Indications for Intrathecal Baclofen Therapy/Pump
Intrathecal baclofen therapy is indicated primarily for severe spastic hypertonia that does not respond to other interventions, including oral antispasticity medications, botulinum toxin injections, and physical modalities. 1
Primary Indications
Spasticity of Spinal Origin
- Multiple sclerosis with severe spasticity
- Spinal cord injury with disabling spasticity
- Spinal cord diseases with significant spasticity
Refractory Spasticity
- Patients who have failed oral baclofen therapy
- Patients who experience intolerable side effects from oral medications
- Patients with severe spasticity requiring higher doses than can be tolerated orally
Post-Stroke Spasticity
- Can be considered as early as 3-6 months after stroke for patients with severe spastic hypertonia refractory to other treatments 1
- Note: While the FDA label does not specifically indicate baclofen for stroke 2, clinical guidelines support its use in severe post-stroke spasticity 1
Clinical Decision Algorithm
First-line treatments (try these before considering ITB):
- Positioning, passive stretching, and range of motion exercises
- Oral antispasticity medications (tizanidine, oral baclofen, dantrolene)
- Targeted botulinum toxin injections for focal spasticity
- Physical modalities (NMES, vibration)
Consider ITB when:
- Spasticity is severe and generalized
- Patient has failed or cannot tolerate maximum doses of oral medications
- Spasticity causes significant functional limitations:
- Pain
- Poor skin hygiene
- Decreased function
- Interference with positioning
- Increased caregiver burden
- Reduced quality of life
Trial before implantation:
- A test dose of intrathecal baclofen should be administered
- Proceed with pump implantation only if satisfactory response is observed
Expected Benefits
- Reduction in Ashworth scores for muscle rigidity 3
- Decrease in spasm frequency and severity 3
- Improved range of motion
- Decreased pain
- Improved sleep quality
- Enhanced ability to perform activities of daily living
- Improved bowel and bladder program performance 4
- Reduced caregiver burden
Important Considerations and Cautions
Withdrawal Risk
- Abrupt cessation of intrathecal baclofen can lead to catastrophic withdrawal syndrome 1
- Withdrawal can evolve over 1-3 days and may become fulminant if not recognized
- Symptoms include increased spasticity, fever, altered mental status, seizures
- Emergency treatment includes resuming intrathecal infusion or high-dose benzodiazepine IV infusion
Complications
- Catheter-related issues (occlusion, breaks, dislodgment)
- Pump malfunction
- Infection (pocket infection, meningitis)
- Drug-related side effects (hypotonia, urinary retention, drowsiness)
- Development of tolerance
Concentration Considerations
- Concentration of baclofen in the pump may affect spasticity control 5
- Higher concentrations may be considered during pandemics or other situations to reduce refill frequency 1
Follow-up Requirements
- Regular pump refills (timing depends on dose and concentration)
- Periodic assessment of efficacy and dose adjustments
- Monitoring for complications or side effects
- Patient education regarding signs of withdrawal or overdose
Intrathecal baclofen therapy represents an advanced intervention for severe spasticity that should be considered when conventional treatments fail to provide adequate relief. The therapy has demonstrated significant improvements in quality of life, function, and caregiver burden for appropriately selected patients.