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LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 4  |  Page : 618-619

Intrathecal baclofen pump implantation in a patient 2 years following a traumatic brain injury resulted in regained oratory capabilities


1 Department of Neurological Surgery, The Charles Clore Hospitalization Tower, West Wing Sheba Medical Center, Ramat Gan; Department of Neurological Surgery, The Chaim Sheba Medical Center, Israel
2 Department of Neurosurgery, Center for Neuromodulation, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
3 Department of Neurological Surgery, The Charles Clore Hospitalization Tower, West Wing Sheba Medical Center, Ramat Gan, Israel

Date of Web Publication4-Aug-2015

Correspondence Address:
Zion Zibly
Department of Neurological Surgery, The Charles Clore Hospitalization Tower, West Wing Sheba Medical Center, Ramat Gan
Israel
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.162092

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How to cite this article:
Ungar L, Sharma M, Zibly Z. Intrathecal baclofen pump implantation in a patient 2 years following a traumatic brain injury resulted in regained oratory capabilities. Neurol India 2015;63:618-9

How to cite this URL:
Ungar L, Sharma M, Zibly Z. Intrathecal baclofen pump implantation in a patient 2 years following a traumatic brain injury resulted in regained oratory capabilities. Neurol India [serial online] 2015 [cited 2019 Oct 16];63:618-9. Available from: http://www.neurologyindia.com/text.asp?2015/63/4/618/162092


Sir,

Traumatic brain injury (TBI) affects more than 1.4 million people in USA and approximately 50,000 die as a result.[1] Spasticity is found in an estimated 25% of patients with TBI. [2] Spasticity as a result of brain injury affects a variety of muscles including the masticatory muscles which may in turn interfere with the ability to orate, ingest, and maintain oral hygiene. [3] Our case is unique, as this is the first report of alleviation of spastic trismus following TBI with intrathecal baclofen (ITB) therapy that restored the patient's ability to speak.

An 18-year-old male patient was admitted following a head trauma, left femoral bone fracture, and traumatic ventricular septal defect due to a motor vehicle accident. The head computed tomography (CT) scan demonstrated an acute right hemispheric subdural hemorrhage and an emergency decompressive craniectomy was performed. Two months later, a ventriculoperitoneal shunt was implanted due to the presence of hydrocephalus. The patient was withdrawn from the ventilator after 5 months and transferred to the rehabilitation unit. One year after the accident, the patient remained minimally responsive, able to focus his gaze, unable to talk, and remained left hemiplegic; however, he was able to slowly execute simple instructions using his right torso which exhibited a relatively poor muscle power. Moreover, during that year, the patient had developed diffuse spasticity affecting his upper and lower extremities with a mild response to maximum tolerable dose of oral baclofen. Interestingly, the patient developed spastic hypertonia of his masticatory muscles causing severe trismus with frequent teeth chatter. The patient was unable to open his mouth for a distance of more than 3 mm between his upper and lower teeth and was fed via a gastric tube. The patient was demonstrating severe generalized spasticity and was able to communicate poorly by signaling with his right torso; a hand movement for 'yes,' and a leg movement for 'no.' Two years following the accident, the patient was readmitted for an ITB trial. The clinical status and CT scan of the patient remained the same as that seen at the previous discharge [Figure 1]. A temporary intrathecal catheter was inserted with the baclofen dose of 50 μg/d, which was gradually increased to the rate of 150 μg/d. During the ITB trial, a moderate improvement in spasticity was observed and a significant reduction in the teeth chatter frequency was demonstrated. Following the successful completion of the trial, the patient underwent placement of an intrathecal pump (Medtronic Synchromed II) at T5-6 level [Figure 2]a and b, which was programmed for a baclofen delivery rate of 30 μg/d. The dosage was gradually increased to a rate of 240 μg/d. Forty-five days following the intrathecal pump placement, the patient displayed no teeth chatter and had almost normal muscle tone in his muscles of mastication. The patient regained his ability to speak. Initially, he managed to utter a few words but after 2 weeks, he was speaking almost normally, smiling and even complaining, suggesting that the mutism attributed to a cognitive impairment was actually the result of severe spastic trismus.
Figure 1: Computed tomography scan image (axial cut) at admission 2 years after the head injury. The image depicts the presence of asymmetrical ventricular enlargement, left intraventricular shunt tube and replaced right frontotemporoparietal bone flap

