Local-spinal Therapy of Spasticity

268 Pages·1988·8.24 MB·English

by  H. Müller

H. MUller, J. Zierski, R. D. Penn (Editors)
Local-spinal Therapy of Spasticity
With 140 Figures and 48 Tables
Springer-Verlag Berlin Heidelberg New York
London Paris Tokyo
Prof. Hermann Miiller, MD
Dept. Anesthesiology and Intensive Care Medicine
Justus-Liebig-University
Klinikstr. 29
D-6300 GieBen, FRG
Priv.-Doz. Jan Zierski, MD
Dept. ~eurosurgery
Justus-Liebig-University
Klinikstr. 29
D-6300 GieBen, FRG
Richard D. Penn, MD
Rush-Presbyterian-St. Luke's Medical Center
Rush Medical College
Dept. ~eurosurgery
1753 West Congress Parkway
Chicago, Illinois 60612, USA
ISBN-13: 978-3-540-18295-5 e-ISBN-13: 978-3-642-72954-6
DOl: 10.1007/ 978-3-642-72954-6
Library of Congress Cataloguing-in-Publication Data:
Local-spinal therapy of spasticity 1 H. MUller, J. Zierski, R. D. Penn (editors).
p. cm.
Based on papers presented at an international meeting held in Giessen, FRG in Apr. 1986 as well as
some additional contributions.
1. Spasticity-Chemotherapy-Congresses. 2. Spinal anesthesia-Congresses. I. MUller, H. (Hermann)
II. Zierski, J. (Jan), 1940- III. Penn, Richard D.
[DNLM: 1. Muscle Spasticity-drug therapy-congresses. WE 550 L811 1986)
RC935.s64L63 1988
616.8'3-dcI9
DNLM/DLC
for Library of Congress 87-37653
CIP
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Typesetting, printing and binding: Graphischer Betrieb, Konrad Triltsch, WUrzburg
2329/3321-543210
Table of Contents
Preface (H. Muller, 1. Zierski, R. D. Penn) . . . . . . . . . . . . . . .
A Short Historical Review of Spasticity and Its Therapy (D. Dralle, H. Muller,
1. Zierski). . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Basic Experiences
Spinal Pharmacology of Agents which Alter Pain Transmission and Muscle Tone
(T. L. Yaksh, P. A. C. Durant, M. S. Monasky, C. W. Stevens, R. R. Schick) .. 19
The Neuropharmacology of Baclofen (W. Zieglgansberger, 1. R. Howe, B. Sutor) . 37
Animal Experiments on the Spinal Action of Midazolam (W. Gerlach, H. Muller,
1. Boldt, G. Hempelmann). . . . . . . . . . . . . . . . . . . . 51
Intrathecal Injection of Antispastic Drugs in Rats: Muscle Relaxant Action
ofMidazolam, Baclofen, 2-Aminophosphonoheptanoic Acid (AP7) and
TIzanidine (M. Schwarz, T. Klockgether, L. Turski, K.-H. Sontag) . . . 65
CSF Compatibility of Antispastic Agents (0. Borner, H. MUller, 1. Zierski,
G. Hempelmann, M. Reinacher) . . . . . . . . . . . . . . . . . 81
Dural Permeability to Bupivacaine, Baclofen and Midazolam: In Vitro
Determination with Human Dura Mater (1. Biscoping, G. Michaelis, D. Friess,
D. KrauB, E. Mutschler, G. Hempelmann) . . . . . . . . . . . . . . .. 85
Clinical Studies
Pharmacotherapy of Spasticity (1. Noth) . . . . . . . . . . . . . . . . 93
Pumps in Pharmacotherapy (H. Muller, 1. Zierski) ........... 97
Implantation of Ports and Pumps. Technique for Intrathecal Administration
of Drugs (1. Zierski, H. Muller). . . . . . . . . . . . . . . . . . . 125
Control of Spasticity with Intrathecal Morphine Sulfate (D. L. Erickson, P. Moreno,
1. Lo, 1. Cameron, M. Michaelson) . . . . . . . . . . . . . . . . . . .. 137
