Heather W. Walker

Botulinum toxin injection techniques for the management of adult spasticity.

Spasticity is often experienced by individuals with injury or illness of the central nervous system from etiologies such as stroke, spinal cord injury, brain injury, multiple sclerosis, or other neurologic conditions. Although spasticity may provide benefits in some patients, it more often leads to complications negatively impacting the patient. Nonpharmacologic treatment options often do not provide long‐term reduction of spasticity, and systemic interventions, such as oral medications, can have intolerable side effects. The use of botulinum neurotoxin injections is one option for management of focal spasticity. Several localization techniques are available to physicians that allow for identification of the selected target muscles. These methods include anatomic localization in isolation or in conjunction with electromyography guidance, electrical stimulation guidance, or ultrasound guidance. This article will focus on further description of each of these techniques in relation to the treatment of adult spasticity and will discuss the advantages and disadvantages of each technique, as well as review the literature comparing the techniques.

Systematic literature review of abobotulinumtoxinA in clinical trials for adult upper limb spasticity.

Objective The aim of this study was to elucidate clinical trial efficacy, safety, and dosing practices of abobotulinumtoxinA (ABO) treatment in adult patients with upper limb spasticity (ULS). Methods A systematic literature review was performed to identify randomized controlled trials and other comparative clinical studies of ABO in the treatment of adult ULS published in English between January 1991 and January 2013. Medical literature databases (PubMed, Cochrane Library, and EMBASE) were searched, and a total of 295 records were identified. Of these, 12 primary publications that evaluated ABO for the management of ULS were included in the final data report. Synthesis Total ABO doses ranged between 500 and 1500 U for ULS. Most of the studies in ULS showed statistically significant benefits (reduction in muscle tone based on Ashworth score) of ABO vs. placebo. Statistical significance was reached for most evaluations of spasticity using the Modified Ashworth Scale. Statistically significant effects on active movement and pain were demonstrated, albeit less consistently. ABO was generally well tolerated across the individual studies; most adverse events reported were considered unrelated to treatment. Adverse events considered associated with ABO treatment included fatigue, tiredness, arm pain, skin rashes, flu-like symptoms, worsening of spasm, and weakness. Conclusions On the basis of data extracted from 12 randomized clinical studies, a strong evidence base (9/12 studies) exists for the use of ABO to reduce ULS caused by stroke.

Systematic Literature Review of AbobotulinumtoxinA in Clinical Trials for Lower Limb Spasticity

AbstractTo elucidate clinical trial efficacy, safety, and dosing practices of AbobotulinumtoxinA (ABO) treatment in adult patients with lower limb spasticity.A systematic literature review was performed to identify randomized controlled trials of ABO in the treatment of adult lower limb spasticity.Of the 295 records identified, 6 primary publications evaluated ABO for the management of lower limb spasticity of various etiologies and were evaluated. Total ABO doses ranged between 500 and 2000 U for lower limb spasticity, depending on the muscles injected. All studies in lower limb spasticity showed statistically significant reduction in muscle tone based on Modified Ashworth Scale of ABO versus placebo. Significant effects on active movement and pain were demonstrated albeit less consistently. ABO was generally well tolerated across the individual studies; most adverse events reported were considered unrelated to treatment. Treatment-related adverse events included but not limited to fatigue, local pain at injection site, hypertonia, dry mouth, weakness of the noninjected muscle, abnormal gait, and urinary tract infection.These data from 6 randomized clinical studies provide the beginnings of an evidence base for the use of ABO to reduce lower limb spasticity. Ongoing studies in this area will add to this evidence base.

Efficacy and Safety of AbobotulinumtoxinA (Dysport) for the Treatment of Hemiparesis in Adults With Upper Limb Spasticity Previously Treated With Botulinum Toxin: Subanalysis From a Phase 3 Randomized Controlled Trial

To assess the efficacy and safety of abobotulinumtoxinA in adults with upper limb spasticity previously treated with botulinum toxin A (BoNT‐A).