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Figure 2: (a) X - ray chest anteroposterior view showing the tip of the intrathecal catheter at T4 - 5 level (red arrow); and, (b) the location of the baclofen pump in the right abdominal wall

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Recently ITB therapy has been shown to improve the level of consciousness and cognitive status following TBI. [4],[5],[6],[7] Five patients with persistent vegetative state (1 with subarachnoid hemorrhage, 1 with intracerebral hemorrhage, 2 with TBI and one with postanoxic encephalopathy) were managed with ITB therapy, 6-10 months after the brain insult. The improvement in consciousness was seen beginning 2 weeks after the ITB therapy and was stable at the end of 6 months (except in one patient) as measured by coma recovery scale revised (CRS-R) score. [5] Two hypotheses were proposed by this group; one is modulation at spinal cord segmental level and the neuronal outputs reaching the cortex; and, second is modulation of sleep-wake cycle which is dysregulated in patients with brain injury. [5] In another recent study, two patients with extremely severe head injury (Glasgow coma scale = 3) underwent implantation of ITB pump, 5 and 9 months following the injury, to manage spasticity. [4] The first, patient had a drastic improvement in spasticity and remained in minimal conscious state following the ITB therapy. [4] The second, patient showed improvement in posttraumatic amnesia with recovery of complete conscious state 3 weeks after the ITB pump implantation. [4] In our report, there was alleviation of the spastic trismus following ITB therapy which restored the patient's ability to speak, proving what was thought to be a cognitive problem, was actually an organic one. In rare cases, a disability thought to be the result of cognitive impairment following TBI may, in fact, be the consequence of physical impairment. In this case, generalized spasticity associated with severe spastic trismus was treated successfully with ITB. ITB may be considered in such difficult situations to treat patients.

 
  References Top

1.
Corso P, Finkelstein E, Miller T, Fiebelkorn I, Zaloshnja E. Incidence and lifetime costs of injuries in the United States. Inj Prev 2006;12:212-8.  Back to cited text no. 1
    
2.
Elovic EP, Simone LK, Zafonte R. Outcome assessment for spasticity management in the patient with traumatic brain injury: The state of the art. J Head Trauma Rehabil 2004;19:155-77.  Back to cited text no. 2
    
3.
Schwerdtfeger K, Jelasic F. Trismus in postoperative, posttraumatic and other brain stem lesions caused by paradoxical activity of masticatory muscles. Acta Neurochir (Wien) 1985;76:62-6.  Back to cited text no. 3
    
4.
Al-Khodairy AT, Wicky G, Nicolo D, Vuadens P. Influence of intrathecal baclofen on the level of consciousness and mental functions after extremely severe traumatic brain injury: Brief report. Brain Inj 2015;29:527-32.  Back to cited text no. 4
    
5.
Sarà M, Pistoia F, Mura E, Onorati P, Govoni S. Intrathecal baclofen in patients with persistent vegetative state: 2 hypotheses. Arch Phys Med Rehabil 2009;90:1245-9.  Back to cited text no. 5
    
6.
Sarà M, Sacco S, Cipolla F, Onorati P, Scoppetta C, Albertini G, et al. An unexpected recovery from permanent vegetative state. Brain Inj 2007;21:101-3.  Back to cited text no. 6
    
7.
Turner MS. Early use of intrathecal baclofen in brain injury in pediatric patients. Acta Neurochir Suppl 2003;87:81-3.  Back to cited text no. 7
    


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