Clinical Experience with Spinal Morphine, Midazolam and Tizanidine in Spasticity
(H. Muller, 1. Zierski). . . . . . . . . . . . . . . . . . . . . . . .. 143
Chronic Intrathecal Baclofen for Severe Rigidity and Spasms (R. D. Penn) . .. 151
Intrathecal Baclofen in Spasticity (H. Muller, 1. Zierski, D. Dralle, O. Hoffmann,
G. Michaelis) . . . . . . . . . . . . . . . . . . . . . . . 155
Chronic Intrathecal Administration of Baclofen in Treatment of Severe
Spasticity (Y. Lazorthes) . . . . . . . . . . . . . . . . . . 215
Pharmacokinetics ofIntrathecal Baclofen (H. Muller, 1. Zierski, D. Dralle,
D. KrauB, E. Mutschler) .................... 223
Intrathecal Baclofen in tetanus (H. Muller, 1. Zierski, 0. Borner, G. Hempelmann) 227
The Value of Spinal Cord Stimulation (SCS) in Treatment of Disorders
of the Motor System (1.-0. Krainick, H. Weisbrod, H. 0. Gerbershagen) 245
Physostigmine Reversal of Baclofen-induced Sedation (G. Muller-Schwefe) 253
Surgical Treatment of Spasticity - A Review (1. Zierski, H. MUller) . 255
Subject Index . . . . . . . . . . . . . . . . . . . . . . . 265
VII
Authors' addresses
Biscoping, J., MD, Klockgether, T., MD,
Dept. Anesthesiology and Intensive Care Dept. Neurology,
Medicine, Justus-Liebig-University, Eberhard-Karls-University,
Klinikstr. 29, 6300 GieSen, FRG Liebermeisterstr. 18-20,
Boldt, J., MD, 7400 Tlibingen, FRG
Dept. Anesthesiology and Intensive Care Hempelmann, G., MD,
Medicine, Justus-Liebig-University, Dept. Anesthesiology and Intensive Care
Klinikstr. 29, 6300 GieSen, FRG Medicine, Justus-Liebig-University,
Bomer, u., MD, Klinikstr. 29, 6300 GieSen, FRG
Dept. Anesthesiology and Intensive Care Hoffmann, 0., MD,
Medicine, Justus-Liebig-University, Dept. Neurosurgery,
Klinikstr. 29, 6300 GieSen, FRG Justus-Liebig-University,
Cameron, J., MD, Klinikstr. 29, 6300 GieSen, FRG
Dept. Neurosurgery, University of Howe, J. R., PhD,
Minnesota Hospitals, Dept. Clinical Neuropharmacology,
420 Delaware Street, Minneapolis, Max-Planck-Institute of Psychiatry,
Minnesota 55455, USA Kraepelinstr. 2, 8000 Munchen, FRG
Dralle, D., MD, Krainick, J.-u., MD,
Dept. Neuropediatrics, Pain Center Mainz,
Justus-Liebig-University, Aufdem Steig 14-16,
Feulgenstr. 12, 6300 GieSen, FRG 6500 Mainz, FRG
Durant, P. A. C., PhD, KrauS, D., MD,
Laboratory ofNeurosurgical Research, Institute of Clinical Pharmacology,
Mayo Clinic, Rochester, Johann-Wolfgang-Goethe-University,
Minnesota 55905, USA 6000 Frankfurt, FRG
Erickson, D. L., MD, Lazorthes, Y., MD,
Dept. Neurosurgery, Neurosurgical Clinic,
University of Minnesota Hospitals, University Paul Sabatier,
420 Delaware Street, Minneapolis, Chemin du Vallon,
Minnesota 55455, USA 31054 Toulouse, France
Friess, D., PhD, Lo,J.,MD,
University Pharmacy, Dept. Anesthesiology,
Eberhard-Karls-University, University of Minnesota Hospitals,
7400 Tubingen, FRG 420 Delaware Street, Minneapolis,
Gerbershagen, H. U., MD, Minnesota 55455, USA
Pain Center Mainz, Michaelis, G., MD,
Aufdem Steig 14-16, Dept. Anesthesiology and Intensive Care
6500 Mainz, FRG Medicine, Justus-Liebig-University,
Gerlach, H., MD, Klinikstr. 29, 6300 GieSen, FRG
