*4.1.5 Other procedures*

Some stereotaxic procedures in the thalamus and cerebellum have been performed for the treatment of spasticity in selected cases. These lesioning procedures include ventrolateral thalamotomy, pulvinarotomy, dentatotomy, and lesion of nucleus fastigii [29]. Due to the complexity, risks and lack of better effectiveness compared to the surgical options for spinal cord and peripheral nerve, these procedures were abandoned [6].

On the other hand, orthopedic surgery is another lesioning option. Neurosurgical procedures are the first choice for the management of spasticity and dystonia, but orthopedic surgery is a complementary surgical option for cases in which spasticity persists after neurosurgical treatment. Orthopedic surgery can reduce spasticity by releasing or lengthening tendons in the affected region. Orthopedic procedures may be indicated primarily when contractures and ankyloses are predominant or like the last option when the deformity is so strong [6].

#### **4.2 Neuromodulation treatment**

The classic procedures to treat spasticity are focused to perform lesions or ablative brain, spinal or nerve surgeries, but in recent times it exists the opportunity of neuromodulation. This term involved the use of chemical or electric pulses to increase or decrease neuron threshold with the main goal to diminish or abolish neurological or/and psychiatry symptoms. Neuromodulation is widespread to treat neuropathic and phantom pain, movement disorders abnormalities like Parkinson's disease, essential tremor and dystonia; partial and generalized epilepsy; obsessive–compulsive disorder, depression or anorexia; motor problems of neurogenic bladder, and neurologic deafness and blindness.

In this sense, neuromodulation in spasticity is concerned mainly to the use of infusion pumps, treatment acknowledged all over the world. Nevertheless, it exists the possibility to utilize electric stimulation in two targets: spinal cord and cerebellar sites to ameliorate the stiffness limb, but is not spread like infusion pumps.

#### *4.2.1 Infusion pumps in spasticity*

The next lines are dedicated to resume the infusion pump in the treatment of spasticity. It should be said that there is no cure to spasticity, but different methods and treatments can be useful. Infusion pumps are generally described as: "Complicated electromechanical systems that are used to deliver anesthetic drugs with moderate precision" [30]. Regarding neurosciences, different drugs are used in order to help patients with spasticity and other similar illnesses, mainly baclofen. Since 1984, the usage of infusion pumps with baclofen was proposed by Richard Penn due to prior scientific evidence that this chemical could work as an analogue of "γ-aminobutyric acid" (GABA) in its B receptor, how it is mentioned [31].

Humans can be treated effectively with intrathecal baclofen to decrease drastically the symptoms, and the burden that this illness means. Baclofen is a GABAergic drug that is transmitted intrathecally by infusion to the subarachnoid space. Although baclofen can be taken orally, the quickness and effectiveness of the chemical is decreased in comparison with the utilization of pumps to treat patients with spasticity. When taken orally, baclofen can have as a maximum dosage approximately 360 mg per day, but when infused intrathecally the dosage reduces to approximately 250–500 μg per day. Although, Baclofen is a very effective chemical it also has some repercussions like muscle weakness and slowness in walking speed due to the effects that induces, but they can be controlled if the dose is adequate for the patient (**Table 4**) [32].

Overall, the experience of scientists and neurosurgeons using intrathecal baclofen can be described as a positive one, but most important good results have been shown for patients with spasticity. In **Table 4**, it can be seen how several authors have been using this technique to improve the development of the pathology. The former table contains twelve different categories in which all the authors present the results obtained by the research. In the "year" column it can be seen when the paper was published, and in the "number of patients" the amount of people that took participation in the research. In general, the "follow-up" period


#### *Neurosurgical Spasticity Treatment: From Lesion to Neuromodulation Procedures DOI: http://dx.doi.org/10.5772/intechopen.96054*

**Table 4.**

*Comparison between authors according to baclofen treatment in this table it has been merged information from different articles that inform about intrathecal baclofen usage [14]; [33–41]. NS = not specified.* was variant, but the tendency as years pass is determined to give the patient a longer period between the follow-up in comparison with the older papers. It should be said, that when analyzing the Ashworth Scale comparing the preoperatory and the post-operatory, results show that using intrathecal baclofen can help reduce drastically the stiffness to a slight increased muscle tone in the majority of the patients.

