COMMENTS ON THE USE OF INTRASPINAL PHENOL-PANTOPAQUE FOR RELIEF OF PAIN AND SPASTICITY

Managing severe lower limb spasticity in multiple sclerosis: does intrathecal phenol have a role?

OBJECTIVE

Established treatment options for managing severe lower limb spasticity and associated pain are of limited value in people with advanced multiple sclerosis (MS). This has resulted in a resurgence of the use of lumbar intrathecal phenol injection (IP). The aim of this study was to investigate the authors' experience with IP.

METHODS

This observational study collected cross sectional data from patients with progressive MS who received IP for severe lower limb spasticity. Data from 25 patients were collected prospectively before and after treatment. In 15 cases the data related to the first treatment and in 10 to serial injections. Outcome measures collected included the Ashworth scale, a spasm frequency scale, a pain rating score, and the percentage achievement of practical goals.

RESULTS

After injection, all patients demonstrated reduced lower limb tone bilaterally. After the initial injection there was significant improvement on the targeted as compared with the non-targeted side (Wilcoxon rank p=0.003), while no difference in the degree of improvement between the targeted and non-targeted side was seen after serial injections (Wilcoxon rank p=0.731). Twenty four patients were easier to position and 21 had a reduction in their spasm frequency and intensity. Eleven patients with pain reported benefit. Carers found washing and dressing easier in 16 patients and improved safety when using the hoist in 10. Six patients had recurrence of skin breakdown and five patients reported transient adverse changes in their bowel function.

CONCLUSIONS

IP can reduce lower limb tone bilaterally after both initial and serial injections. This is most noticeable on the targeted side after initial injection. IP can reduce spasms and pain, leading to improvements in care and overall comfort. IP is an effective treatment option in the management of severe spasticity. Documented selection criteria are essential.

Endovascular Treatment of Excessive Spasticity from Spinal Cord Injury

We report a new treatment for excessive spasticity using an endovascular technique. A 52-year-old woman with intractable spasticity of the hip joints and abdominal muscles was treated with an injection of 70% alcohol into Adamkiewicz's artery, which destroyed the spinal cord fed by Adamkiewicz's artery and cut the reflex arcs of excessive spasticity. Immediately after the treatment a significant change was noticed in muscle tonicity of the lower extremities, and intractable spasticity disappeared. Skin necrosis and muscle damage occurred because of the alcohol that leaked into the muscle branch of the subcostal artery. However, these complications could be treated by simple necrotomy. No recurrence was observed during the follow-up period.

We believe this endovascular treatment will become a new strategy for excessive spasticity arising from spinal cord injury.

Treatment of acquired muscle spasticity using phenol peripheral nerve blocks

The use of phenol motor nerve blocks is advantageous in the early period of acquired spasticity (ie, that occurring following traumatic brain injury or incomplete spinal cord injury), when increased muscle tone is often the most severe. Because acquired spasticity is dynamic and usually improves slowly, a temporary treatment method used to ameliorate increased muscle tone is desirable. Phenol nerve infiltration provides a temporary motor nerve block that lasts for weeks or months. It allows passive limb mobilization in a comprehensive rehabilitation program that attempts to prevent fixed soft tissue contractures. Permanent or irreversible methods such as operative tendon lengthening, muscle release or recession, or neurectomy are usually best delayed until the spasticity has become static, when the need for surgical correction becomes more firmly indicated, and outcomes of operative intervention are more predictable. Although phenol nerve blocks were initially administered at the spinal cord level to control spasticity, the potential side effects have caused a loss of popularity of this method of administration. The safer and more common use of phenol infiltration at the peripheral nerve level is now more accepted for brain injury and spinal cord injury patients. This report reviews the indications, current concepts, and development of the different methods used to administer phenol nerve blocks. Comparisons to other methods to control spasticity are discussed.

Intrathecal phenol and glycerin in metrizamide for treatment of intractable spasms in paraplegia. Case report

Intractable lower extremity spasms after spinal cord injury is a significant source of morbidity. A case of refractory spasticity in paraplegia was successfully converted to flaccid paraplegia by intrathecal injection of phenol and glycerin in metrizamide. This chemical rhizolysis is simple and effective, and the presence of metrizamide allows both fluoroscopic guidance for accurate intrathecal phenol placement and good miscibility with cerebrospinal fluid. A brief comparative review of alternative therapeutic modalities is presented.

Percutaneous epidural neurostimulation in modulation of paraplegic spasticity. Six case reports

Six cases of paraplegic, post-traumatic spasticity, alleviated by percutaneous epidural neurostimulation with temporary or permanent implanted neuroelectrodes from the L1 to L4 intervertebral levels are presented. Modulation of this spasticity and secondary beneficial physiological effects were achieved, including regulation of bowel regimens, production of sweating and piloerection below the level of the lesion, and morning erections. The main advantages of percutaneous epidural neurostimulation in modulating spasticity are the avoidance of destructive neurosurgical procedures, the regulation of secondary physiological and autonomic responses, the avoidance of antispasticity medications, and the reversibility of the neurostimulation procedure.