A 40-year-old male patient presented to us with a history of severe head injury in a bus accident while traveling in it. Initial Glasgow Coma Scale (GCS) was about 6/15 with bilateral normal. There was no focal neurological deficit, deep tendon jerks (DTR) were absent in all the limbs and computerized tomography (CT) scan of head was grossly normal without any surgical lesion. Conservative management was started considering the case as diffuse axonal injury (DAI).
Though there was some improvement in neurological status after few weeks, he went on to a vegetative state, i.e. remained unconscious with GCS about 9/15 and without any specific motor and verbal function. He could occasionally open eyes and move limbs spontaneously, but there was no verbal function, no purposeful limb movement, no bowel and bladder control and he did not respond to any verbal command. Finally, he developed generalized spasticity. Considering an appropriate candidate, ITB was planned. Baclofen injection was not available in Nepal and ITB therapy was never used before in this country. Fortunately, Prof. Taira had brought a few ampoules of injection baclofen from Japan and gave them to us as a gift.
But, we did not have baclofen pump and other accessories for ITB. Therefore, an epidural catheter, which is used by an anesthetist for spinal anesthesia or for continuous lumbar drainage [Figure 1], was inserted into the thecal sac at second and third lumbar space and was fixed. The catheter was placed in situ throughout the ITB period and baclofen was injected everyday through it with aseptic precaution. Patency of catheter was confirmed every time before ITB by free flow of cerebrospinal fluid (CSF). We injected 50 mug of baclofen intrathecally everyday for the first 2 weeks and then increased the dose to 100 mug everyday. Oral baclofen was stopped. Patient was placed in lying position during ITB and bedside physiotherapy was continued. In due course of time with ITB, his limbs became less stiff and clonus improved significantly. His higher mental function also showed signs of improvement, and he started producing few words and sounds, followed verbal commands and moved limbs purposefully. Occasionally, he also started showing his emotion in terms of agitation and irritation especially with his family members.
Slowly, we increased physiotherapy, made him sit on wheel chair few times a day, started catheter clamping for his bladder training. His higher mental function improved day by day, could speak a few sentences, followed verbal commands well, and understood and recognized his surroundings and family members. However, we had to stop ITB after about 5 weeks due to CSF leakage through skin puncture site.
By the time he was discharged from the hospital after about 2.5 months of hospital stay, he was fully conscious, i.e. he was well oriented, could speak appropriately and walk with support. He did not have any neurological deficit except for squint due to internuclear ophthalmoplegia that he had developed immediately after trauma and mild spasticity of limbs. Bladder catheter was removed and he could pass urine by himself. He had some behavioral problem, occasionally used to get agitated and violent and also had some psychotic features. Therefore, he was referred to a psychiatrist. Electroencephalogram (EEG) done in 2 months of follow-up was normal.