Indian Journal of Pain

CASE REPORT
Year
: 2017  |  Volume : 31  |  Issue : 3  |  Page : 201--203

Successful use of botulinum toxin a in intractable, severe muscle spasms in spinal cord injury: A case report


Madhuri A Lokapur, Gautam D Modak, Kalpana V Kelkar, Vinaya R Kulkarni 
 B.J. Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India

Correspondence Address:
Gautam D Modak
Vishwadhar, Near Mata Mandir, Dharampeth, Nagpur 440010, Maharashtra
India

Abstract

Botulinum toxin is a protein produced by Clostridium botulinum, which inhibits muscle contraction by transiently blocking the release of acetylcholine at the neuromuscular junction. At a neuromuscular junction, the toxin inactivates some of the fusion proteins, such as SNAP-25, syntaxin, or synaptobrevin, which are essential for cellular function. This process involves the temporary inhibition of presynaptic acetylcholine release; consequently, its effects are restricted to motor neurons that depend on the cholinergic transmission (muscular plate, gland innervating cells). Injections of botulinum toxin A have been shown to be useful in the treatment of etiologically diverse types of muscle spasms. Ultrasonography (USG) has been used as a guide for confirming muscle fasciculations and also is an effective tool for confirming precise needle positioning and correct drug placement. We describe a case of a 25-year-old man with meningomyelocele and paraparesis with painful muscle spasms in bilateral thighs treated by USG-guided botulinum toxin injection.



How to cite this article:
Lokapur MA, Modak GD, Kelkar KV, Kulkarni VR. Successful use of botulinum toxin a in intractable, severe muscle spasms in spinal cord injury: A case report.Indian J Pain 2017;31:201-203


How to cite this URL:
Lokapur MA, Modak GD, Kelkar KV, Kulkarni VR. Successful use of botulinum toxin a in intractable, severe muscle spasms in spinal cord injury: A case report. Indian J Pain [serial online] 2017 [cited 2019 Oct 22 ];31:201-203
Available from: http://www.indianjpain.org/text.asp?2017/31/3/201/223675


Full Text



 Introduction



Botulinum toxin (BoNT) is produced by the anaerobic bacterium Clostridium botulinum. BoNT-A causes flaccid paralysis by blocking acetylcholine, required for muscle contraction, from release at the nerve terminal.[1],[2] Best known for its beneficial role in facial aesthetics, it is now being used for multiple noncosmetic medical and surgical purposes.[3],[4],[5],[6] Ultrasonography (USG) is a practical and efficient tool for detecting muscle spasms and twitches.[7],[8] Owing to its advantage of being painless and easy to use, USG has been used for guiding BoNT injections for functional shortening of iliopsoas muscle [9] and also for piriformis syndrome. We report a rare and novel attempt of using ultrasound guidance for intramuscular BoNT injection for treatment of painful muscular spasms in an operated case of meningomyelocele.

 Case report



A 25-year-old man came with the chief complaint of painful spasms and twitches in bilateral thighs, which were exacerbated on lying down. He was diagnosed with meningomyelocele and paraparesis at birth and operated on multiple times. On examination, the patient was wheelchair bound; power was grade 2/5 in bilateral lower limbs with spasticity and exaggerated reflexes. Studies revealed severe chronic axon degeneration affecting predominantly bilateral L5, S1 motor roots and to a lesser extent L2, L3, and L4 motor roots. The patient had been given conservative treatment with nonsteroidal anti-inflammatory drugs (tab etoricoxib 45mg b.d.) and skeletal muscle relaxants (tab Baclofen 10mg b.d.) as well as physiotherapy that proved ineffective. Hence, he was referred to a pain clinic for further management.

