Intrathecal baclofen as a treatment for spasticity: Review of the cases treated in our hospital

Santin-Amo, José María; Flores-Justa, Ana; Román-Pena, Paula; Raposo-Furelos, Martín; Frieiro-Dantas, Carla; Serramito García, Ramón; Villa, Juan Manuel; Gelabert-González, Miguel

doi:10.1016/j.neucie.2019.05.003

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espasticidad: revisión de los casos presentes tratados en nuestro servicio" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1254 "Ancho" => 2188 "Tamanyo" => 172012 ] ] "descripcion" => array:1 [ "en" => "Difference between initial dose and final dose in the sample." ] ] ] "textoCompleto" => "IntroductionWe define spasticity as a motor-type disorder, in which there is an increase in muscle tone with exaggerated stretch reflexes, both directly proportional to the velocity, which results from an abnormal processing in the spine of afferent pathways.<a class="elsevierStyleCrossRef" href="#bib0090">1</a>Knowledge of the prevalence of spasticity helps us to assess the overall social dimension of the problem, as it affects both the patient and their family. Here in Spain, there is an approximate prevalence of 300,000–400,000 people affected by spasticity, representing therefore a significant medical problem with high incidence (10 per 1000 population).Spasticity has multiple causes and its prevalence is closely linked to that of the corresponding diseases. It affects both adults and children and occurs in a large number of neurological disorders such as cerebral palsy, multiple sclerosis, cerebrovascular accidents, etc. Spasticity is the abnormality most often associated with cerebral palsy, with almost 70% affected.<a class="elsevierStyleCrossRef" href="#bib0095">2</a> This damage is typical of the upper motor neuron or first motor neuron, and both the brain stem and the spinal cord may be affected (encephalopathy, demyelinating diseases, traumatic brain injuries, trauma, tumours, etc.).The clinical signs of spasticity have classically been divided into two groups<a class="elsevierStyleCrossRef" href="#bib0100">3</a>: positive clinical signs, which include increased muscle tone, reflex hyperactivity and extensor plantar responses; and the negative clinical signs, referring to the functions that the patient loses due to spasticity, i.e. loss of agility, loss of selective motor control and poor coordination.<a class="elsevierStyleCrossRef" href="#bib0105">4</a>The treatments range from the field of rehabilitation to drug therapy and surgical interventions, both destructive and conservative. Neurosurgical treatments began at the beginning of the 20th century after the classic Sherrington studies.<a class="elsevierStyleCrossRef" href="#bib0110">5</a>The main complications that appear in the literature derived from surgical treatment are: infection (10%); externalisation of the device; rupture of the catheter and displacement of the device (10%); CSF leak (15%); and tolerance to baclofen (5%).Material and methodsWe performed a retrospective descriptive study of 17 patients with spasticity secondary to various diseases, diagnosed and treated surgically by implanting an intrathecal baclofen infusion device in our neurosurgery department in the period 2005–2018, with a minimum follow-up of one year for each patient. Due to the small sample size, we analysed the results descriptively. In addition to the basic epidemiological data, we analysed the different causes of spasticity, the treatment applied and its complications, surgical outcomes and progress. Clinical follow-up was possible in all but one of the patients.The quantitative assessment of spasticity and spasms is important for assessing the effects of treatment, as well as the patient's degree of disability. We have clinical assessment methods available, such as the Ashworth Scale (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) and the modified Ashworth Scale based on muscle tone. These scales, the most used nowadays, are simple, quick to perform and do not require instruments. We can also assess another clinical parameter, the frequency of muscle spasms, using the Spasm Frequency Scale<a class="elsevierStyleCrossRef" href="#bib0115">6</a> and the Penn Scale (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The inclusion criteria in our study were as follows: patients with severe spasticity (Ashworth greater than 3) in ≥2 limbs with at least 2 muscle groups affected in the lower limbs, in whom conservative treatments had failed, with positive response to the baclofen test and a sufficiently high body mass. Clear objectives were set by the multidisciplinary team: to improve patient independence; to facilitate the work of caregivers; to improve the quality of life of patients and family members; to promote hygiene; to reduce pain; and to prevent complications.The criteria used for exclusion were: recent infection; hypersensitivity to baclofen; insufficient body mass; and negative response to the baclofen test.In patients who met the inclusion criteria, we performed an efficacy test involving different doses of intrathecal baclofen being administered on consecutive days (initial 25mcg, 50mcg, 75mcg up to a maximum of 100mcg). If the patient responded, i.e. improved their score on the Ashworth Scale, at any of the above doses, they were considered as candidates for this treatment. If the patient obtained no response even at the maximum dose of 100mcg, they would not benefit from implantation of a baclofen pump.Patients with a positive baclofen test had a continuous infusion pump implanted. The technique used in our centre is as follows: an intrathecal catheter is inserted at the lumbar level (the level