Intrathecal Baclofen Infusion-Botulinum Toxin Combined Treatment Efficacy in the Management of Spasticity due to Cerebral Palsy.

BACKGROUND: Cerebral Palsy (CP) is a group of permanent, but not unchanging, disorders of movement and/or posture and motor function, which are due to a non-progressive interference, lesion, or abnormality of the developing/immature brain. One clinical presentation is muscle spasticity, which leads to a significant impact on the individual's functionality and quality of life. Spasticity treatment is multidisciplinary and includes pharmacological and physical intervention; intrathecal baclofen shows a positive effect in severe spasticity and suboptimal response to oral drugs, while local injection of Botulinum toxin type A (BTXA) improves muscle tone, motion and pain. OBJECTIVE: The aim of this study was to evaluate the efficacy of the combined intrathecal baclofen infusion (ITB) - botulinum toxin treatment in the management of spasticity in CP. METHODS: 8 patients with spastic tetraparesis were enrolled. All patients were treated with intrathecal Baclofen; in lower limbs, no spastic symptoms appeared, while marked spasticity was noted in upper limbs. We injected the right and left Biceps Brachial (BB) and Flexor Digitorum Superficialis (FDS) muscles with botulinum toxin type A. All patients underwent Myometric measurement, Ashworth Scale, Numerical Rating Scale, and Visual Analogic Scale evaluation before infiltration (T0), 30 days after injection (T1), 60 days after injection (T2), and 90 days after treatment (T3). RESULTS: All data demonstrated an improvement in spasticity, pain, quality of life, and self-care during the study, with p < 0.05. No side effects appeared. CONCLUSION: This study demonstrated the efficacy and safety of intrathecal baclofen infusion and botulinum toxin combined treatment in the management of spasticity, pain, quality of life, and selfcare in CP patients.

Comparison Between Ventricular and Spinal Infusion Tests in Suspected Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) is an often-overlooked or misdiagnosed brain disorder characterized by overt ventriculomegaly and associated with gait disturbances, cognitive impairment, and urinary incontinence. If correctly diagnosed, it is considered the only form of dementia treatable with surgery, namely through a ventriculoperitoneal or ventriculoatrial shunt with programmable valves.Among the 856 spinal and ventricular infusion tests performed from 2001 to 2017 at our institution, we analyzed 106 cases selected for suspected normotensive hydrocephalus. In all cases, Intracranial Elastance Index (IEI) and outflow resistance (Rout) values were calculated: 52 of these patients underwent Spinal Katzman Test (SKT), and the remaining 54 underwent an intraventricular infusion test (IVKT). Of the 40 patients in the SKT group with pathological elastance (71%), 17 also had a Rout >12 mmHg and 23 a Rout <12 mmHg. Of the 50 patients in the IVKT group with pathological elastance (92%), 38 also had a Rout >12 mmHg and 12 a Rout <12 mmHg.IVKT and SKT to date represent two useful tools in the diagnosis of normal pressure hydrocephalus. Despite being more invasive, IVKT, including both the intracranial elastance index (IEI) and Rout analysis, could be considered more reliable than SKT and therefore could be reserved for the most controversial cases.

Intercompartmental communication between the cerebrospinal and adjacent spaces during intrathecal infusions in an acute ovine in-vivo model.