 Management



USG guidance was used to confirm the presence of twitches and spasms that showed jerky movements, which were localized to bilateral vastus lateralis and to the tensor fascia lata. It was decided to inject BoNT through USG guidance in the affected muscles. Consequently, after explaining the procedure and the possible side effects involved to the patient, appropriate consent was taken. With all resuscitative measures kept ready, USG-guided intramuscular injection of BoNT 50 IU each in vastus lateralis of bilateral lower limbs was administered. A week later when the patient presented for follow-up, there was complete resolution of spasms in the left lower limb with minor residual twitches present in the right lower limb. Visual Analog Scale (VAS) score improved from a score of 8–9 before the procedure to a score of 3–4 after the procedure. There was reemergence of spasms in the adductors 15 days after injection for which the procedure was repeated in the adductors [Figure 1].{Figure 1}

 Discussion



The therapeutic use of BoNT was first proposed in 1973 by Scott et al.,[10] who used the serotype A toxin to correct strabismus. Injections of BoNT are currently used to treat primary and secondary dystonia, poststroke and post-traumatic spasticity, and cerebral palsy.[4],[5],[11],[12] More recent applications include neuromuscular blockade associated with spasmodic dysphonia, anal spasms, vaginismus, achalasia, and altered ocular movements such as those of nystagmus [13],[14],[15] and exocrine glands affected by autonomic hyperactivity (as in hyperhidrosis or sialorrhea).[16],[17] The toxin has also been successfully used in the treatment of pain associated with the myofascial pain syndrome, lumbar back pain, migraines, and tension headaches.

Muscle pain in spasms can be evoked by chemical C and A fiber stimulation because of local production of lactate and acidic pH induced by long-term contracture and ischemia. The predominant sensations experienced during ischemia are aching and burning, which are believed to be associated with unmyelinated nerve fibers.[18] In the rat model of tourniquet ischemia, Chabel et al.[19] demonstrated that after tourniquet application, spontaneous myelinated fiber activity decreases while previously inactive C fibers begin to spontaneously discharge. The reduction of muscle contracture obtained by BoNT-A or BoNT-B injections may explain the decrease in the pain. Moreover, BoNT-A has been found to inhibit bradykinins, serotonin, potassium, prostaglandin E2, substance P, and the neuropeptide Calcitonin Gene related peptide reducing sensitization of muscle nociceptors.[20],[21],[22] For this reason, BoNT-A can be used to treat myofascial pain syndrome and pain from chronic muscle spasm.[23]

In most cases, the BTX-A therapy is effective for 2 or 3 days after the injection, and the maximum effect is observed after about 3 weeks. They last up to 3–4 months. After this period, the chemical denervation induced by the toxin is hindered by spontaneous neoinnervation.

USG is well established as a reliable and reproducible imaging method in muscle anatomy. It has proved superiority at the accuracy of delivery and procedural effectiveness over blind procedures when used in association with interventional pain procedures. It has multiple advantages over blind procedures, and other imaging modalities, including ease of performance, the absence of ionizing radiation, better visualization of soft tissue (e.g., muscle and ligament) and blood vessels, real-time visualization of needle advancement, and the ability to observe the spread of injectate.[24] It also avoids the need for the use of contrast agents that can be associated with allergic reactions and renal damage, is portable, and is cost-effective. In the present case, the image guidance for injections was necessary to avoid the BoNT spreading to neurovascular structures. There are no known contraindications to its use.[24] Possible limitations are the images are operator dependent, it has a learning curve and needs training, and difficulty in visualizing the deeper structures in the obese.

In the present case scenario, we injected BoNT under ultrasound guidance into the affected muscles, which led to a decrease in the VAS score. This line of treatment was decided based on the advantages of USG-guided BoNT injections over routine blind procedures that have been enumerated earlier.

 Conclusion



Painful spasms in bilateral paretic limbs in a patient operated for meningomyelocele were successfully managed by USG-guided intramuscular injection of BoNT. We propose that USG guidance might be an excellent technique for BoNT injection in the treatment of chronic pain. Although there are previous case reports of BoNT being used for chronic pain, we found no literature of botulinum use in a patient with paraparesis who was operated for meningomyelocele.

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