legs are in a crossed position and he screams in excruciating pain. Suhail’s pain is a 24 hour phenomenon and there is no time when he is free of it!

The good news for Suhail: he is responding to a new treatment – Intrathecal Baclofen – a treatment which one may say is old wine in a new bottle!

What is spasticity and who are its victims? Dr.Sujay Rao, Consultant Neurosurgeon, Manipal Hospital, Bangalore explains, “Spasticity is continuous, unrelenting stiffness of the limbs, an increased muscle tone that interferes with the ability of an individual to carry out simple, routine tasks as talking, dressing, eating, or even walking. This can happen because of any injury, head or spinal cord injury, stroke, tumor, encephalitis, cerebral palsy, multiple sclerosis and infections. Since it can be caused by a multitude of factors, no age is barred from the condition. Patients with severe spasticity have four major problems: They suffer unbearable pain, severe stiffness of limbs with legs and arms forming scissors across each other in painful spasms when the patients lie down, frozen joints, and finally, in many patients, especially those with spinal cord injury, there’s total paralysis. Yet, when spasticity is relieved, a surprising amount of movement is often seen in the limbs which may not be anywhere near normal but an improvement, nevertheless in an otherwise hopeless situation.”

Treatment with Intrathecal Baclofen is the latest treatment modality for spasticity, with very good results, says Dr.Rao. “While Baclofen itself is not a new drug in the treatment of spasticity, the way it is administered, is making all the difference in achieving the desired results in patients. Baclofen basically helps to control the over stimulation of the motor nerves which cause spasticiy. When it is delivered directly to areas of the spinal where it is required to loosen muscles and prevent spasms, it is more effective than taken orally, as was done earlier.”

Dr.Rao explains the basis of treatment, “If used orally, Baclofen can never be given in the amounts required to make any significant impact, because of its side effects which include great muscle flaccidity, drowsiness and vomiting. On the other hand, the present treatment involves using an implantable, programmable and refillable pump, to directly deliver Baclofen to the desired areas of the spine in micro-quantities, all day long. This continuous infusion of the drug makes possible maximum relaxation of spasticity, with minimal incidence of the unwanted side effects and enables the patient to do physiotherapy.”

The bio-friendly, battery-driven pump is implanted on the chest in the same way as a pacemaker. Dr.Rao explains, “A tube leads out under the skin and into the space around the spinal cord. The pump is programmed to deliver the necessary amount of Baclofen, continuously. Depending on the dose and rate of delivery of the drug, the pump needs to the refilled periodically. This can be done easily by a simple injection through the skin. A remote device allows the rate of delivery to be adjusted from outside, giving both patient and doctor enormous control over the therapy and side effects. If a patient feels he can tolerate a certain degree of spasticity, to that extent, you could actually give him a very low dose! The rate of delivery can be reduced at night and increased a trifle during the day time when patients need to be more active. Also, it can be switched off when the patient sleeps and restarted during his waking up hours.”

Ideally, treatment with Intrathecal Baclofen is suggested for individuals with severe spasticity whose routine chores are affected, making them dependent on others and in patients where other measures to control spasticity have failed.

However, before beginning treatment with this therapy, a trial dose of Intrathecal Baclofen is administered directly into the patient’s spine and changes in muscle tone are monitored for four to six hours. If the patient responds to the treatment, surgeons go ahead with the implant which involves about 1 – 2 hours of surgery.

Does it then mean that treatment with Intrathecal Baclofen will enable the individual to get back to work? Dr.Rao is emphatic, “No. The drug, however administered, will not reverse the spasticity. But the quality of the patient’s life is greatly improved. Firstly, for instance in the case of Suhail, he has paralysis of all 4 limbs and therefore he is going to remain wheelchair bound. But the pains and cramps that he experiences will now be reduced in severity. Secondly, we can actually find out what kind of power he has in his muscles, by giving him exercises to improve muscle strength and may be make a difference to him. Without Intrathecal Baclofen treatment, his muscles would continue to have leadpipe-like stiffness about them. Thirdly, a problem faced by these patients is that you can’t make them sit at a potty! The physical stress of managing the patients by their family members is tremendous. These problems will be diminished to a large extent with the new treatment.”

That is not to say that patients with severe spasticity will remain useless from a financial point of view, assures Dr.Rao. “Employability depends on what kind of muscle power we can see after the spasticity is relieved with Intrathecal Baclofen. The patients may be able to feed themselves, write, sit at a desk and do some simple work. They may be able to earn something for themselves which allows them to live with dignity and a certain amount of independence. Such patients are mentally absolutely normal and hence can even get hooked up to a telephone system with a voice activation, so that they perform the task of a telephone operator, for instance”.

Depending on the extent of spasticity, individual goals are set for each patient with respect to his or her rehabilitation. Also, the implant procedure is entirely reversible, should there be a medical breakthrough, promising more enhanced results for these victims.

Patients on Intrathecal Baclofen treatment have to be on the drug life long, but it does not have any long term side effects because of the manner in which it is administered, assures Dr.Rao.

What are the possible complications of this implant surgery? Dr.Rao explains, “As with any surgery, we worry about infection due to the implant but these can be taken care of with antibiotic cover. In most cases like that of Suhail, apart from infection from surgery itself, since patients are unable to control urine and bowel there’s increased risk of repeated urinary tract infection.”


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