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 of spasticity. As interventional pain physicians are rapidly becoming the experts in intrathecal drug 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. While uncomplicated 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 more delicate approach. This is the first case series in the literature reporting a trial using an indwelling temporary catheter and inpatient admission. Moreover, while the technical aspects of intrathecal therapy trialing and implantation might be familiar for the interventional physician, we review the 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 severe upper and lower extremities spasticity complication for which a single shot technique may be inadequate. 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 extremities with preserved left-sided function due to diffuse axonal injury. A 45-year-old woman with traumatic brain injury and severe spasticity of the left upper extremity with minimal dysfunction in the right upper extremity. A 34-year-old woman with Multiple Sclerosis and severe spasticity in the right upper extremity and bilateral lower extremities. Intervention: Placement of a temporary intrathecal catheter and an inpatient trial of intrathecal baclofen. Results: In all patients, there was significant improvement in spasticity as documented by decreased Modified Ashworth Scale scores while preserving motor strength and coordination in the 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 patients with severe hemiparetic spasticity or in patients where weakness in the unaffected limb might significantly 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 effective trial method.