depends on whether or not there are symptoms in the upper limbs) and tunnelled to the abdomen, usually on the left flank, where the pump is implanted. The pump is then programmed as follows: if the duration of effect of the test dose is greater than 12h, that will be the initial dose; if the duration of effect of the test dose is less than 12h, the initial daily dose will be twice the test dose.The system is recharged and programmed externally by means of a telemetry system, so the dose adjustment is made once the device is implanted. Follow-up is then carried out at scheduled consultations supervised by a specialised nurse and the neurosurgeon. In our centre, we carry out a check-up at 24h and subsequent days until we achieve good control of the spasticity without side effects. Once the dose has been established, the patient is given an appointment for 3–6 months to recharge the pump and assess their clinical response using the Ashworth and Penn scales. Depending on the type of patient, additional follow-up by rehabilitators, neurologists, paediatricians and/or physiotherapists is recommended.It is important to be aware that the dose should not be increased in the first 24h. The increase in dose per day should not exceed 10% to 30% of the previous dose in patients with spinal spasticity, and from 5% to 15% in patients with cerebral spasticity.ResultsAt Hospital Clínico, Santiago de Compostela, a total of 17 patients had surgery for implantation of a baclofen pump. In our sample there was a clear predominance of females (15 females to two males). Mean age at implantation of the pump was 45 (11–79). The causes of spasticity of the patients in our series were: multiple sclerosis in five patients (29.4%); cerebral palsy in six patients (35.4%); secondary to subarachnoid haemorrhage in two patients (11.7%); post-traumatic in two patients (11.7%); tumour in one patient (5.9%); and unknown in one patient (5.9%). Multiple sclerosis is the leading cause over the age of 35. Congenital diseases are the most common causes in children and young people, and the main cause of spasticity in males. In our sample, the spasticity in the two male patients was post-traumatic in one and congenital in the other. The incidence of road traffic and other accidents was similar in males and females, being more predominant in young people.After passing the phase for inclusion in the treatment, the patients’ doses were determined by analysing the symptoms before and after implantation of the device. Of the 17 patients, 6 (35.4%) remained on the starting dose. However, seven patients (41.1%) needed to have the initial dose increased, although the increase was only significant in patient number 13, as the expected improvement was not obtained. Four patients (23.5%) were able to gradually decrease the dosage thanks to their great improvement (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The mean improvement on the Ashworth Scale at six months was two points (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) in 15 of the patients (88.2%), with patient 13 being the only one to only improve by one point. For muscle spasms assessed with the Penn Scale at six months, improvements of one point were achieved in cases where therapeutic dose was maintained and there were no problems such as fever or infection, which reduce the effects of baclofen. In six of the patients, the Penn Scale score improved from four to three points, and in ten of the patients, from three to two points. Of our 17 patients, only one had a poor outcome, despite the therapeutic efforts. One of the cases could not be assessed as they were lost to follow-up.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The complications in our sample were minimal, mostly being related to the device. In three patients (17%) it was necessary to re-operate; in two because of dysfunction of the infusion system, one due to disconnection of the catheter and the other rotation of the pump; and in the third, the system had to be removed and repositioned at six months due to a cerebrospinal fluid leak. We can therefore conclude that the treatment has minimal complications, with the vast majority being related to the surgical intervention itself.DiscussionThe neurophysiological bases of spasticity have been widely debated. The classic stretch reflex includes the stretch receptor in the muscle spindle and its afferent fibre (Ia) in the dorsal root, which directly or indirectly excites the α motor neuron in the spinal cord.<a class="elsevierStyleCrossRef" href="#bib0120">7</a> The chronic loss of suprasegmental impulses leads to overactivity of the α motor neuron. This phenomenon, added to an abnormal processing of the spinal afferents, leads to the monosynaptic arch being hyperactive. The last step of this process is the increase in acetylcholine release in the neuromuscular junction and, finally, muscle contraction.<a class="elsevierStyleCrossRef" href="#bib0125">8</a>We think of spasticity as a chronic process in which changes take place over time, i.e. we are talking about a dynamic disease in which the properties of the soft tissues alternate until in the end, muscle fibrosis is produced. At this point, musculoskeletal changes occur, usually accompanied by pain. These changes can be divided into various phases. The first is the spastic phase, then the vicious circle phase, in which there is a muscle imbalance due to the predominance of spasticity in certain muscle groups; typical being predominance of the plantar flexors and varus deformity-forming muscles of the foot, the adductors and hip flexors, and the elbow, wrist and finger flexors in the upper limbs.