200 Section - Intraventricular Baclofen as a Salvage Strategy for Upper-Limb Spasticity: Two Case Reports

We present two cases illustrating intraventricular baclofen as an alternative delivery strategy in patients with severe, treatment-refractory upper-limb spasticity or dystonia when conventional intrathecal catheter placement provided insufficient clinical benefit or was complicated by technical failure.

Case Description:

The first case concerns a 29-year-old man with a C4 AIS B spinal cord injury who developed severe spasticity despite multimodal spasticity management. Spasticity interfered with daily functioning and independence. Treatment with an intrathecal baclofen (ITB) pump with a high thoracic catheter tip initially resulted in functional improvement. However, recurrent spasticity exacerbations occurred in the context of catheter-related complications, including dysfunction and arachnoiditis, and were accompanied by loss of independent living. Conversion to intraventricular baclofen administration improved upper-limb function. Persistent lower-limb spasticity was subsequently managed by implantation of a second ITB pump with thoracic catheter placement, resulting in satisfactory control.

The second case describes a 60-year-old man with post-stroke painful upper-limb dystonia refractory to Botulinum NeuroToxin-A. ITB with thoracic catheter placement reduced dystonia but provided insufficient pain relief. Given limited clinical benefit and constraints related to catheter positioning, the system was converted to intraventricular administration to enhance drug distribution.

Discussions:

ITB is widely used for the management of severe spasticity interfering with comfort or function and refractory to oral medication. However, catheter-related complications or insufficient clinical response may limit its long-term benefit. In cases of inadequate response, catheter position may be relevant, as baclofen distribution within the cerebrospinal fluid depends on its location and may affect clinical efficacy, particularly in the upper limb. 

Conclusions:

In the absence of randomized controlled trials, intraventricular baclofen administration may represent a salvage option for carefully selected patients when conventional intrathecal delivery strategies fail to address upper-limb spasticity or dystonia.