Dept. Anesthesiology,
University Dusseldorf,
Moorenstr. 5,4000 Dusseldorf, FRG
VIII Authors' addresses
Michaelson, M., MD, Schwarz, M., MD,
Dept. Neurosurgery, Dept. Neurology and
University of Minnesota Hospitals, Clinical Neurophysiology,
420 Delaware Street, Minneapolis, Alfried Krupp Hospital,
Minnesota 55455, USA Alfried-Krupp-Str.2l,
Monasky, M. S., PhD, 4300 Essen, FRG
Laboratory of Neurosurgical Research, Sontag, K.-H., MD,
Mayo Clinic, Rochester, Max-Planck-Institute for Experimental
Minnesota 55905, USA Medicine, Hermann-Rein-Str. 3,
Moreno, P., MD, 3400 GOttingen, FRG
Dept. Neurosurgery, Stevens, C. W., PhD,
University of Minnesota Hospitals, Laboratory of Neurosurgical Research,
420 Delaware Street, Minneapolis, Mayo Clinic, Rochester,
Minnesota 55455, USA Minnesota 55905, USA
Muller, H., MD, Sutor, B., PhD,
Dept. Anesthesiology and Intensive Care Dept. Clinical Neuropharmacology,
Medicine, Justus-Liebig-University, Max-Planck-Institute for Psychiatry,
Klinikstr. 29, 6300 GieSen, FRG Kraepelinstr. 2, 8000 Munchen, FRG
Muller-Schwefe, G. MD, Turski, L., MD,
Hauptstr. 50, 7320 GOppingen, FRG Dept. N europsychopharmacology,
Mutschler, E., MD, Schering AG, Mullerstr. 170-178,
Institute of Clinical Pharmacology, 1000 Berlin, FRG
Johann-Wolfgang-Goethe-University, Weisbrod, H., MD,
6000 Frankfurt, FRG Pain Center Mainz,
Noth, J., MD, Aufdem Steig 14-16,
Dept. Neurology and 6500 Mainz, FRG
Clinical Neurophysiology, Yaksh, T. L., PhD,
Alfried Krupp Hospital, Laboratory of Neurosurgical Research,
Alfried-Krupp-Str.21, Mayo Clinic, Rochester,
4300 Essen, FRG Minnesota 55905, USA
Penn, R. D., MD, Zieglgansberger, W., MD,
Rush-Presbyterian-St. Luke's Medical Dept. Clinical Neuropharmacology,
Center, Rush Medical Center, Max-Planck-Institute of Psychiatry,
Dept. Neurosurgery, Kraepelinstr. 2, 8000 Munchen, FRG
1753 West Congress Parkway, Chicago, Zierski, J., MD,
Illinois 60612, USA Dept. Neurosurgery,
Reinacher, M., MD, Justus-Liebig-University,
Institute of Veterinary Pathology, Klinikstr. 29, 6300 GieSen, FRG
Justus-Liebig-University,
Frankfurter Str. 96,
6300 GieSen, FRG
Preface
Historical photograph of spinal
anaesthesia
In 1884 the American neurologist J. L. eases. His discovery, however, marks the
Corning, by blocking the neural con onset of the era of regional anaesthesia. It
duction to the hind extremities of a dog by took almost one hundred years until his
injecting cocaine-solution into the lumbar original idea of "local medication of the
vertebral interspace, was the first to per cord" was again reconsidered due to two
form spinal (or epidural?) anaesthesia [1]. reasons:
At that time, he was unaware of the local I. The discovery of different drug receptors
anaesthetic properties of cocaine (dis in the spinal cord made it possible, by in
covered in the same year by C. Koller, who trathecal injection (or epidural appli
applied cocaine to the eye of one of his pa cation, if the drug penetrates the dura),
tients [3]) and did not intend to introduce to alter nociceptive or motor transmis
an anaesthetic procedure. Corning's pri sion within the spinal cord.