INTRODUCTION: The treatment of hydrocephalus has been a topic of intense research ever since the first clinically successful use of a valved cerebrospinal fluid shunt 72 years ago. While ample studies elucidating different phenomena impacting this treatment exist, there are still gaps to be filled. Specifically, how intracranial, intrathecal, arterial, and venous pressures react and communicate with each other simultaneously. METHODS: An in-vivo sheep trial (n = 6) was conducted to evaluate and quantify the communication existing within the cranio-spinal, arterial, and venous systems (1 kHz sampling frequency). Standardized intrathecal infusion testing was performed using an automated infusion apparatus, including bolus and constant pressure infusions. Bolus infusions entailed six lumbar intrathecal infusions of 2 mL Ringer's solution. Constant pressure infusions were comprised of six regulated pressure steps of 3.75 mmHg for periods of 7 min each. Mean pressure reactions, pulse amplitude reactions, and outflow resistance were calculated. RESULTS: All sheep showed intracranial pressure reactions to acute increases of intrathecal pressure, with four of six sheep showing clear cranio-spinal communication. During bolus infusions, the increases of mean pressure for intrathecal, intracranial, arterial, and venous pressure were 16.6 ± 0.9, 15.4 ± 0.8, 3.9 ± 0.8, and 0.1 ± 0.2 mmHg with corresponding pulse amplitude increases of 2.4 ± 0.3, 1.3 ± 0.3, 1.3 ± 0.3, and 0.2 ± 0.1 mmHg, respectively. During constant pressure infusions, mean increases from baseline were 14.6 ± 3.8, 15.5 ± 4.2, 4.2 ± 8.2, and 3.2 ± 2.4 mmHg with the corresponding pulse amplitude increases of 2.5 ± 3.6, 2.5 ± 3.0, 7.7 ± 4.3, and 0.7 ± 2.0 mmHg for intrathecal, intracranial, arterial, and venous pulse amplitude, respectively. Outflow resistances were calculated as 51.6 ± 7.8 and 77.8 ± 14.5 mmHg/mL/min for the bolus and constant pressure infusion methods, respectively-showing deviations between the two estimation methods. CONCLUSIONS: Standardized infusion tests with multi-compartmental pressure recordings in sheep have helped capture distinct reactions between the intrathecal, intracranial, arterial, and venous systems. Volumetric pressure changes in the intrathecal space have been shown to propagate to the intraventricular and arterial systems in our sample, and to the venous side in individual cases. These results represent an important step into achieving a more complete quantitative understanding of how an acute rise in intrathecal pressure can propagate and influence other systems.

Evaluation of Therapies for Peripheral and Neuraxial Opioid-induced Pruritus based on Molecular and Cellular Discoveries.

Opioids are a mainstay of treatment for pain worldwide. Pruritus, a common side effect of opioids, is a patient dissatisfier that limits their use in many clinical settings. Both parenteral and neuraxial administration of opioids frequently evoke pruritus. The ability of opioids to suppress pain while causing itch continues to perplex clinicians and researchers alike. Several mechanisms have been proposed to explain how opioids can give rise to pruritus, but specific knowledge gaps perpetuate debate. This review summarizes the clinical burden of opioid-induced pruritus and emphasizes recent discoveries of peripheral and central mechanisms for opioid-induced pruritus, particularly with respect to scientific and conceptual advances in spinal cord circuitry and mast cell biology. The mechanisms and effectiveness of existing medications used for clinical management of pruritus will be evaluated, and we will highlight the emerging preclinical utility of selective κ-opioid receptor agonists, such as nalfurafine, for the management of opioid-induced pruritus.

Effectiveness and safety of cervical catheter tip placement in intrathecal baclofen treatment of spasticity: A systematic review.

OBJECTIVE: To evaluate the effectiveness and safety of intrathecal baclofen treatment of spasticity, administered via a cervical catheter tip. DESIGN: A review of PubMed and the Cochrane Library up to September 2020. No restriction in study design. Two reviewers independently evaluated eligibility, extracted data and evaluated risk of bias. Studies were included in which patients were treated with intrathecal baclofen for spasticity, with the catheter tip at or above the first thoracic level, independent of diagnosis and age. RESULTS: Thirteen studies were eligible, with a moderate to critical risk of bias. Improvement in spasticity was seen only in the upper extremity in 6% of subjects, only in the lower extremity in 2%, in both upper and lower extremities in 50% and without specification of location in 41%. Upper extremity function improved in 88% of cases. Neither drug-related (1%) nor technical (21%) complications occurred more often than in lower placement of the tip. Effects on respiratory function and sleep apnoea were not investigated. CONCLUSION: Cervically administered intrathecal baclofen seems to improve upper extremity spasticity and function, without causing more complications than thoracolumbar intrathecal baclofen. However, the mainly drug-related complications have not been thoroughly investigated and the available literature is of poor methodological quality. Further research is needed to confirm the efficacy and safety of this procedure.

