Intrathecal baclofen in tetanus: four cases and a review of reported cases

Spasms in patients with generalized tetanus can be suppressed by a spinal intrathecal infusion of baclofen. We report on four patients and review reported cases treated by this method elsewhere.

Intrathecal baclofen infusion was started with a bolus dose (300-500 micrograms) and continued at a steady rate of 500-1000 micrograms/day. The dose was increased in daily steps as needed.

Doses of baclofen of 500, 1000, or 2000 micrograms/day were effective in three patients, while 1500 micrograms/day was insufficient in the fourth. Bradycardia and hypotonia occurred in one patient at a dose of 2000 micrograms/day but resolved after the dose was reduced to 1500 micrograms/day. Another patient developed hypotonia when a bolus of 500 micrograms was given after a steady infusion of 1500 micrograms/day. Voluntary movements were preserved in one and returned in two patients when sedation, induced by initial diazepam infusions, receded. The fourth patient needed diazepam during most of the treatment with intrathecal baclofen and required mechanical ventilation while being treated with baclofen.

A catheter position higher than T11 would possibly have yielded better results. It may be necessary to adapt the dose during the course of the illness. The preservation of respiratory drive and voluntary movements is the main advantage of treating tetanus with intrathecal baclofen. Additionally it helps to reduce sympathetic hyperactivity. Mortality may thereby be reduced.