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A total of 93 patients with intractable spasticity due to either spinal cord injury (59 cases), multiple sclerosis (31 cases), or other spinal pathology (three cases) were entered into a randomized double-blind placebo-controlled screening protocol of intrathecal baclofen test injections. Of the 88 patients who responded to an intrathecal bolus of 50, 75, or 100 micrograms of baclofen, 75 underwent implantation of a programmable pump system for chronic therapy. Patients were followed for 5 to 41 months after surgery (mean 19 months). No deaths or new permanent neurological deficits occurred as a result of surgery or chronic intrathecal baclofen administration. Rigidity was reduced from a mean preoperative Ashworth scale score of 3.9 to a mean postoperative score of 1.7. Muscle spasms were reduced from a mean preoperative score of 3.1 (on a four-point scale) to a mean postoperative score of 1.0. Although the dose of intrathecal baclofen required to control spasticity increased with time, drug tolerance was not a limiting factor in this study. Only one patient withdrew from the study because of a late surgical complication (pump pocket infection). Another patient received an intrathecal baclofen overdose because of a human error in programming the pump. The results of this study indicate that intrathecal baclofen infusion can be safe and effective for the long-term treatment of intractable spasticity in patients with spinal cord injury or multiple sclerosis.

Abstract-Objective:To provide an evidence-based statement to guide physicians in the management of Guillain-Barré syndrome (GBS). Methods: Literature search and derivation of evidence-based statements concerning the use of immunotherapy were performed. Results: Treatment with plasma exchange (PE) or IV immunoglobulin (IVIg) hastens recovery from GBS. Combining the two treatments is not beneficial. Steroid treatment given alone is not beneficial. Recommendations: 1) PE is recommended for nonambulant adult patients with GBS who seek treatment within 4 weeks of the onset of neuropathic symptoms. PE should also be considered for ambulant patients examined within 2 weeks of the onset of neuropathic symptoms; 2) IVIg is recommended for nonambulant adult patients with GBS within 2 or possibly 4 weeks of the onset of neuropathic symptoms. The effects of PE and IVIg are equivalent; 3) Corticosteroids are not recommended for the management of GBS; 4) Sequential treatment with PE followed by IVIg, or immunoabsorption followed by IVIg is not recommended for patients with GBS; and 5) PE and IVIg are treatment options for children with severe GBS. NEUROLOGY 2003;61:736 -740 Guillain-Barré syndrome (GBS) affects between 1 and 4 per 100,000 of the population annually throughout the world, 1 causing respiratory failure requiring ventilation in approximately 25%, death in 4 to 15%, 2-6 persistent disability in approximately 20%, 7 and persistent fatigue in 67%. 8 The costs in the United States have been estimated as $110,000 for direct health care and $360,000 in lost productivity per patient. 9 This practice parameter classifies the relevant evidence on immunotherapy to provide evidence-based recommendations for the management of GBS. 10Evidence review. A search of MEDLINE from 1966 and of the Cochrane library was performed in March 2002. "Polyradiculoneuritis" was limited by "human" and cross-referenced with "therapy." The search results were reviewed for each question by at least two members of the practice parameter group and supplemented from the reference lists in the articles retrieved and the personal reference lists of the members of the practice parameter group. Those titles representing relevant randomized controlled trials (RCTs) are included in the tables on the Neurology Web site for this article (www.neurology.org). Recommendations were graded according to the levels established by the AAN Quality Standards Subcommittee at the inception of this project (table).

There was a consistent trend toward a more rapid functional improvement regardless of when a patient with DAI-associated TBI was started on amantadine in the first 3 months after injury.

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