<a class="elsevierStyleCrossRef" href="#bib0130">9</a> The muscle retraction phase is characterised by the persistence of this vicious circle, with unequal growth between agonist and antagonist muscle groups leading to the structuring of this circle due to the lack of accommodation of the sarcomere, which is unable to achieve normal muscle growth. Muscle retraction is understood to be the opposing resistance by the muscle to movement when it is not in contraction.<a class="elsevierStyleCrossRefs" href="#bib0115">6,10</a> The next phase is osteoarticular deformities, the aim being to prevent this phase with conservative treatment or using the baclofen pump; the collaboration of orthopaedic surgeons would be needed to perform far more invasive interventions.In the treatment of spasticity, baclofen is considered the pharmacological treatment of choice. It is an analogue of γ-aminobutyric acid and acts centrally, inhibiting stretch reflexes and decreasing muscle tone. It is therefore capable of managing severe spasticity of cerebral or spinal origin causing functional disability. Alternatively, diazepam, tizanidine or dantrolene sodium may be used as second choice.<a class="elsevierStyleCrossRef" href="#bib0140">11</a> Botulinum toxin is widely used in patients with spasticity. Its mechanism of action is to block the release of acetylcholine, with an effect that can last 4–6 months in the treated region. The disadvantages are that it can cause local pain, muscle atrophy, allergic reactions and immunoresistance.<a class="elsevierStyleCrossRef" href="#bib0145">12</a>Rehabilitation treatment is fundamental in the approach to spasticity, both focal and generalised, from the beginning, throughout all the evolutionary stages. Physiotherapy should be started early to prevent the onset of spasticity or reduce its intensity. The treatments used include the following: postural therapy, kinesiotherapy, cryotherapy, electrostimulation, biofeedback, hydrotherapy and strengthening of the antagonists.<a class="elsevierStyleCrossRef" href="#bib0150">13</a> Splints and the orthoses can also be used.We know that spasticity often acts as a substitute for muscle strength deficit, allowing the preservation of certain functionality. However, it is not uncommon for it to become painful and reduce motor function, resulting in a functional worsening.When spasticity does not improve after rehabilitation treatment, neuromuscular blocks and oral drugs, surgical treatment is indicated.<a class="elsevierStyleCrossRefs" href="#bib0115">6,14,15</a> In our centre, these patients are initially treated with rehabilitation treatment, neuromuscular blocks and oral drugs and are followed up by neurologists and/or paediatricians, who refer patients to our neurosurgery department if they do not respond adequately to conservative treatment, to be assessed for surgical intervention. These patients are given the baclofen test or efficacy test. In this article, we have focused on intrathecal baclofen infusion devices, a non-ablative or reversible procedure which acts on the central nervous system. The intrathecal infusion of baclofen is the main neuromodulation technique. It is able to act at the medullary level without causing central damage. Patients who may benefit from this type of treatment are those with have severe chronic spasticity (spinal or cerebral) with poor response to oral antispastic agents or those who suffer unacceptable side effects with effective oral doses.Creamer et al.<a class="elsevierStyleCrossRef" href="#bib0165">16</a> show better results in patients with spasticity secondary to stroke treated with intrathecal baclofen, with a reduction in Ashworth score of 99% compared to those treated with conventional oral drugs, who had a reduction of 43%. Sammaraiee et al.<a class="elsevierStyleCrossRef" href="#bib0170">17</a> show good long-term results in patients with multiple sclerosis treated with intrathecal baclofen, with reduced pain, stiffness and spasms measured with the Penn Scale and spasticity measured with the Ashworth Scale, with statistically significant results.In our series, we obtained improvements of two points in the Ashworth Scale and one point in the Penn Scale. The need for dose modification will depend largely on intercurrent processes such as infections, other diseases or medications that affect the efficacy of baclofen, as well as the progression of some diseases which course with outbreaks, such as multiple sclerosis.From our point of view, this system has a large number of advantages over conventional treatment: measurable efficacy before implantation; minimally invasive technique; it can be complemented by other therapies (rehabilitation, orthopaedic surgery, etc.); as it is given by intrathecal infusion, the dose required is much lower than with pharmacological treatment, so there are also fewer side effects. Disadvantages include the need to recharge the pump after a certain time or for repeat surgery due to breakdown of the device.We are aware of the small number of patients in our sample, so we consider this work to be a starting point, which should be continued in the future in order to obtain statistically significant results. However, despite the small number of patients treated, the good results obtained in our study show us that a greater number of patients could benefit from this type of therapy, improving the quality of life of both the patient and the caregiver.The implantation of the baclofen pump is one of the surgical techniques of choice in our department. However, it is used in very few centres, with Santiago de Compostela and La Coruña being the only ones specialised in this treatment in the region of Galicia.We would recommend