Reducing Intrathecal Baclofen Related Infections: Service Evaluation and Best Practice Guidelines.

OBJECTIVES: Intrathecal baclofen (ITB) pumps are an effective treatment for spasticity; however infection rates have been reported in 3-26% of patients in the literature. The multidisciplinary ITB service has been established at The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square, London for over 20 years. Our study was designed to clarify the rate of infection in our ITB patient cohort and secondly, to formulate and implement best practice guidelines and to determine prospectively, whether they effectively reduced infection rates. METHODS: Clinical record review of all patients receiving ITB pre-intervention; January 2013-May 2015, and following practice changes; June 2016-June 2018. RESULTS: Four of 118 patients receiving ITB during the first time period (3.4%, annual incidence rate of infection 1.4%) developed an ITB-related infection (three following ITB pump replacement surgery, one after initial implant). Infections were associated with 4.2% of ITB-related surgical procedures. Three of four pumps required explantation. Following change in practice (pre-operative chlorhexidine skin wash and intraoperative vancomycin wash of the fibrous pocket of the replacement site), only one of 160 ITB patients developed infection (pump not explanted) in the second time period (0.6%, annual incidence rate 0.3%). The infection rate related to ITB surgical procedures was 1.1%. In cases of ITB pump replacement, the infection rate was reduced to 3.3% from 17.6%. CONCLUSIONS: This study suggests that a straightforward change in clinical practice may lower infection rates in patients undergoing ITB therapy.

Intrathecal baclofen for multiple sclerosis related spasticity: A twenty year experience.

OBJECTIVE: Evaluate long-term efficacy and safety of ITB in treating MS-related spasticity over ∼ 20 years of service provision in a single centre. METHODS: A single centre prospective observational cohort study was performed. Eligible subjects underwent ITB trial by bolus dose via lumbar puncture and responders proceeded to pump implantation. Demographics, spasticity scores (Ashworth), spasm score (Penn), stiffness, pain and discomfort (Visual Analogue Scale), mobility (10 M walk), spasticity treatment, and ITB doses were analysed longitudinally. RESULTS: 106 people were included with 568 patient years of data. Ashworth, Penn and VAS/NRS mean scores improved post-trial compared with baseline (p < 0.001). Sustained efficacy was reported on Ashworth, Penn and VAS scores over time. After 1 year, 73 (69%) discontinued all oral antispasticity medications. Complication rates were low at 0.05 complications per pump year and mostly mechanical (usually catheter) related. In 8 ambulatory subjects, 7 (87%) continued to walk one year after pump insertion, 5 (62%) were still walking at time of analysis (mean follow up 3.4 years). CONCLUSIONS: ITB is an effective and safe long term treatment for refractory MS related spasticity. Efficacy was sustained over time and the majority of subjects subsequently discontinued systemic medications. In a small cohort, ability to walk was preserved, indicating ITB should be considered earlier in this cohort.