Intrathecal baclofen (ITB), administered by an implanted pump, has emerged as an efficacious therapy for the treatment of hypertonicity in pediatrics. Although ITB has been used for more than 20 years clinically, much is still unknown about the most optimal dosing regimens and intrathecal catheter tip placement. Clinician experience, animal research, and advanced imaging is guiding the use of ITB. The rationale for high cervical catheter tip placement and pulsating flex dosing is described.