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Table of Contents INTRATHECAL BACLOFEN THERAPY FOR TREATMENT OF SPASTICITY AND DYSTONIA IN CHILDHOOD Amr Ammar M.B.B.Ch., MSc., MRCSEd. Thesis submitted to the University of Nottingham For the degree of Doctor of Philosophy The University of Nottingham 2018 ABSTRACT Spasticity is a common presentation in a wide variety of neurological disorders like cerebral palsy (CP), multiple sclerosis, and spinal cord injury. Management of spasticity involves multiple modalities such as physical and occupational therapy, oral medicines, Botulinum toxin injection, and orthopaedic and neurosurgical intervention. Intrathecal Baclofen (ITB) therapy is one neurosurgical intervention to control spasticity in CP patients. The ITB pump is implanted subcutaneously or sub-facially in the abdomen which delivers the baclofen directly to the intrathecal space via a catheter. As a result of by-passing the blood-brain-barrier, intrathecal administration of a hundredth part of the oral baclofen dose is sufficient to relieve spasticity and therefore preventing the peripheral side-effects seen with oral administration. Although the ITB delivery systems demonstrate significant effectiveness in improving spasticity, the ITB delivery system is associated with a high complication rate which could interfere with the desired effect of ITB therapy. Therefore, in a retrospective observational study we aimed to analyse the ITB complications in a large (n=222) consecutive series of patients. The complication rate in relation to the long period of follow-up (939 pump years), was found to be similar or less than those reported in literature. Dystonia, young age and presence of gastrostomy tube were significantly associated with infective complications. Catheter complications were influenced by presence of dystonia and the surgical technique, whether it was a subfascial or subcutaneous implantation. The pump is refilled by baclofen solution. The frequency of refilling is dependent on the daily dosing regime and the concentration of the aqueous i solution of baclofen in the pump. Baclofen solutions are available as commercial and compounded products. An experimental controlled study was conducted to evaluate the safety of using higher concentrations of compounded baclofen in comparison to commercial baclofen. Baclofen concentration of the compounded solution was found to be less accurate than the commercial product although it was within an acceptable range from the expected value. The number of invisible particulates was significantly higher in the compounded solution than in commercial baclofen. However, no clinical complications were reported in the compounded or in the commercial baclofen groups. As patients receiving ITB therapy may have clinical benefits of reduction of the severity of spasticity, they could also have improvements in their functional status and quality of life. A survey study to evaluate changes in functional status and heath related quality of life, showed improvement in both aspects, moreover, the improvement in the health related quality of life was more significant than the change in functional status. ii This thesis is dedicated to the children and their families whose lives have been affected by spasticity and cerebral palsy iii ACKNOWLEDGMENTS I am deeply indebted to my parents, my wife and my children, without their support this work wouldn’t be accomplished. I would like to express my extreme thanks to associate Professor Michael Vloeberghs and Professor David Walker for their supervision, constant support and guidance throughout this work. I am very grateful to Mr Robert Bates (Senior Technician – Quality Control Unit-Nottingham University Hospitals) for conducting the chemical analysis of baclofen solutions in quality control unit in NUH. I am very grateful to all the patients and their families who agreed to take part in this study. I would also like to thank Dr Michail Tsagris (post-doctoral researcher, Mathematical Sciences School, Univeristy of Nottingham) for helping in statistical analysis of this project. I am very obliged to Dr Mohammed Aleskandarany (Research Fellow at University of Nottingham) for helping in proofreading this thesis. I would like to extend my sincerest thanks and appreciation to my colleagues and staff at Neurosurgery Department, Nottingham University Hospital especially Mr Ahmed Mousa, Sam Ul-Muquit and Mr Isamail Ughratdar. iv PUBLICATIONS: Intrathecal baclofen therapy--how we do it Ammar A1, Ughratdar I, Sivakumar G, Vloeberghs MH. J Neurosurg Pediatr. 2012 Nov;10(5):439-44. doi: 10.3171/2012.8.PEDS11475. Epub 2012 Sep 21. Cervical implantation of intrathecal baclofen pump catheter in children with severe scoliosis. Ughratdar I1, Muquit S, Ingale H, Moussa A, Ammar A, Vloeberghs M. J Neurosurg Pediatr. 