Treatment and Management of Loin Pain Hematuria Syndrome.

PURPOSE OF REVIEW: Loin pain hematuria syndrome (LPHS) is rare and seldom diagnosed, yet it has a particularly significant impact on those affected. This is a review of the latest and seminal evidence of the pathophysiology and diagnosis of LPHS and presents the typical clinical presentation and treatment options available. RECENT FINDINGS: LPHS is typically found in young women with characteristic symptoms, including severe recurrent flank pain and gross or microscopic hematuria. The majority of patients will experience crippling pain for many years without effective therapy, often requiring frequent use of narcotic medication. However, the lack of conclusive pathophysiology, in conjunction with the rarity of LPHS, has prohibited the development and trial of definitive treatment options. Nevertheless, in order to combat this rare but severe disease, management strategies have continued to evolve, ranging from conservative measures to invasive procedures. This review presents an overview of the current hypotheses on the pathophysiology of LPHS in addition to summarizing the management strategies that have been utilized. Only 30% of LPHS patients will experience spontaneous resolution, whereas the majority will continue to face chronic, crippling pain. Several methods of treatment, including invasive and non-invasive, may provide an improved outcome to these patients. Treatment should be individually tailored and multi-disciplinary in nature. Further research is required to further elucidate the pathophysiology and develop new, specific, treatment options.

Targeted Drug Delivery (Intrathecal and Intracranial) for Treatment of Facial Pain.

Despite the high incidence of facial pain, targeted drug delivery remains a rarely used technique for treatment of otherwise refractory pain. Two distinct paths have been described. The intraventricular route allows direct access to intracerebral opioid receptors. The more recently introduced upper cervical or cisternal intrathecal route, is based on the same theories as classical intrathecal route. Intraventricular route was first described by A.K. Ommaya; its use remains limited, mostly with morphine, despite a high clinical efficiency, probably because of the invasive nature of the procedure and the need for daily direct injections. The ability to connect the catheter to an implantable pump may help to facilitate the acceptance of this approach. The also rarely used high cervical intrathecal or cisternal route is very efficient, because facial pain signals are transmitted mainly via the trigeminal nerve roots and synapse on the second-order neurons in an area that extends from the lower brainstem to the C1 and C2 levels of the spinal cord. The risks of cervical puncture may explain the rarity of its use. However, new devices allowing a simpler lumbar approach and the ongoing opioid crisis are the factors that may facilitate the wider use of this effective technique for the treatment of facial pain.

Control analgésico continuo en paciente con múltiples fracturas costales mediante colocación de catéter en el plano profundo del músculo erector de la espina / Continuous analgesic control in a patient with multiple rib fractures by placing a catheter in the deep plane of the erector muscle of the spine

Las fracturas costales tienen una elevada prevalencia en nuestra sociedad. Un adecuado y precoz control analgésico resulta fundamental a la hora de evitar complicaciones respiratorias y favorecer una rápida recuperación funcional en los pacientes con fracturas costales. Se han empleado diferentes estrategias para dicho control analgésico, desde fármacos intravenosos hasta técnicas regionales más clásicas como el catéter epidural o el bloqueo paravertebral torácico. El bloqueo ecoguiado del plano profundo del músculo erector de la espina (ESPB) constituye una alternativa eficaz en el manejo del dolor agudo derivado de las fracturas costales, permitiendo una fisioterapia y rehabilitación precoz

Rib fractures have a high prevalence in our society. An adequate and precocious analgesic control is essential to avoid respiratory complications and favor a rapid functional recovery in patients with rib fractures. Different strategies have been used for analgesic control, from intravenous drugs to more classic regional techniques such as epidural catheter or thoracic paravertebral block. Ultrasound-guided blockade of the deep plane of the erector spine muscle (ESPB) is an effective alternative in the management of acute pain derived from rib fractures, allowing physiotherapy and early rehabilitation

Intermittent epidural bolus versus continuous epidural infusions for labor analgesia: A meta-analysis of randomized controlled trials.

