Armstrong R W, Steinbok P, Cochrane D D, Kube S D, Fife S E, Farrell K
Department of Paediatrics, University of British Columbia, British Columbia's Children's Hospital, and Sunny Hill Health Centre for Children, Vancouver, Canada.
J Neurosurg. 1997 Sep;87(3):409-14. doi: 10.3171/jns.1997.87.3.0409.
Management of severe spasticity in children is often a difficult problem. Orally administered medications generally offer limited benefits. This study examines the value of intrathecally administered baclofen in the treatment of 19 children with severe spasticity of cerebral origin: eight of whom sustained brain injury associated with trauma, near drowning, or cardiac arrest; 10 with cerebral palsy (spastic quadriplegia); and one child with Leigh's disease. At the time of entry into the study, patients ranged from 4 to 19 years of age, and all were completely dependent on caretakers for activities of daily living. Children who responded positively to a trial dose of intrathecal baclofen underwent insertion of a drug delivery system for continuous infusion. This was followed by a double-blind trial of baclofen or placebo and follow-up review at 3 and 6 months, and yearly thereafter. Seven children did not undergo pump implantation because of excess sedation or poor response. The 12 remaining children have been followed for a period of 1 to 5 years. Favorable responses were present in all 12 children as determined by the Ashworth Scale, with the greatest benefit being reduction of lower limb tone. Except in the case of one child who had reduction in lower limb tone that resulted in difficulty with transfers, the caretakers all reported significant benefits from intrathecal baclofen, with improvement in muscle tone, behavior, sitting, and general ease of care being most commonly noted. Central side effects were seen in some children who received continuous intrathecal baclofen infusion and included hypotension (two patients), bradycardia (two), apnea or respiratory depression (two), and sedation (one). During a total of 568 months of pump operation there were 10 mechanical complications, including two related to pump or side port failure and eight related to catheter kinks, extrusions, or dislodgment. Pump pocket effusion occurred in five children and a cerebrospinal fluid fistula was seen in one child. Local infection occurred in three children and meningitis in two children. The results demonstrate the potential value of continuous intrathecal baclofen infusion for treatment of severe spasticity of cerebral origin. However, this treatment can result in significant complications and more experience is required before the long-term benefits can be determined.
儿童严重痉挛的管理往往是个难题。口服药物通常效果有限。本研究探讨鞘内注射巴氯芬治疗19例脑源性严重痉挛儿童的价值：其中8例因创伤、近乎溺水或心脏骤停导致脑损伤；10例患有脑瘫（痉挛性四肢瘫）；1例患有 Leigh 病。在进入研究时，患者年龄在4至19岁之间，所有患者在日常生活活动方面完全依赖照顾者。对鞘内注射巴氯芬试验剂量反应阳性的儿童接受了药物输送系统的植入以进行持续输注。随后进行了巴氯芬或安慰剂的双盲试验，并在3个月和6个月时进行随访复查，此后每年复查一次。7名儿童因过度镇静或反应不佳未接受泵植入。其余12名儿童已随访1至5年。根据Ashworth量表，所有12名儿童均有良好反应，最大益处是下肢肌张力降低。除1例儿童下肢肌张力降低导致转移困难外，照顾者均报告鞘内注射巴氯芬有显著益处，最常见的是肌张力、行为、坐姿和总体护理便利性的改善。一些接受持续鞘内注射巴氯芬输注的儿童出现了中枢性副作用，包括低血压（2例患者）、心动过缓（2例）、呼吸暂停或呼吸抑制（2例）和镇静（1例）。在泵运行的总共568个月中，出现了10例机械并发症，包括2例与泵或侧端口故障有关，8例与导管扭结、挤出或移位有关。5名儿童出现泵袋积液，1名儿童出现脑脊液瘘。3名儿童发生局部感染，2名儿童发生脑膜炎。结果表明，持续鞘内注射巴氯芬输注治疗脑源性严重痉挛具有潜在价值。然而，这种治疗可能会导致严重并发症，在确定长期益处之前还需要更多经验。