greater collaboration from other services, as we believe there is a large number of patients who would benefit from this therapy.ConclusionWe believe that the treatment of spasticity should be personalised. It is important that the objectives are agreed with the patient and the caregiver, while making sure that expectations are always realistic. The purpose is to improve function, promote hygiene, reduce pain, prevent complications and, as a consequence, improve quality of life. Among all the surgical techniques used for the treatment of spasticity, the implantation of intrathecal baclofen infusion devices has proved to be a simple, reversible technique with corroborated results and very few drawbacks. One of these drawbacks is the need for refills every three to six months depending on the dose received, but this allows us to modulate the doses according to the needs of the patient. This treatment improves patient autonomy, and the majority of patients and their caregivers are satisfied with the implant.Conflicts of interestThe authors declare that they have no conflicts of interest regarding the publication of this article." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1261132" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1167947" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1261133" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1167946" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-01-06" "fechaAceptado" => "2019-05-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1167947" "palabras" => array:4 [ 0 => "Spasticity" 1 => "Baclofen" 2 => "Ashworth" 3 => "Surgical treatment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1167946" "palabras" => array:4 [ 0 => "Espasticidad" 1 => "Baclofeno" 2 => "Ashworth" 3 => "Tratamiento quirúrgico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionSpasticity represents a medical problem whose incidence is increasing during the last years due to pathologies such as cerebral palsy, stroke, multiple sclerosis, trauma or encephalopathy, affecting both adults and children. The treatments include rehabilitation, pharmacotherapy and surgery, among which we highlight intrathecal baclofen infusion devices. Material and methodsIntrathecal baclofen devices implanted patients in Clinical Hospital of Santiago de Compostela from 2005 to 2018 were selected for retrospective analysis using assessment of spasticity scales, such as Ashworth Scale. Complications are described. ResultsSurgery was performed in 17 patients for baclofen pump implant, achieving an improvement of 2 points on the Ashworth Scale in 88.2% of the patients and of 1 point on the Penn Scale in 94%. Complications were seen in 3 patients. ConclusionsIntrathecal baclofen is a simple technique with good results for improving the quality of life of patients with spasticity." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa espasticidad representa un problema médico cuya incidencia está aumentando debido a enfermedades como parálisis cerebral, ictus, esclerosis múltiple, traumatismos o encefalopatías, afectando tanto a adultos como a niños. Los tratamientos incluyen rehabilitación, farmacoterapia y cirugía, entre las cuales destacamos las bombas de baclofeno intratecal. Material y métodosSeleccionamos a los pacientes portadores de bomba de baclofeno intratecal implantada en el Hospital Clínico de Santiago de Compostela entre 2005-2018 y analizamos retrospectivamente los resultados mediante escalas de valoración de espasticidad, como la de Ashworth, así como las complicaciones observadas. ResultadosSe implantaron bombas de baclofeno a 17 pacientes, obteniendo una mejoría de 2 puntos en la escala de Ashworth en el 88,2% y de 1 punto en la escala de Penn en el 94%. Se observaron complicaciones en 3 pacientes. ConclusionesEl tratamiento con baclofeno intratecal es una técnica sencilla con resultados muy positivos para mejorar la calidad de vida de pacientes con espasticidad." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Santin-Amo JM, Flores-Justa A, Román-Pena P, Raposo-Furelos M, Frieiro-Dantas C, Serramito García R, et al. Baclofeno intratecal para el tratamiento de la espasticidad: revisión de los casos presentes tratados en nuestro servicio. Neurocirugia. 2019;30:288–293." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1254 "Ancho" => 2188 "Tamanyo" => 172012 ] ] "descripcion" => array:1 [ "en" => "Difference between initial dose and final dose in the sample." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1266 "Ancho" => 2145 "Tamanyo" => 185994 ] ] "descripcion" => array:1 [ "en" => "Variations in scores for the patients in the series according to the Ashworth Scale before and after implantation of the baclofen pump." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal tone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Slight hypertonia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate hypertonia: examiner's force passive movement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Considerable hypertonia: passive movement difficult \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extreme hypertonia: joint rigid in flexion or 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\t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spasms only to stimulation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><1 spasm per hour \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥1 spasm per hour \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n 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It affects both adults and children and occurs in a large number of neurological disorders such as cerebral palsy&#44; multiple