Spasticity That Helps: A C4 AIS B Patient Who Wants It Gone
A 47-year-old man with C4 AIS B tetraplegia from a diving injury 14 months ago lives at home with his wife. He uses a power wheelchair with chin control and can do a pivot transfer with maximal assistance of one person; he relies on extensor spasms in his legs to lock his knees during the transfer. Flexor spasms have become more frequent, triggered by catheterization and colostomy care, and have caused two falls and a skin tear. He takes baclofen 20 mg three times daily and tizanidine 4 mg three times daily. He asks for 'something stronger, maybe that pump.' His wife is worried about the falls but also about him becoming more dependent.
1. How do you determine whether his spasticity is harmful or useful, and what would you do before considering intrathecal baclofen?
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Assess whether the spasms help or hinder function. Use a structured measure such as the SCI-SET, which captures both beneficial and problematic effects, plus the MAS or Penn scale for severity and a functional assessment of transfers, sitting, and skin. Ask about triggers: UTI, constipation, catheter blockage, pressure injury, ingrown toenails, fractures, and tight clothing. Review medications for sedation and weakness. Because his extensor spasms lock his knees, global tone reduction could make transfers less safe. Before intrathecal baclofen, treat triggers, optimize the timing and dose of oral baclofen and tizanidine, and consider focal botulinum toxin to the hip flexors or adductors that drive the flexor spasms, along with physical therapy for transfer technique. If intrathecal baclofen is still considered, do a trial bolus with formal functional testing.
2. If intrathecal baclofen is pursued, what functional risks are specific to this patient and how would you mitigate them?
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Risks include loss of the extensor tone needed for pivot transfers, generalized hypotonia, weakness, somnolence, catheter or pump infection, CSF leak, and withdrawal if the system is interrupted. Mitigation starts with a test dose and physical therapy assessment of transfers and sitting before implantation. Start at a low dose and titrate to the lowest effective rate, preserve some extensor tone, and set goals around reducing falls and skin tears rather than achieving zero spasticity. Have a backup plan, train the patient and wife about pump alarms, and avoid abrupt cessation. Also recognize that intrathecal baclofen will not fix triggers and may unmask weakness, so continue trigger management and therapy.
3. What would you tell the wife about baclofen withdrawal?
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Baclofen withdrawal is a medical emergency. Abrupt reduction can cause high fever, rigidity, rebound spasticity, rhabdomyolysis, seizures, autonomic instability, and death. If the pump fails or the catheter dislodges, give oral baclofen, consider intrathecal replacement via lumbar puncture in some settings, use benzodiazepines for rigidity, give IV fluids, and monitor in an ICU; do not wait for symptoms to worsen. Tell her to know the pump alarm, keep a rescue plan, and call emergency services rather than waiting until morning. She should also know the signs of early withdrawal: increasing spasms, itching, fever, and agitation.