Treatment of spasticity with selective posterior rhizotomy and intrathecal
Baclofen pumps
Cerebral palsy is a non-progressive motor disorder caused by
injury to the brain during critical periods of brain development, usually within
the first three years of life. It is one of the most common disabling conditions
of childhood and is among the most common conditions treated at Penn State Children's Hospital.
Many children with cerebral palsy are affected by spasticity
characterized by tightness or stiffness of muscles during movement. This
abnormal muscle tone creates difficulty with voluntary movement, passive
movement of arms and legs and, ultimately, may produce pain and progressive
deformities.
At Penn State Children's Hospital, we have developed a
multi-disciplinary spasticity management program, which incorporates new
treatments for spasticity. These treatments are available for children with
cerebral palsy, spinal cord injury and other disorders. This program provides
evaluations by specialists in pediatric rehabilitation medicine, pediatric
orthopedic surgery and pediatric neurosurgery, as well as by specialists in
pediatric physical and occupational therapy.
The team evaluates each child with spasticity and determines
which individualized treatment approach would be the most beneficial for that
child. Management options include oral medications, intramuscular injections
with botulinum toxin–A (BTX-A), intrathecal baclofen (ITB), orthopaedic
surgery, or selective posterior rhizotomy.
Baclofen, the drug used in ITB therapy, works at the
spinal cord, allowing abnormal reflexes to be diminished and muscles to relax.
Baclofen may be administered as an oral medication which helps some patients;
but for others, it is not effective because the orally administered route does
not provide enough relief and causes negative side effects.
What makes ITB therapy different from oral medication is that it
delivers the drug baclofen directly into the spinal canal using a pump that is
surgically placed in the body. It releases spasticity with only tiny amounts of
the medication, less than one percent of the oral dosage typically used. The
drug is delivered to its primary site of action and does not circulate
throughout the body and the bloodstream. This helps minimize side effects.
Similar benefits to children with severe generalized spasticity
and spinal cord injury have been seen. Pumps are placed in children with
traumatic spinal cord injuries, resulting in tetraplegia and severe spasticity,
and the reduction of spasticity has had enormous functional benefits for some of
the children. The pump is refilled by nurse specialists every 6-12 weeks in the
outpatient clinic setting. Primary complications have been treatable and have
included infection, spinal fluid leak and catheter problems.
Children with cerebral palsy and more focal spasticity affecting
isolated muscle groups have been treated for the short-term with intramuscular
BTX-A injections. The purified neurotoxin (botulinum toxin-A) temporarily blocks
transmission of signals between nerve and muscles. Muscle relaxation is achieved
for periods of 3-4 months.
The use of BTX-A appears to be safe, but it is currently only
FDA approved for the treatment of strabismus and blepharospasm, associated with
dystonia, in patients 12 and older. Use in cerebral palsy remains
investigational. Many Children's Hospitals are currently investigating the role
of BTX-A in improving spasticity and ambulation in cerebral palsy.
The specialists here at Penn State Children's Hospital continue
to offer traditional orthopaedic surgery and selective posterior rhizotomy for
children with cerebral palsy. TMulti-disciplinary management can offer the best
treatment specifically tailored to a child's needs.
It is clear that the treatment of cerebral palsy continues to
evolve and the physicians at Penn State Children's Hospital continue to be
involved by providing innovative and state-of-the-art management of spasticity
and other movement disorders. In the last decade, there have been tremendous
advances in the management of cerebral palsy and the contributions of Penn State Children's Hospital
physicians will likely continue to benefit children everywhere.
Questions and referrals can be directed to (717) 531-8807.
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