sclerosis&#44; cerebrovascular accidents&#44; etc&#46; Spasticity is the abnormality most often associated with cerebral palsy&#44; with almost 70&#37; affected&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> This damage is typical of the upper motor neuron or first motor neuron&#44; and both the brain stem and the spinal cord may be affected &#40;encephalopathy&#44; demyelinating diseases&#44; traumatic brain injuries&#44; trauma&#44; tumours&#44; etc&#46;&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The clinical signs of spasticity have classically been divided into two groups<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a>&#58; positive clinical signs&#44; which include increased muscle tone&#44; reflex hyperactivity and extensor plantar responses&#59; and the negative clinical signs&#44; referring to the functions that the patient loses due to spasticity&#44; i&#46;e&#46; loss of agility&#44; loss of selective motor control and poor coordination&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The treatments range from the field of rehabilitation to drug therapy and surgical interventions&#44; both destructive and conservative&#46; Neurosurgical treatments began at the beginning of the 20th century after the classic Sherrington studies&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The main complications that appear in the literature derived from surgical treatment are&#58; infection &#40;10&#37;&#41;&#59; externalisation of the device&#59; rupture of the catheter and displacement of the device &#40;10&#37;&#41;&#59; CSF leak &#40;15&#37;&#41;&#59; and tolerance to baclofen &#40;5&#37;&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We performed a retrospective descriptive study of 17 patients with spasticity secondary to various diseases&#44; diagnosed and treated surgically by implanting an intrathecal baclofen infusion device in our neurosurgery department in the period 2005&#8211;2018&#44; with a minimum follow-up of one year for each patient&#46; Due to the small sample size&#44; we analysed the results descriptively&#46; In addition to the basic epidemiological data&#44; we analysed the different causes of spasticity&#44; the treatment applied and its complications&#44; surgical outcomes and progress&#46; Clinical follow-up was possible in all but one of the patients&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The quantitative assessment of spasticity and spasms is important for assessing the effects of treatment&#44; as well as the patient&#39;s degree of disability&#46; We have clinical assessment methods available&#44; such as the Ashworth Scale &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and the modified Ashworth Scale based on muscle tone&#46; These scales&#44; the most used nowadays&#44; are simple&#44; quick to perform and do not require instruments&#46; We can also assess another clinical parameter&#44; the frequency of muscle spasms&#44; using the Spasm Frequency Scale<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> and the Penn Scale &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The inclusion criteria in our study were as follows&#58; patients with severe spasticity &#40;Ashworth greater than 3&#41; in &#8805;2 limbs with at least 2 muscle groups affected in the lower limbs&#44; in whom conservative treatments had failed&#44; with positive response to the baclofen test and a sufficiently high body mass&#46; Clear objectives were set by the multidisciplinary team&#58; to improve patient independence&#59; to facilitate the work of caregivers&#59; to improve the quality of life of patients and family members&#59; to promote hygiene&#59; to reduce pain&#59; and to prevent complications&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The criteria used for exclusion were&#58; recent infection&#59; hypersensitivity to baclofen&#59; insufficient body mass&#59; and negative response to the baclofen test&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In patients who met the inclusion criteria&#44; we performed an efficacy test involving different doses of intrathecal baclofen being administered on consecutive days &#40;initial 25<span class="elsevierStyleHsp" style=""></span>mcg&#44; 50<span class="elsevierStyleHsp" style=""></span>mcg&#44; 75<span class="elsevierStyleHsp" style=""></span>mcg up to a maximum of 100<span class="elsevierStyleHsp" style=""></span>mcg&#41;&#46; If the patient responded&#44; i&#46;e&#46; improved their score on the Ashworth Scale&#44; at any of the above doses&#44; they were considered as candidates for this treatment&#46; If the patient obtained no response even at the maximum dose of 100<span class="elsevierStyleHsp" style=""></span>mcg&#44; they would not benefit from implantation of a baclofen pump&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Patients with a positive baclofen test had a continuous infusion pump implanted&#46; The technique used in our centre is as follows&#58; an intrathecal catheter is inserted at the lumbar level &#40;the level depends on whether or not there are symptoms in the upper limbs&#41; and tunnelled to the abdomen&#44; usually on the left flank&#44; where the pump is implanted&#46; The pump is then programmed as follows&#58; if the duration of effect of the test dose is greater than 12<span class="elsevierStyleHsp" style=""></span>h&#44; that will be the initial dose&#59; if the duration of effect of the test dose is less than 12<span class="elsevierStyleHsp" style=""></span>h&#44; the initial daily dose will be twice the test dose&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The system is recharged and programmed externally by means of a telemetry system&#44; so