There are inconsistent results regarding the efficacy and safety of intermittent epidural bolus (IPB) versus continuous epidural infusions (CPI) for labor analgesia. This study used a meta-analytic approach to assess the safety and treatment efficacy of IPB versus CPI for labor analgesia based on randomized controlled trials (RCTs). Four electronic databases were used to identify eligible RCTs. Pooled effect estimates at 95% confidence intervals (CIs) were calculated using a random-effects model. Twenty-two RCTs with 2,573 parturients were selected for final analysis. The findings revealed no significant differences between IPB and CPI for the incidences of cesarean and instrumental delivery. IPB was shown to be associated with shorter total duration of labor [weighted mean difference (WMD): -21.46; 95% CI: -25.07 to -17.85; P < 0.001], duration of the first of stage of labor (WMD: -13.41; 95% CI: -21.01 to -5.81; P = 0.001), and duration of the second stage of labor (WMD: -4.98; 95% CI: -9.32 to -0.63; P = 0.025). Furthermore, IPB significantly reduced the incidences of required anesthetic interventions compared with CPI [relative risk (RR): 0.61; 95% CI: 0.39-0.95; P = 0.030], whereas there was no significant difference between IPB and CPI for the time required in the first anesthetic intervention (WMD: 7.73; 95% CI: -33.68-49.15; P = 0.714). The local anesthetic IPB (bupivacaine equivalents) was associated with lower milligrams per hour of local anesthetic (WMD: -0.89; 95% CI: -1.41 to -0.36; P = 0.001) and better maternal satisfaction (WMD: 8.76; 95% CI: 4.18-13.35; P < 0.001). There were no significant differences between IPB and CPI for the risk of adverse events. This study found that parturients with IPB have short total duration of labor and duration of the first and second stage of labor, reduced requirements for additional anesthetic interventions, and improved maternal satisfaction.

Estudio comparativo de diferentes sets de infusión epidural a velocidades máximas para analgesia del parto / Comparative study of different epidural infusion sets at maximum speeds for labor analgesia

INTRODUCCIÓN: Una de las ventajas de utilizar bolos epidurales es que se ejerce mayor presión de inyección y por tanto más difusión produciendo un mayor bloqueo sensitivo. Por tanto si a mayor velocidad de administración del bolo más presión se ejerce cabe esperar que el nivel sensitivo alcanzado sea mayor. OBJETIVO: Nuestro objetivo fue comparar el nivel sensitivo alcanzado con el set de alto flujo y el de flujo estándar a velocidades máximas. MATERIAL Y MÉTODOS: Se incluyeron setenta y tres gestantes primíparas que solicitaron analgesia epidural utilizando bolos epidurales intermitentes programados a 10ml cada 60 min de ropivacaína al 0,1% con fentanilo 2ug/ml más analgesia epidural controlada por la paciente. Dichos bolos se administraron con set de infusión estándar a 250ml/h o de alto flujo a 500ml/h según la práctica clínica habitual de cada anestesiólogo. El objetivo primario fue evaluar el nivel sensitivo alcanzado. Los objetivos secundarios fueron la escala visual analógica, la escala modificada de Bromage y el consumo anestésico en términos de analgesia de rescate (analgesia epidural controlada por la paciente y bolos administrados por el anestesiólogo). RESULTADOS: La mediana del nivel sensitivo máximo fue T9 en el grupo de alto flujo y T7 en el de flujo estándar, siendo dicha diferencia significativa estadísticamente (P=0,0002). No hubo diferencias significativas en la escala visual analógica, Bromage o analgesia de rescate. CONCLUSIÓN: El set de alto flujo no ofrece beneficios en cuanto a los resultados analizados por lo que hay que valorar su uso ya que conlleva un coste adicional

