Acta neurochirurgica. Supplement
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Acta Neurochir. Suppl. · Jan 2007
ReviewIntrathecal baclofen in the treatment of post-stroke central pain, dystonia, and persistent vegetative state.
Intrathecal baclofen (ITB) administration is a fully established treatment for severe spasticity. However, it is not widely known that baclofen, an agonist of the GABA-B receptor, has additional beneficial effects in other conditions such as chronic pain, coma, dystonia, tetanus, and hyypothalamic storm. Sporadic cases of dramatic recovery from persistent vegetative state after intrathecal administration of baclofen have been reported. ⋯ On the other hand, epidural spinal cord stimulation (SCS) has been used in the management not only of pain but also of spasticity, dystonia, and in order to improve deteriorated consciousness, but the effects so far have been modest and variable. Similarities between ITB and SCS are interesting as both involve the spinal GABAergic system. Based on a 15-year personal experience of intrathecal baclofen, I would stress the importance of this treatment not only for spasticity but also for other difficult neurological disorders.
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Acta Neurochir. Suppl. · Jan 2007
ReviewEfficacy of intrathecal baclofen delivery in the management of severe spasticity in upper motor neuron syndrome.
In the treatment of patients with severe spasticity, intrathecal administration of baclofen (ITB) was introduced in order to exert its effect directly at the receptor sites in the spinal cord, and have better therapeutic efficacy with smaller drug doses compared to oral antispasmodic medications. Apart from our own research in Groningen, a review is performed to present and discuss the efficacy of ITB in patients with spasticity and hypertonia as symptoms of the upper motor neuron syndromes. The majority of the ITB studies describe proven efficacy in the reduction of spasticity and spasms in short-term and long-term follow-up. ⋯ A few studies reported significant improvement in walking performance in ambulant patients. The studies that have been done on the efficacy of ITB in relation to quality of life (QOL) showed some evidence of improvement. Future research is needed on fine tuning in the ITB therapy using functional assessment instruments.
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Acta Neurochir. Suppl. · Jan 2007
Randomized Controlled Trial Clinical TrialImplantation of surgical electrodes for spinal cord stimulation: classical midline laminotomy technique versus minimal invasive unilateral technique combined with spinal anaesthesia.
The implantation of surgical electrodes is still considered painful and invasive. Is there a possibility to diminish these disadvantages by applying a less invasive implantation procedure at the thoracic level and eventually combine this approach with a less stressful paresthesia coverage testing in the intraoperatively awake patient? In this paper, the postoperative outcome of two surgical techniques to insert surgical plate electrodes at the thoracic level is compared. In a prospective single blind study. the Classical Midline Laminotomy technique (CML) is opposed to a Minimal Invasive unilateral Technique (MIT). ⋯ In all comparisons, the MIT group scored significantly better. It can be concluded that a minimal invasive unilateral technique has some advantages over midline laminotomy. Refinements of the implantation procedure are discussed, i.e minimal invasive unilateral technique in combination with spinal (intrathecal) anaesthesia, surgical hints and the technique's use in revision surgery for migrated electrodes.
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Acta Neurochir. Suppl. · Jan 2007
ReviewAn introduction to operative neuromodulation and functional neuroprosthetics, the new frontiers of clinical neuroscience and biotechnology.
Operative neuromodulation is the field of altering electrically or chemically the signal transmission in the nervous system by implanted devices in order to excite, inhibit or tune the activities of neurons or neural networks and produce therapeutic effects. It is a rapidly evolving biomedical and high-technology field on the cutting-edge of developments across a wide range of scientific disciplines. The authors review relevant literature on the neuromodulation procedures that are performed in the spinal cord or peripheral nerves in order to treat a considerable number of conditions such as (a) chronic pain (craniofacial, somatic, pelvic, limb, or due to failed back surgery), (b) spasticity (due to spinal trauma, multiple sclerosis, upper motor neuron disease, dystonia, cerebral palsy, cerebrovascular disease or head trauma), (c) respiratory disorders, (d) cardiovascular ischemia, (e) neuropathic bladder, and (f) bowel dysfunction of neural cause. ⋯ The authors highlight promising lines of research such as endoneural prostheses for peripheral nerve stimulation, closed-loop systems for responsive neurostimulation or implanted microwires for microstimulation of the spinal cord to enable movements of paralyzed limbs. The above growing scientific fields, in combination with biological regenerative methods, are certainly going to enhance the practice of neuromodulation. The range of neuromodulatory procedures in the spine and peripheral nerves and the dynamics of the biomedical and technological domains which are reviewed in this article indicate that new breakthroughs are likely to improve substantially the quality of life of patients who are severely disabled by neurological disorders.
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Brain stimulation has been receiving increasing attention as an alternative therapy for epilepsy that cannot be treated by either antiepileptic medication or surgical resection of the epileptogenic focus. The stimulation methods include transcranial magnetic stimulation (TMS) or electrical stimulation by implanted devices of the vagus nerve (VNS), deep brain structures (DBS) (thalamic or hippocampal), cerebellar or cortical areas. TMS is the simplest and least invasive approach. ⋯ Finally, another line of research investigates the usefulness of implantable seizure detection devices. The current chapter presents the most important evidence on the above methods. Furthermore, other important issues are reviewed such as the selection criteria of patients for brain stimulation and the potential role of brain stimulation in the treatment of depression in epileptic patients.