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.
The authors have retrospectively analyzed 840 cerebrospinal fluid shunting procedures over a 25-year period to determine the relationships between infection rates and several possible influences on infection. Two-thirds of all shunt infections occurred within 1 month of surgery. The very young and very old had higher infection rates. Infections became less prevalent over the period of the study, and mortality from infection decreased from 35% to 6%. Successive shunts (revisions) were found to have progressively higher infection rates. Ventriculoatrial and ventriculoperitoneal silicone plastic shunts had similar infection rates (11.4% and 12.0%). The uncontrolled use of prophylactic antibiotics had no effect on shunt infections. Staphylococcus epidermidis became gradually more prevalent over the period of the study, and eventually caused one-half of all infections. Where infection occurred in the presence of prophylaxis, the infectious organism was usually sensitive to the antibiotic being used. The surgeon was found to be the largest single factor in the incidence of shunt infections. A 25-fold variance in infection rates among surgeons could be related to individual experience and technique.
Juxtafacet cysts are an uncommon cause of radiculopathy. Surgical resection is the treatment of choice with low rates of complications, recurrences, and residual complaints.
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