INTRODUCTION: The higher injection pressure obtained with epidural boluses give greater anaesthetic spread, and therefore better sensory block. Therefore, it stands to reason that anaesthetic administered at greater injection pressure and a higher flow rate would spread to a higher sensory level. OBJECTIVE: Our aim was to compare the sensory level reached with the high flow. and standard flow set at maximum rates. MATERIAL AND METHODS: We included 73 primiparous women who requested epidural analgesia for labour using programmed intermittent epidural boluses of 0.1% ropivacaine at a flow rate of 10ml/h and 2 ug/ml fentanyl plus patient-controlled epidural analgesia. The boluses were administered with a standard (250ml/h) or high-flow (500ml/h) infusion set, according to the usual clinical practice of each anaesthesiologist. The primary objective was to evaluate the sensory level reached. Secondary objectives were pain on a visual analogue scale, motor block measured on the modified Bromage scale, and anaesthesia consumption in terms of rescue analgesia (patient-controlled epidural analgesia) and anaesthesiologist-administered boluses. RESULTS: The median maximum sensory level reached was T9 in the high flow group and T7 in the standard flow group; this difference was statistically significant (p=.0002). There were no significant differences in visual analogue scale, Bromage or rescue analgesia between groups. CONCLUSION: Our results show that the high flow set does not offer benefits. The use of such sets need to be evaluated due to their higher cost

Pharmacodynamics of intrathecal and epidural fadolmidine, an α2-adrenoceptor agonist, after bolus and infusion in dogs-comparison with clonidine.

An α2-adrenoceptor agonist, clonidine, is extensively used in both anesthesia and intensive care medicine. However, clonidine may produce pronounced hemodynamic side effects such as hypotension and bradycardia which may limit its usefulness in certain conditions. Fadolmidine is a potent α2-adrenoceptor agonist with different physicochemical properties than clonidine. Here, the effects of fadolmidine and clonidine on analgesia (an increase in thermal skin twitch response latency), sedation, blood pressure, heart rate, respiratory rate, and body temperature were evaluated either up to 8 h after either intrathecal or epidural bolus injections or during a 24-h continuous intrathecal infusion at equipotent analgesic doses in non-anesthetized Beagle dogs. Fadolmidine and clonidine produced a dose-dependent and equipotent maximal antinociception after intrathecal bolus injection (ED50: 67 µg and 78 µg, respectively), but the duration of action of fadolmidine was more long-lasting. During the intrathecal infusion, fadolmidine achieved a good analgesic effect without evoking cardiovascular side effects, e.g., hypotension; these were evident during clonidine infusion. Epidurally, the antinociceptive potency of fadolmidine was weaker (ED50: 128 µg) than when intrathecally administered and weaker than that of epidural clonidine (ED50: 51 µg). At analgesic doses, fadolmidine injection induced moderate initial hypertension concomitantly with a decrease in heart rate whereas clonidine evoked hypotension and bradycardia. These results suggest that especially when non-opioid long-term pain relief is needed, an intrathecal infusion of fadolmidine can provide long-term antinociception with less of the known use-limiting adverse effects associated with clonidine.

The Rate of Infectious Complications After Intrathecal Drug Delivery System Implant for Cancer-Related Pain Is Low Despite Frequent Concurrent Anticancer Treatment or Leukopenia.

