MANAGEMENT OF SPASTICITY DUE TO SPINAL CAUSES

Abstract

Spasticity is considered now as one of the most worldwide distributed disabling condition in both adults and pediatrics. It remarkably affects the human and national resources. The anatomical and physiological consideration, clinical presentation and pathological mechanisms, especially the later which is obviously changed among the last two decades due to technical advances, should be well known. The different assessment modalities including the electrophysiological techniques, the physical methods, spasticity rating scales and measures for disability are also crucial for those who work in this field. History of spasticity management over the last decades, management algorithms, medical and surgical techniques and neuromodulation techniques are also reviewed. A prospective study was done at Ain Shams University Hospitals and Dar El-Shefa Hospital on 65 patients with spinal cause of spasticity, 43 of them with paraplegia, 17 with quadriplegia, and one with hemiplegia, the mean follow up duration was 6.3 months. All patients were subjected to an arsenal of routine investigations, instrumented and manual physical evaluation, electrophysiological evaluation and orthopedic evaluation for concomitant joint deformities. MANAGEMENT OF SPASTICITY DUE TO SPINAL CAUSES Summary 137 All patients were selected according to standard inclusion criteria for each modality of treatment used in this work. Patients were grouped into three groups according to the modality used. Intra-operative electrophysiological monitoring was used in all surgical cases, either neurostimulation for selective neurotomies or EMG monitoring and somatosensory evoked potentials in microsurgical DREZotomy. Selective peripheral neurotomy is applied to (30) patients; statistically significant physical and functional improvement was shown in those patients. The tibial nerve is the most commonly operated; 40 neurotomies, the sciatic is the second; 36 neurotomies, the obturator; 24 neurotomies, and one median neurotomy. Botulinum toxin type A was used as a minimally invasive modality to control spasticity in moderate spasticity with no fixed contracture in 30 patients, a need to repeat injection with more or less same doses occurred in eight of 30 patients (26.6%). The recurrence of reflex activity can be anticipated with Hmax/Mmax ratio and spontaneous activity recording. Five patients underwent microsurgical dorsal root entry zone lesioning (MDT) (Three females and two males). MANAGEMENT OF SPASTICITY DUE TO SPINAL CAUSES Summary 138 They were paraplegic with no clinical evidence of voluntary control despite of minimal electrophysiological motor unit potentials.