the dose adjustment is made once the device is implanted&#46; Follow-up is then carried out at scheduled consultations supervised by a specialised nurse and the neurosurgeon&#46; In our centre&#44; we carry out a check-up at 24<span class="elsevierStyleHsp" style=""></span>h and subsequent days until we achieve good control of the spasticity without side effects&#46; Once the dose has been established&#44; the patient is given an appointment for 3&#8211;6 months to recharge the pump and assess their clinical response using the Ashworth and Penn scales&#46; Depending on the type of patient&#44; additional follow-up by rehabilitators&#44; neurologists&#44; paediatricians and&#47;or physiotherapists is recommended&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is important to be aware that the dose should not be increased in the first 24<span class="elsevierStyleHsp" style=""></span>h&#46; The increase in dose per day should not exceed 10&#37; to 30&#37; of the previous dose in patients with spinal spasticity&#44; and from 5&#37; to 15&#37; in patients with cerebral spasticity&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">At Hospital Cl&#237;nico&#44; Santiago de Compostela&#44; a total of 17 patients had surgery for implantation of a baclofen pump&#46; In our sample there was a clear predominance of females &#40;15 females to two males&#41;&#46; Mean age at implantation of the pump was 45 &#40;11&#8211;79&#41;&#46; The causes of spasticity of the patients in our series were&#58; multiple sclerosis in five patients &#40;29&#46;4&#37;&#41;&#59; cerebral palsy in six patients &#40;35&#46;4&#37;&#41;&#59; secondary to subarachnoid haemorrhage in two patients &#40;11&#46;7&#37;&#41;&#59; post-traumatic in two patients &#40;11&#46;7&#37;&#41;&#59; tumour in one patient &#40;5&#46;9&#37;&#41;&#59; and unknown in one patient &#40;5&#46;9&#37;&#41;&#46; Multiple sclerosis is the leading cause over the age of 35&#46; Congenital diseases are the most common causes in children and young people&#44; and the main cause of spasticity in males&#46; In our sample&#44; the spasticity in the two male patients was post-traumatic in one and congenital in the other&#46; The incidence of road traffic and other accidents was similar in males and females&#44; being more predominant in young people&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">After passing the phase for inclusion in the treatment&#44; the patients&#8217; doses were determined by analysing the symptoms before and after implantation of the device&#46; Of the 17 patients&#44; 6 &#40;35&#46;4&#37;&#41; remained on the starting dose&#46; However&#44; seven patients &#40;41&#46;1&#37;&#41; needed to have the initial dose increased&#44; although the increase was only significant in patient number 13&#44; as the expected improvement was not obtained&#46; Four patients &#40;23&#46;5&#37;&#41; were able to gradually decrease the dosage thanks to their great improvement &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The mean improvement on the Ashworth Scale at six months was two points &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; in 15 of the patients &#40;88&#46;2&#37;&#41;&#44; with patient 13 being the only one to only improve by one point&#46; For muscle spasms assessed with the Penn Scale at six months&#44; improvements of one point were achieved in cases where therapeutic dose was maintained and there were no problems such as fever or infection&#44; which reduce the effects of baclofen&#46; In six of the patients&#44; the Penn Scale score improved from four to three points&#44; and in ten of the patients&#44; from three to two points&#46; Of our 17 patients&#44; only one had a poor outcome&#44; despite the therapeutic efforts&#46; One of the cases could not be assessed as they were lost to follow-up&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The complications in our sample were minimal&#44; mostly being related to the device&#46; In three patients &#40;17&#37;&#41; it was necessary to re-operate&#59; in two because of dysfunction of the infusion system&#44; one due to disconnection of the catheter and the other rotation of the pump&#59; and in the third&#44; the system had to be removed and repositioned at six months due to a cerebrospinal fluid leak&#46; We can therefore conclude that the treatment has minimal complications&#44; with the vast majority being related to the surgical intervention itself&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">The neurophysiological bases of spasticity have been widely debated&#46; The classic stretch reflex includes the stretch receptor in the muscle spindle and its afferent fibre &#40;Ia&#41; in the dorsal root&#44; which directly or indirectly excites the &#945; motor neuron in the spinal cord&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> The chronic loss of suprasegmental impulses leads to overactivity of the &#945; motor neuron&#46; This phenomenon&#44; added to an abnormal processing of the spinal afferents&#44; leads to the monosynaptic arch being hyperactive&#46; The last step of this process is the increase in acetylcholine release in the neuromuscular junction and&#44; finally&#44; muscle contraction&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">We think of spasticity as a chronic process in which changes take place over time&#44; i&#46;e&#46; we are talking about a dynamic disease in which the properties of the soft tissues alternate until in the end&#44; muscle fibrosis is produced&#46; At this point&#44; musculoskeletal changes occur&#44; usually accompanied by pain&#46; These changes can be divided into various phases&#46; The first is the spastic