BACKGROUND: The efficacy of intrathecal drug delivery (IDD) for cancer-related pain is well established. Cancer therapies are often associated with immunosuppression and increased risk of infection, and the rate of infection after intrathecal drug delivery system (IDDS) implant in cancer patients has been reported as 2.4%-6.3%. Our objective is to report on the rate of surgical site infections (SSI) in patients implanted with IDDS for cancer-related pain and to provide a data-driven discussion on the relationship between antineoplastic treatment, leukopenia, and other clinical or demographic characteristics and SSI. METHODS: Following local institutional review board approval, we conducted a retrospective chart review of IDDS implants from May 2014 through December 2018. Data collected included demographic data, health status, prophylactic antibiotic administration, surgery duration, presence of leukopenia (white blood cell [WBC] count of <4.0 K/µL) or moderate neutropenia (absolute neutrophil count [ANC] of <1000/µL) within the 30 days before IDDS implant, and details of antineoplastic treatment or systemic corticosteroid use in the perioperative period. This information was assessed in relation to SSI incidence up to 6 months following implant. RESULTS: Two hundred seventeen IDDS implants were identified. A majority of patients (79.3%) received ≥1 form of antineoplastic therapy within 30 days before or after implant, and 42.4% received multiple forms of antineoplastic therapy. Therapies included chemotherapy in 46.5%, immunotherapy in 28.6%, systemic steroids in 32.3%, and radiation therapy in 28.1%. One-quarter of patients (25.8%) were leukopenic within 30 days before implant, with 3.2% having moderate neutropenia. There were 2 infectious complications representing an infection rate of 0.9% (95% CI, 0.1%-3.3%), with limited shared characteristics between those experiencing SSI. CONCLUSIONS: SSI risk after IDDS placement for cancer pain is low, despite frequent concurrent antineoplastic therapy and leukopenia in the perioperative period. Concomitant cancer therapies should not be a barrier to the implementation of IDD for cancer pain.

Efficacy of continuous epidural infusion with epidural electric stimulation compared to that of conventional continuous epidural infusion for acute herpes zoster management: a retrospective study.

BACKGROUND: Continuous epidural infusions are commonly used in clinical settings to reduce the likelihood of transition to postherpetic neuralgia via pain control. The purpose of this study was to compare the efficacy of conventional continuous epidural infusion to that of continuous epidural infusion in which the catheter is guided by electric stimulation to areas with neurological damage for the treatment of zoster-related pain and prevention of postherpetic neuralgia. METHODS: We analyzed the medical records of 114 patients in this study. The patients were divided into two groups: contrast (conventional continuous epidural infusion) and stimulation (continuous epidural infusion with epidural electric stimulation). In the contrast group, the position of the epidural catheter was confirmed using contrast medium alone, whereas in the stimulation group, the site of herpes zoster infection was identified through electric stimulation using a guidewire in the catheter. Clinical efficacy was assessed using a numerical rating scale (pain score) up to 6 months after the procedures. We compared the percentage of patients who showed complete remission (pain score less than 2 and no further medication) in each group. We also investigated whether the patients required additional interventional treatment due to insufficient pain control during the 6-month follow-up period after each procedure. RESULTS: After adjusting for confounding variables, the pain score was significantly lower in the stimulation group than in the contrast group for 6 months after the procedure. After adjustment, the odds of complete remission were 1.9-times higher in the stimulation group than in the contrast group (95% confidence interval [CI]: 0.81-4.44, P = 0.14). Patients in the contrast group were significantly more likely to require other interventions within 6 months of the procedure than patients in the stimulation group (odds ratio: 3.62, 95% CI: 1.17-11.19, P = 0.03). CONCLUSION: Epidural drug administration to specific spinal segments using electric stimulation catheters may be more helpful than conventional continuous epidural infusion for improving pain and preventing postherpetic neuralgia in the acute phase of herpes zoster.

Encephalopathy of Unknown Origin in a Baclofen Patient: Case Report and Review of the Literature.

BACKGROUND: Encephalopathy is reported to have affected 250,000 people in the United States over the last decade, with considerable morbidity and mortality. Baclofen, a gamma-aminobutyric acid-B agonist that acts on the central nervous system, is the drug most widely used to treat spasticity. Baclofen overdose is a potentially deadly condition that can cause encephalopathy and can result from multiple etiologies. Renal disease can contribute to baclofen overdose and encephalopathy, and there are currently no dosing recommendations for patient's on baclofen with renal impairment. CASE DESCRIPTION: We report an unusual case of a man aged 35 years who presented with persistent fevers, seizures, and normal mentation. The patient presented with intrathecal baclofen use and prior exposure to West Nile Virus. He developed acute kidney injury at hospital secondary to vancomycin use, and mental status declined. CONCLUSIONS: This case highlights that patients with baclofen overdose can initially appear to have serious brain injury, however, full patient recovery can occur in <72 hours. This case provides additional insight into the guidelines for the treatment and management for unknown cause encephalopathy. This case also highlights the link between renal disease, baclofen, and encephalopathy through a review of the literature.