Regarding the "dose", the difference between pediatric and adult treatment should be addressed to understand how to apply intrathecal pumps. Some factors in children may affect the treatment, that is why there should be a pediatrician involved in the process of treating infants in order to apply the correct dosage and time to realize the pump implantation, and do not interfere with their development. In adults, it can be said that covering a good dosage is easier because developed organisms can receive intrathecal treatments better with doses from 200–600 μg/day. Moreover, due to biological variability different patients need more baclofen if they are still showing symptoms of spasticity, and less in the case of having problems with movement and also muscle weakness; that is why the doctor should be ready to evaluate when to adjust the dose of the drug according to patients' requirements.

Authors with long number of participants tend to have similar results, that is why it is important to have a correct number of participants and dose to generate a more accurate investigation. The dose of those investigations with more than a hundred participants express that the amount of baclofen needed to help a patient can approximately be 220 μg/day as a good reference to start the drug's usage. Although, none of the authors used another drug in their papers it should be said that baclofen is an effective chemical that can help patients with spasticity infused intrathecally. Also, it is important that doctors have to analyze correctly the dose for a better performance of the pump in each individual, and avoid toxicity problems (**Figures 2**–**6**).

In the following years, neurosurgeons and their teams have been adding information to the methods and the correct usage of this technique, gathering approximately 35 years of experience in the field of infusion pumps and the usage of baclofen in order to treat spasticity.

#### *4.2.2 Spinal cord stimulation*

The first person who used SCS in the treatment of an illness was Shealy when he was neurosurgery resident in the 60's decade. In the 50's, the original idea was emerged after the use of battery connected to cardiac electrodes located in the animal's atrium and modified the myocardial electricity in the treatment of arrhythmias. After an experimental period, the use of a voltaic pile and heart electrodes brings the first pacemaker in man, and stablished one of the most important medical knowledge about implants in the human being until now.

Shealy thought this principle of pacemakers, first in dogs and after in humans, could be used in neurologic patients. He took the first patients with uncontrolled pain cancer, and he implanted in the spinal cord, a system similar to the cardiac patients. The results are the amelioration of pain. Indeed, in this moment Shealy was opened the door to Neuromodulation at the neurologic patients [42, 43].

With respect to spasticity, based in the experience of Shealy with SCS for pain treatment in 1973, Cook and Wenstein reported one Multiple Sclerosis (MS) patient with pain alleviation but with the fortuitous finding that also limb spasticity amelioration was presented [44]. In 1976, Illis in UK introduced percutaneous electrodes in two MS patients and peridural space was stimulated and improved spasticity [45]. In 1979, Richardson and cols wrote an article with six spastic patients, in which spasticity was measure by a scale similar to Ashworth, with 36.11% of improvement, and also for first time the article described SCS

*Neurosurgical Spasticity Treatment: From Lesion to Neuromodulation Procedures DOI: http://dx.doi.org/10.5772/intechopen.96054*