mary aim was the application of drugs in 2. Implantable devices for long-term appli
proximity of the central nervous system, i.e. cation of drugs to specific sites of the
spinal cord, in order to treat or even heal body, including the spinal spaces, were
different, especially painful, nervous dis- developed during the 1970's.
2 Preface
Long-term spinal drug administration for basic knowledge of spinal cord function
pain was introduced into clinical use about and of possibilities of pharmacological
6 years ago [4] and since that time has manipulations of these functions will pos
gained wide-spread use. Spinal treatment sibly change our criteria to select spastic
of spasticity using this technique, which patients for ablative surgery.
proved to be effective during spinal opiate Another purpose of this volume is to
analgesia, was introduced 3 years later [5] draw the attention of the reader to the pos
and, so far, has been applied in only a few sible problems of this method. Of course,
patients. This volume presents papers of every new technique is associated with
different authors that were originally pre problems, which sometimes we only be
sented at the first international meeting on come aware of if this method is used in a
this method, which took place in April 1986 great number of patients. Spinal medi
in GieSen, FRG. In addition, some authors cation for spasticity with central depressive
have been invited to contribute to this vol drugs such as baclofen, morphine or ben
ume. zodiazepines may, under certain con
The purpose of this volume is to inform ditions, lead to life threatening cerebral im
those clinicians who are not yet aware of pairment. The spinal use of antispastic
this new technique. We are convinced that agents must not be treated lightly. How
a considerable number of patients with ever, the fact that this method has proved
spasticity may profit from this therapy, es to be more effective than all other anti
pecially those patients who must undergo spastic therapies so far, makes it worthwile
destructive surgical procedures in order to to present the data and results collected in
reduce spasticity. In our opinion, the clini this volume. In addition, the technique of
cal experience with spinal medication for spinal medication described in this book
spasticity has already demonstrated, in may be of great importance in the near fu
spite of the small number of patients treat ture. Other pharmacological systems of the
ed so far, its superiority to ablative surgery. central nervous system, no doubt many yet
Similar to chordotomy in pain treatment, undefined, may offer even more specific
destructive surgical measures were the only forms for local therapy.
therapy for spasticity for a long period of
time. It is not only by chance that Foers
ter's operation (dorsal root section) was in January 1988 Hermann Muller
troduced almost at the same time as chor Jan Zierski
dotomy [2, 6]. The explosive increase of our Richard D. Penn
References
1. Coming JL (1885) Spinal anaesthesia and lo pain of malignant origin. Mayo Clin Proc
cal medication of the cord. NY Med J 42:483 56:516-520
2. Foerster 0 (1911) Die Behandlung spastischer 5. Penn RD, Kroin JS (1984) Intrathecal bac1o
Uhmungen durch Resektion hinterer Riicken fen alleviates spinal cord spasticity. Lancet
markswurzeln. Ergeb Chir 2: 174-209 I: 1078
3. Koller C (1884) V'ber die Verwendung des Co 6. Spiller WO, Martin E (1912) The treatment of
cains zur Anaesthesierung am Auge. Wiener persistent pain of organic origin in the lower
Medizinische Blatter 7: 1352 part of the body by division of the anterolat
4. Onofrio BM, Yaksh lL, Arnold PO (1981) eral column of the spinal cord. JAMA
Continuous low-dose intrathecal morphine 58: 1489-1490
administration in the treatment of chronic
A Short Historical Review of Spasticity
and its Therapy
D. Dralle, H. MUller, J. Zierski
Introduction
The terms "spasms" and "spasticity" have nominibus spasmorum graecis et latinis")
been an important subject of medical was discussed and supplemented by
literature for a long time. In 1678 c.Y. Schneider's own experiences. This led him
Schneider's work on "Spasmorum natura et to distinguish between different types of
subjecto, nec non et de causis eorum spas motor disturbancies, such as spasms, spas
morum ac earum motionum spasticarum et tic movements, paralysis and convulsions
epilepticarum" was published in Wit [58]. In addition, Schneider was the first to
tenberg (Fig. I). In this voluminous book, declare that nasal secretion was not due to
containing 6 chapters and 430 pages, the an outflow from the brain, as was previ
development of the medical knowledge of ously believed.