2012 Jul;10(1):34-8. doi: 10.3171/2012.3.PEDS11474. Epub 2012 Jun 15. Related publications Intrathecal baclofen pumps do not accelerate progression of scoliosis in quadriplegic spastic cerebral palsy. Rushton PR, Nasto LA, Aujla RK, Ammar A, Grevitt MP, Vloeberghs MH. Eur Spine J. 2016 May 6. Combined selective dorsal rhizotomy and scoliosis correction procedure in patients with cerebral palsy Muquit S, Ammar A, Nasto L, Moussa AA, Mehdian H, Vloeberghs MH. Eur Spine J. 2016 Feb;25(2):372-6. doi: 10.1007/s00586-015-4179-4. Epub 2015 Aug 20. v Oral presentations SBNS September 2015 York Review of factors influencing catheter complications of Intrathecal baclofen (ITB) systems: findings from 13 years of clinical practice A.M.A. Ammar, I. Ughratdar, A.A. Moussa, S. Muquit & M.H. Vloeberghs SBNS April 2015 Southampton Intrathecal Baclofen (ITB) therapy in children has greater impact on health related quality of life measures rather than functional status A.M.A. Ammar, I. Ughratdar, A.A. Moussa,& M.H. Vloeberghs Poster presentations SBNS meeting April 2015 Infectious complications of intrathecal baclofen pump (ITB) devices in 222 consecutive paediatric cases : Case series review A. Ammar , I. Ughratdar & M. Vloeberghs SBNS meeting Spring 2014 Use of higher concentration compounded intrathecal baclofen (ITB): Is it safe? A. Ammar , I. Ughratdar & M. Vloeberghs Queen ' s Medical Centre, Nottingham, UK EANS meeting, Groningen Netherlands 26-28 March 2010 Intrathecal Baclofen Catheter Complications In Children - 10 Years’ Experience (255). A. Ammar, G. Sivakumar, I.A. Ughratdar, M. Vloeberghs. EANS meeting, Groningen Netherlands 26-28 March 2010 Insertion of Intrathecal Baclofen Implant By Modified Subfascial Technique As To Subcutaneous Placement Of Implant In Children (295). A. Ammar, I.A. Ughratdar, G. Sivakumar, M. Vloeberghs. vi Table of Contents ABSTRACT..................................................................................................................................................................i ACKNOWLEDGMENTS.........................................................................................................................................iv PUBLICATIONS…………………………….……….………...….……………….……………..……………..….v TABLE OF CONTENTS..………………….………………………….………..…..……...……………..……...vii LIST OF FIGURES...................................................................................................................................................xi LIST OF TABLES.....................................................................................................................................xii ABBREVIATIONS………………………………………………………………………….………..…………..xiii 1 CHAPTER ONE : GENERAL INTRODUCTION ...................................................... 1 1.1 NEUROPHYSIOLOGY OF SPASTICITY .............................................................................................2 1.2 SPASTICITY ..................................................................................................................................4 1.2.1 Definition ...........................................................................................................................4 1.2.2 Causes of spasticity in children .........................................................................................6 1.2.3 Consequences of spasticity ................................................................................................6 1.2.4 Cognitive state and spastic cerebral palsy ........................................................................8 1.2.5 The impact of caring for a child with spastic cerebral palsy.............................................9 1.3 ASSESSMENT OF SPASTICITY ...................................................................................................... 11 1.4 MANAGEMENT OF SPASTICITY AND DECISION-MAKING ............................................................. 11 1.4.1 Factors affecting decision making for spasticity treatment: ............................................ 12 1.5 MODALITIES OF SPASTICITY MANAGEMENT ............................................................................... 14 1.5.1 Non-pharmacological Therapy: ...................................................................................... 14 1.5.2 Pharmacological management of spasticity (general and reversible) ............................ 14 1.5.2.1 Agents Acting Through the GABAergic System ...................................................................... 15 1.5.2.2 Central α-2 adrenergic receptor agonists ................................................................................... 21 1.5.2.3 Peripheral acting muscle relaxant .............................................................................................
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