Comparison of Programmed Intermittent Epidural Boluses With Continuous Epidural Infusion for the Maintenance of Labor Analgesia: A Randomized, Controlled, Double-Blind Study.

BACKGROUND: Programmed intermittent epidural boluses may improve the spread of local anesthetics compared to continuous epidural infusion, improving labor analgesia and obstetric outcomes. However, there are limited data from studies using commercially available pumps capable of coadministering programmed intermittent epidural boluses or continuous epidural infusion with patient-controlled epidural analgesia. Therefore, we performed this prospective, randomized, double-blind study to compare the impact of programmed intermittent epidural boluses versus continuous epidural infusion on labor analgesia and maternal/neonatal outcomes. We hypothesized that programmed intermittent epidural boluses will result in lower patient-controlled epidural analgesia consumption compared to that with continuous epidural infusion. METHODS: Following standardized initiation of epidural labor analgesia, women were randomized to receive 0.1% ropivacaine with 2 µg/mL fentanyl as 6-mL programmed intermittent epidural boluses every 45 minutes or continuous epidural infusion at 8 mL/h in a double-blind fashion with similar patient-controlled epidural analgesia settings in both groups. The primary outcome was patient-controlled epidural analgesia consumption per hour. Secondary outcomes included a need for physician interventions, patterns of patient-controlled epidural analgesia use, motor blockade, number of patients who developed hypotension, pain scores, duration of second stage of labor, mode of delivery, and maternal satisfaction. RESULTS: We included 120 patients (61 in programmed intermittent epidural boluses group and 59 in continuous epidural infusion group) in the analysis. The median (interquartile range) patient-controlled epidural analgesia volume consumed per hour was not significantly different between the groups: 4.5 mL/h (3.0-8.6 mL/h) for the continuous epidural infusion group and 4.0 mL/h (2.2-7.1 mL/h) for the programmed intermittent epidural boluses group (P = .17). The Hodges-Lehmann location shift estimate of the difference (95% CI) from the continuous epidural infusion to the programmed intermittent epidural boluses group is 0.9 mL/h (-0.4 to 2.2 mL/h). There were also no significant differences between the groups in any of the secondary outcomes except for higher median (interquartile range) patient-controlled epidural analgesia attempts per given ratio per hour in the programmed intermittent epidural bolus group (0.17 [0.10-0.30] vs 0.12 [0.08-0.18]; P = .03) and more motor block in the continuous epidural infusion group (those with Bromage score <5, 27.5% vs 50.0%; P = .03). CONCLUSIONS: Under the conditions of our study, we did not find improved outcomes with programmed intermittent epidural boluses compared to continuous epidural infusion except for less motor block with programmed intermittent epidural boluses. Future studies should assess whether smaller but clinically important differences exist and evaluate different parameters of programmed intermittent epidural boluses to optimize analgesia and outcomes with this mode of analgesia.

Intrathecal Baclofen Infusion Pumps in the Treatment of Spasticity: A Retrospective Cohort Study in a Portuguese Centre.