these terms dating from Hippocrates ("De
CONRADI VICTORIS
SCHNEID ERr,
Phil: added: Dod: Profefs~ p~
&c. &c.&~.
LIBER.
DE
SPASMORUM'
NATURA ET SUBJECTO"
NEe NON ET DE: CAUSIS EOltUM
SPASMORUM AC EARUM MOT/ONUM
SPASTICARUM ET EPILEPTICARIlM,
Q.VA=; AL1<!VANDO IN RECENS D£FUNCTIS
AC /N OCCIS/$ CORPORIBUS MAXIME MILtTUM,
Q.Vl IN ACIE PUGNA TES CEC/DE8.UNT. ETlAN
·NUM MANIFESTANTUR, AC NON SINS
ADM/RATtONE DEPREHEN.
DUNTUR.
~(o)~
PJ7JTTEBERGAt.
Ap."JlP.EM: ~rrvl B;b!ioP. .
TyPiJ 10HANNIS BORCXJ\RDI.ACad-TypoV
tScud.bll S I M 0 N lil&tr~frf. Fig. 1. Frontpage of C. V. Schneider's
4 ... 0 M OCLX It fJ X. monography on spasticity, printed in 1678
4 D. Dralle et al.
Neurophysiological Examinations
In Greek literature, electricity was defined storage of electricity (Kant 1745/Muschen
as attractive power, which could be in broek 1745) in quantities high enough to
duced by rubbing together pieces of amber provoke muscle contractions in animal ex
(= electron). Although in the 17th century periments [Caldani 1756: cit. in Rothschuh:
several machines that produced electro 56]. In 1757 Fontana applied electrical
static energy were constructed (Guericke stimulation directly to the cortex of animals
1680), they did not serve any purpose ex or to the brain of people after execution.
cept for public amusement: people touch Basic experiments demonstrating the
ing these machines experienced the un role of spinal cord for muscle contraction
usual feeling of electricity [cit. in Thomas: were performed by S. Hales (1730), who
67]. was able to show that muscular movement
At that time the term "reflex" did not yet in frogs could be provoked even after de
exist. Muscular movement was looked capitation but ceased after destruction of
upon as a consequence of the action of an the spinal cord (Fig. 3). Similar exper
immaterial "animus", and the link between iments were done by R. Whytt from Edin
soul and brain was thought to be in the re burgh (An assay on the vital and other in
gion of the epiphysis (R. Descartes 1596 voluntary motions). He was the first to de
-1650) (Fig. 2). In 1677 Francis Glisson put fine pupillary constriction to light as a
forward his theory of "irritability", a gen "muscular reaction of the iris, induced by a
eral quality of all living tissues, which he stimulus and mediated by brain".
thought to be independent from brain and Almost at the same time, in 1753, A. von
nerves. According to Hansen (1743), irrita Haller found that contractions of isolated
bility was due to an electrical fluidum re muscles could be provoked by mechanical
sponsible for muscle activity. At the same and chemical stimulation as well [28].
time, primitive condensators were con Nevertheless, he thought that nerves played
structed, which for the first time allowed an active role in th process of muscular
Fig. 2. The role of the epiphysis as con
nection between the central nervous sys
tem and the immaterial "animus". Draw
ing from Descartes "Essay on humanity"
1667, National Library, Paris