Intrathecal baclofen (ITB) infusion has been shown to be an effective treatment for spasticity secondary to both cerebral palsy and spinal cord injury. Its effect on the ambulatory status of individuals with cerebral spasticity, however, has not previously been addressed. We reviewed the effect of ITB on functional ambulation in 24 patients who were ambulatory to some extent, either with or without assistive devices. Twenty-one pumps were placed in patients with spastic cerebral palsy and 3 in patients with spasticity secondary to traumatic brain injury (13 boys and 11 girls, mean age 18 years). The mean ITB dose was 200 µg/day (range 22–550 µg/day) and the mean length of follow-up was 52 months. Ambulation was retrospectively graded on four functional levels: community, household, non-functional, and non-ambulatory. The level of ambulation improved by one functional level in 9 patients, did not change for 12 patients, and was worse in 3 patients. Gait was considered to be improved in 20 of 24 patients by the patients or their families. The overall functional improvement not directly related to ambulation was found to be improved in 20 patients, unchanged in 2 patients, and worse in 2 patients. ITB allows for improved ambulation in a certain subset of patients with lower extremity spasticity. It is not contraindicated in patients who rely upon their spasticity for support during ambulation. ITB infusion allows for baclofen dosage titration to balance between extensor tone for support and suppression of hyperactive reflexes which may impede normal locomotion.
Low-dose external beam radiation therapy administered 24 hours before laminectomy in a dog model significantly decreased the extent and density of peridural fibrosis as well as nerve root entrapment and sublaminar fibrosis. This treatment strategy may be efficacious in patients with recurrent radicular pain after lumbar discectomy that is thought to be secondary to peridural fibrosis on the basis of gadolinium-enhanced MRI studies, and who might benefit from reoperation for nerve root decompression.
Physicians are guided by the teachings of their chosen field, standards of accepted practice, peer pressure, prior training, and other sources of bias. When potential bias begins to impact recommendations for care in the field of tumor management, physicians may fail to realize the importance of emerging medical innovations. Some of these ultimately turn out to be ‘disruptive innovations.’ These innovations are more often than not both low risk and cost effective. But the leaders in the field often initially ignore these newer technologies in favor of more mature existing technologies. However, over time these technologies gradually improve and become mainstream management practices. Intracranial radiosurgery is one such innovation which was not embraced by the neurosurgical community in the beginning. Nowadays, a wide variety of brain and body disorders are treated with radiosurgery. Acoustic neuromas and brain metastases are examples of rapidly growing indications of radiosurgery. In this report, the authors describe the emergence of stereotactic radiosurgery as a disruptive innovation in the field of medicine.
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