INTRODUCTION: Spasticity is a complex problem in patients with neurological disorders and may distress their quality of life. Intrathecal baclofen infusion pumps reduce spasticity with low doses and minimal side effects but are not free from complications. We aimed to evaluate the efficacy and safety of intrathecal baclofen infusion pumps as well as patients' satisfaction. MATERIAL AND METHODS: Retrospective cohort study including all intrathecal baclofen infusion pumps placed up to December 2015. Demographic characteristics, clinical diagnoses, date of placement or withdrawal/replacement of intrathecal baclofen infusion pumps, baclofen dosage and complications of intrathecal baclofen infusion pumps were collected. Assessments from the Ashworth and Penn's scales, Katz index and patients' global satisfaction were analysed. RESULTS: In 19 years we placed 251 intrathecal baclofen infusion pumps in 155 patients. The mean age was 41.1 ± 15.8 years. The most frequent conditions were: trauma (34%), cerebral palsy (14%), multiple sclerosis (12%) and stroke (12%). Eighty-five patients (55%) required a second pump, and eleven (7%) a third one. The lifetime of the first pump was 72 (36 - 89) and the total follow-up time was 96 (9 - 132) months. The causes of withdrawal/replacement were: battery failure (57%), catheter migration/kinking (24%), infection (14%) and pump displacement/exteriorization (7%). The complication rate was 0.21 events/month. There was a significant improvement in the Ashworth and Penn's scales after the placemen of intrathecal baclofen infusion pumps (p < 0.001 for all diagnoses) and the patients were satisfied with the treatment. DISCUSSION: The incidence of complications was within range of other international studies despite our long follow-up time. Events per month, loss to follow-up, re-intervention rate, incidence of infection and mortality were similar to other studies. CONCLUSION: Intrathecal baclofen infusion pumps are safe and effective in the treatment of spasticity. Infusion pumps provide a high level of satisfaction regarding treatment and quality of life.

Introdução: A espasticidade é um problema complexo em doentes com distúrbios neurológicos influenciando a sua qualidade de vida. As bombas perfusoras intratecais de baclofeno reduzem a espasticidade com doses baixas e efeitos laterais mínimos, mas não estão livres de complicações. Pretendemos avaliar a eficácia, segurança e satisfação dos doentes com bombas perfusoras intratecais de baclofeno. Material e Métodos: Estudo de coorte retrospetivo, incluindo todas as bombas perfusoras intratecais de baclofeno colocadas até dezembro de 2015. Foram avaliadas as características demográficas, diagnósticos, data de colocação ou retirada/substituição e complicações das bombas perfusoras intratecais de baclofeno. Analisaram-se as escalas Ashworth, Penn, Katz e satisfação dos doentes. Resultados: Durante 19 anos colocaram-se 251 bombas perfusoras intratecais de baclofeno em 155 doentes. A idade média foi 41,1 ± 15,8 anos. As patologias mais freqüentes foram: traumatismo (34%), paralisia cerebral (14%), esclerose múltipla (12%) e acidente vascular cerebral (12%). Oitenta e cinco doentes (55%) precisaram de uma segunda e onze (7%) de uma terceira bomba. A semi-vida da primeira bomba foi 72 (36 ­ 89) e o tempo total de seguimento 96 (9 ­ 132) meses. As causas de retirada/substituição foram: falha de bateria (57%), migração/kinking do cateter (24%), infeção (14%) e deslocamento/exteriorização da bomba (7%). A taxa de complicações foi 0,21 eventos/mês. Houve uma melhoria significativa nas escalas de Ashworth e Penn após colocação das bombas perfusoras intratecais de baclofeno (p < 0,001 para todos os diagnósticos) e os doentes ficaram satisfeitos com o tratamento. Discussão: A incidência de complicações situou-se dentro do intervalo reportado por outros estudos internacionais, apesar do longo tempo de seguimento. Número de eventos por mês, perda de seguimento, taxas de re-intervenção ou infecção e mortalidade foram semelhantes a outros estudos. Conclusão: As bombas perfusoras intratecais de baclofeno são seguras e eficazes no tratamento da espasticidade e oferecem um alto nível de satisfação quanto ao tratamento e qualidade de vida.

Manejo perioperatorio de pacientes portadores de sistemas electrónicos implantables para el control del dolor crónico / Perioperative management of patients with implanted electronic devices for the treatment of chronic pain

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