phase&#44; then the vicious circle phase&#44; in which there is a muscle imbalance due to the predominance of spasticity in certain muscle groups&#59; typical being predominance of the plantar flexors and varus deformity-forming muscles of the foot&#44; the adductors and hip flexors&#44; and the elbow&#44; wrist and finger flexors in the upper limbs&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> The muscle retraction phase is characterised by the persistence of this vicious circle&#44; with unequal growth between agonist and antagonist muscle groups leading to the structuring of this circle due to the lack of accommodation of the sarcomere&#44; which is unable to achieve normal muscle growth&#46; Muscle retraction is understood to be the opposing resistance by the muscle to movement when it is not in contraction&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;10</span></a> The next phase is osteoarticular deformities&#44; the aim being to prevent this phase with conservative treatment or using the baclofen pump&#59; the collaboration of orthopaedic surgeons would be needed to perform far more invasive interventions&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In the treatment of spasticity&#44; baclofen is considered the pharmacological treatment of choice&#46; It is an analogue of &#947;-aminobutyric acid and acts centrally&#44; inhibiting stretch reflexes and decreasing muscle tone&#46; It is therefore capable of managing severe spasticity of cerebral or spinal origin causing functional disability&#46; Alternatively&#44; diazepam&#44; tizanidine or dantrolene sodium may be used as second choice&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> Botulinum toxin is widely used in patients with spasticity&#46; Its mechanism of action is to block the release of acetylcholine&#44; with an effect that can last 4&#8211;6 months in the treated region&#46; The disadvantages are that it can cause local pain&#44; muscle atrophy&#44; allergic reactions and immunoresistance&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Rehabilitation treatment is fundamental in the approach to spasticity&#44; both focal and generalised&#44; from the beginning&#44; throughout all the evolutionary stages&#46; Physiotherapy should be started early to prevent the onset of spasticity or reduce its intensity&#46; The treatments used include the following&#58; postural therapy&#44; kinesiotherapy&#44; cryotherapy&#44; electrostimulation&#44; biofeedback&#44; hydrotherapy and strengthening of the antagonists&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> Splints and the orthoses can also be used&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">We know that spasticity often acts as a substitute for muscle strength deficit&#44; allowing the preservation of certain functionality&#46; However&#44; it is not uncommon for it to become painful and reduce motor function&#44; resulting in a functional worsening&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">When spasticity does not improve after rehabilitation treatment&#44; neuromuscular blocks and oral drugs&#44; surgical treatment is indicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;14&#44;15</span></a> In our centre&#44; these patients are initially treated with rehabilitation treatment&#44; neuromuscular blocks and oral drugs and are followed up by neurologists and&#47;or paediatricians&#44; who refer patients to our neurosurgery department if they do not respond adequately to conservative treatment&#44; to be assessed for surgical intervention&#46; These patients are given the baclofen test or efficacy test&#46; In this article&#44; we have focused on intrathecal baclofen infusion devices&#44; a non-ablative or reversible procedure which acts on the central nervous system&#46; The intrathecal infusion of baclofen is the main neuromodulation technique&#46; It is able to act at the medullary level without causing central damage&#46; Patients who may benefit from this type of treatment are those with have severe chronic spasticity &#40;spinal or cerebral&#41; with poor response to oral antispastic agents or those who suffer unacceptable side effects with effective oral doses&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Creamer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> show better results in patients with spasticity secondary to stroke treated with intrathecal baclofen&#44; with a reduction in Ashworth score of 99&#37; compared to those treated with conventional oral drugs&#44; who had a reduction of 43&#37;&#46; Sammaraiee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> show good long-term results in patients with multiple sclerosis treated with intrathecal baclofen&#44; with reduced pain&#44; stiffness and spasms measured with the Penn Scale and spasticity measured with the Ashworth Scale&#44; with statistically significant results&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In our series&#44; we obtained improvements of two points in the Ashworth Scale and one point in the Penn Scale&#46; The need for dose modification will depend largely on intercurrent processes such as infections&#44; other diseases or medications that affect the efficacy of baclofen&#44; as well as the progression of some diseases which course with outbreaks&#44; such as multiple sclerosis&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">From our point of view&#44; this system has a large number of advantages over conventional treatment&#58; measurable efficacy before implantation&#59; minimally invasive technique&#59; it can be complemented by other therapies &#40;rehabilitation&#44; orthopaedic surgery&#44; etc&#46;&#41;&#59; as