200 Section - Comprehensive survey on the management of severe spasticity treated with intrathecal baclofen and botulinum toxin type A.

Objectives : The primary aim was to determine the frequency and clinical profile of patients requiring combined ITB and BoNT-A therapy. Secondary objectives included identifying unmet treatment goals with ITB alone, investigating the rationale for introducing BoNT-A,  characterizing BoNT-A administration parameters.

Design: A retrospective single-center survey in a University Hospital. Data were collected from patients' records. The study population consisted of 28 adult patients (17 females, 12 males; mean age 48.3 years) with spasticity.

Results: The primary diagnoses were MS (30.43%), SCI (21.74%), CP (17.39%), and stroke (13.04%). The mean age at first pump implantation was 42.2 years. Most patients were non-ambulatory (65.21%). The mean daily ITB dose was 245 µg/day (range 15-1035 µg/day). 52% had Simple Continuous infusion mode. 14 patients (50%) received BoNT-A injections due to persistent focal spasticity inadequately controlled by ITB. The mean total BoNT-A dose per session was 337.5 IU (range 100-600 IU), with injection frequency from 3 to 9 months. 

The most commonly treated patterns were elbow flexion (6 patients), finger flexion (5), shoulder adduction (3), thumb flexion (3), wrist flexion (3), ankle plantar flexion (3) and hallux flexion (2).


The primary active goals were mobility improvement (5 patients), arm function (2), and hygiene improvement (1). The main passive goals included posture improvement (6 patients), hygiene improvement (5), and pain reduction (3).

Conclusion: This survey shows that approximately 50% of patients with implanted ITB pumps may require BoNT-A injections to manage residual focal spasticity, particularly in distal upper limb muscles. The combination of ITB and BoNT-A represents a valuable multimodal approach for patients with generalized spasticity and persistent focal patterns that compromise functional outcomes. These findings support the integration of focal chemodenervation with systemic spasticity management to optimize therapeutic goals, improve function, and enhance quality of life in patients with severe spasticity.