**Figure 2.** *It is shown how baclofen should be injected into the pump's reserve.*

electric parameters of stimulation (Voltage from 0.5 to 2 V, frequency 33 to 75 HZ, and pulse width of 100 to 200 μsec) [46]. In 1980, Read and cols reported 16 MS patients: 9 had spasticity amelioration, 3 without change and 2 had worst evolution with increase in spasticity; the total alleviation was 56.25% in the group [47]. In the same year, Siegfried showed his experience with originally 26 patients using test stimulation before definitive implantation, consisting in percutaneous electrodes and depending if the test was positive, they implanted a definitive one. Only 11 patients were operated and followed 3 years with amelioration of the spasticity. Best results depending of spinal and partial damage more than cerebral site of spasticity. They also used electrophysiological measures like H-reflex to contrast the amelioration [48]. Also, in this year, Dimitrijevic showed the results of 11 patients with spasticity that improved 56.56% after SCS, mainly clonus and EMG patterns. In 1985, Barolat-Romana reported 6 spasticity patients with spasms and the immediate alleviation after SCS [49]. In 1986, Dimitrijevic and cols studied 59 patients in which spasticity was reduced in 63% of the group. They found spasticity was controlled better if the electrode was located below the spinal lesion more than above, also patients had better results with partial lesion that with complete ones [50]. In 1986, the same group with Campos (like the first author) described 8 patients with minimal function of posterior columns, 90% responded to the

#### **Figure 3.**

*It is demonstrated how the pump should be implanted, so as the stitch used in order to seal the neck of the gadget with the catheter.*

epidural stimulation [51]. In 1988, Barolat made a clinical trial expanded the initial experience to 16 myelopathic subjects with amelioration of spasm and clonus, inclusive from one year of follow-up [52]. In 1993, the same group was amplified the experience of 509 plates implanted in patients suffered pain and spasticity: 350 in the whole group, 227 for pain, 105 for motor disturbances (spasms/spasticity following spinal cord or cranial trauma, multiple sclerosis, cerebral palsy, spasmodic torticollis and other motor problems) and 18 patients with both condition: pain and spasticity. From these, 3.4% had infection, 1.1% with electrode migration and less of 1%, breakage [53]. In the decade of 1990's it existed poorly advanced in this area. In 2000, Pinter and Dimitrijevic discovered that severe spasticity in paraplegic patients could improve with the electrode's position upper to the spinal lesion, with frequency of 50–100 Hz, 2–7 Volts and 210 μsec and adapted depended of the case [54]. In 2015, Dekopov and Russian team evaluated two groups of spasticity patients: Cerebral palsy and spinal cord lesion. SCS ameliorated Ashworth scale (58.8%) in cerebral palsy group, but it did not for the spinal cord lesion [55].

*Neurosurgical Spasticity Treatment: From Lesion to Neuromodulation Procedures DOI: http://dx.doi.org/10.5772/intechopen.96054*

#### **Figure 4.**

*In the implantation process is important to attach the pump handles to the tissue surrounding the equipment in order to stabilize the device and prevent future complications.*

#### *4.2.3 Cerebellar stimulation*

The understanding of cerebellar human stimulation began in the experiments developed in rats, cats, dogs and monkeys. It was based in these antecedent that Cooper and cols in 1973 located electrodes on the anterior and posterior surface of cerebellum to treat not only spasticity, but seizures also [56–58]. After these reports, Cooper and his group contribute significantly to this neuromodulation area with different types of articles including implantation technique, clinic evolution, surgical complications, neurophysiological changes, psychological reactions, between other issues [59–64]. Other groups started to perform CS. In 1977, Manrique and cols implanted 4 patients with good results to diminished spasticity [65], Penn found in some patients diminished spasticity and, in other, no changes [66, 67]. Cooper's work was continued by Davis [68–73] spreading the experience in this field. In 2003 and 2007, respectively, Galanda & Horvath proposed new insights about CS [74, 75]. In the last decade there has been no progress in this area.

#### **Figure 5.**

*Post-operatory picture of the pump immediately after the implantation surgery. X-ray image must be taken to verify the correct placement of the equipment.*

#### **Figure 6.**

*X-ray image shows the infusion pump implanted in the lower part of the left hypochondria. The red arrow indicates the catheter connected to the infusion pump, and the tip goes to T-10 level into the subarachnoid space.* *Neurosurgical Spasticity Treatment: From Lesion to Neuromodulation Procedures DOI: http://dx.doi.org/10.5772/intechopen.96054*