it is given by intrathecal infusion&#44; the dose required is much lower than with pharmacological treatment&#44; so there are also fewer side effects&#46; Disadvantages include the need to recharge the pump after a certain time or for repeat surgery due to breakdown of the device&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">We are aware of the small number of patients in our sample&#44; so we consider this work to be a starting point&#44; which should be continued in the future in order to obtain statistically significant results&#46; However&#44; despite the small number of patients treated&#44; the good results obtained in our study show us that a greater number of patients could benefit from this type of therapy&#44; improving the quality of life of both the patient and the caregiver&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The implantation of the baclofen pump is one of the surgical techniques of choice in our department&#46; However&#44; it is used in very few centres&#44; with Santiago de Compostela and La Coru&#241;a being the only ones specialised in this treatment in the region of Galicia&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">We would recommend greater collaboration from other services&#44; as we believe there is a large number of patients who would benefit from this therapy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0155" class="elsevierStylePara elsevierViewall">We believe that the treatment of spasticity should be personalised&#46; It is important that the objectives are agreed with the patient and the caregiver&#44; while making sure that expectations are always realistic&#46; The purpose is to improve function&#44; promote hygiene&#44; reduce pain&#44; prevent complications and&#44; as a consequence&#44; improve quality of life&#46; Among all the surgical techniques used for the treatment of spasticity&#44; the implantation of intrathecal baclofen infusion devices has proved to be a simple&#44; reversible technique with corroborated results and very few drawbacks&#46; One of these drawbacks is the need for refills every three to six months depending on the dose received&#44; but this allows us to modulate the doses according to the needs of the patient&#46; This treatment improves patient autonomy&#44; and the majority of patients and their caregivers are satisfied with the implant&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest regarding the publication of this article&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Spasticity represents a medical problem whose incidence is increasing during the last years due to pathologies such as cerebral palsy&#44; stroke&#44; multiple sclerosis&#44; trauma or encephalopathy&#44; affecting both adults and children&#46; The treatments include rehabilitation&#44; pharmacotherapy and surgery&#44; among which we highlight intrathecal baclofen infusion devices&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intrathecal baclofen devices implanted patients in Clinical Hospital of Santiago de Compostela from 2005 to 2018 were selected for retrospective analysis using assessment of spasticity scales&#44; such as Ashworth Scale&#46; Complications are described&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Surgery was performed in 17 patients for baclofen pump implant&#44; achieving an improvement of 2 points on the Ashworth Scale in 88&#46;2&#37; of the patients and of 1 point on the Penn Scale in 94&#37;&#46; Complications were seen in 3 patients&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Intrathecal baclofen is a simple technique with good results for improving the quality of life of patients with spasticity&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
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            "titulo" => "Introduction"
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            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La espasticidad representa un problema m&#233;dico cuya incidencia est&#225; aumentando debido a enfermedades como par&#225;lisis cerebral&#44; ictus&#44; esclerosis m&#250;ltiple&#44; traumatismos o encefalopat&#237;as&#44; afectando tanto a adultos como a ni&#241;os&#46; Los tratamientos incluyen rehabilitaci&#243;n&#44; farmacoterapia y cirug&#237;a&#44; entre las cuales destacamos las bombas de baclofeno intratecal&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Seleccionamos a los pacientes portadores de bomba de baclofeno intratecal implantada en el Hospital Cl&#237;nico de Santiago de Compostela entre 2005-2018 y analizamos retrospectivamente los resultados mediante escalas de valoraci&#243;n de espasticidad&#44; como la de Ashworth&#44; as&#237; como las complicaciones observadas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se implantaron bombas de baclofeno a 17 pacientes&#44; obteniendo una mejor&#237;a de 2 puntos en la escala de Ashworth en el 88&#44;2&#37; y de 1 punto en la escala de Penn en el 94&#37;&#46; Se observaron complicaciones en 3 pacientes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El tratamiento con baclofeno intratecal es una t&#233;cnica sencilla con resultados muy positivos para mejorar la calidad de vida de pacientes con espasticidad&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Santin-Amo JM&#44; Flores-Justa A&#44; Rom&#225;n-Pena P&#44; Raposo-Furelos M&#44; Frieiro-Dantas C&#44; Serramito Garc&#237;a R&#44; et al&#46; Baclofeno intratecal para el tratamiento de la espasticidad&#58; revisi&#243;n de los casos presentes tratados en nuestro servicio&#46; Neurocirugia&#46; 2019&#59;30&#58;288&#8211;293&#46;</p>"
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