Poster 203 Systematic Literature Review of AbobotulinumtoxinA in Randomized, Controlled Clinical Trials for Adult Lower Limb Spasticity.

for possible paraneoplastic etiology of diffuse demyelinating polyneuropathy. Conclusions: Paraneoplastic diffuse demyelinating peripheral neuropathy is an uncommon cause of progressive weakness in the setting of malignancy and should be considered in the differential diagnosis of otherwise unexplained weakness in individuals with cancer. Acute inpatient rehabilitation can also help improve functional outcomes. Level of Evidence: Level V

Poster 308 Improvement of Spasticity, Active Movements and Active Function after Repeated Injections of AbobotulinumtoxinA (Dysport) in Adults with Spastic Paresis in the Upper Limb: Results of a Phase III Open-Label Extension Study

Disclosures: George Francis: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Sacral neoplasms often present as large masses refractory to chemotherapy and radiation, requiring a sacrectomy. Multiple sacral nerve roots and vessels may be compromised, resulting in immobility, pressure ulcers, orthostasis, and neurogenic bowel and bladder. Our goal is to review the rehabilitative needs and outcomes post-sacrectomy via two inpatient case presentations. A 58-year-old woman with a solitary fibrous tumor underwent an en bloc resection involving a subtotal sacrectomy from S2 to coccyx, an L5-S1 laminectomy, ligation of her bilateral S2-5 nerve roots, neurolysis of bilateral S1 and sciatic nerve roots, and bilateral gluteal flap closures. Post-operatively, activity precautions included no walking initially and no hip flexion for two weeks. She required tilt table treatments and was ambulating at post-op Day 8. The rehabilitation challenges included: training on the management of her neurogenic bowel and bladder, controlling her neuropathic and somatic pain, and mobilizing her despite the hip restrictions. The second case includes a 67-year-old male with a sacral chordoma who underwent a two-stage surgery. Stage one involved preparation for the en bloc resection of the sacral tumor. One day later, stage two involved an L5-S1 laminectomy, ligation of the S2-5 nerve roots, en bloc resection of the sacral, bilateral S1 root and sciatic neurolysis, and bilateral gluteus muscle flaps for closure. His rehabilitation challenges included: severe protein malnutrition, orthostatic hypotension, delayed wound healing, fluid collection, uncontrolled pain, and neurogenic bowel and bladder. Setting: Tertiary cancer center. Results: Highly functional outcomes are seen in these patients, including independent bowel and bladder management and return to pre-operative ambulatory status. Discussion: Rehabilitation interventions for these patients include: medical stabilization, pain management, wound healing, transfers, mobility, and neurogenic bowel and bladder management. Conclusions: These are highly complex surgical patients with extensive rehabilitation needs that require the management by a physiatrist. Level of Evidence: Level V

Spinal cord injury following operative shoulder intervention: A case report.

Abstract Context Cervical myelopathy is a spinal cord dysfunction that results from extrinsic compression of the spinal cord, its blood supply, or both. It is the most common cause of spinal cord dysfunction in patients greater than 55 years of age. Findings: A 57-year-old male with right shoulder septic arthritis underwent surgical debridement of his right shoulder and sustained a spinal cord injury intraoperatively. The most likely etiology is damage to the cervical spinal cord during difficult intubation requiring multiple attempts in this patient with underlying asymptomatic severe cervical stenosis. Conclusion Although it is not feasible to perform imaging studies on all patients undergoing intubation for surgery, this patients outcome would suggest consideration of inclusion of additional pre-surgical screening examination techniques, such as testing for a positive Hoffmans reflex, is appropriate to detect asymptomatic patients who may have underlying cervical stenosis.

Development of hydronephrosis secondary to poorly managed neurogenic bowel requiring surgical disimpaction in a patient with spinal cord injury: A case report

Abstract Context Case of an adult patient with paraplegia managing neurogenic bladder with intermittent catheterization who was not performing a standard bowel program for management of neurogenic bowel. Findings Patient presented with increasing spasticity, fecal incontinence, and abdominal pain and ultimately was hospitalized for management. Imaging revealed massive fecal impaction, resulting in ureteral obstruction and hydronephrosis. Despite repeated aggressive bowel regimens, serial abdominal X-rays showed continued large stool burden. Ultimately surgical intervention was required to evacuate the colon and subsequently the hydronephrosis resolved. Conclusion/Clinical relevance This case illustrates the importance of proper management of neurogenic bowel, as significant medical complications, such as hydronephrosis can occur with poorly managed neurogenic bowel.

Poster 505 Spinal Cord Infarction Following Right Sided L3-4 Transforaminal Epidural Steroid/Anesthetic Injection: A Case Report

for each muscle CSA measurement. Results: Reliability and precision of the CSA measurement for each muscle was high for both groups. The ICC ranged 0.905 to 0.984. The SEM of the ECR CSA measurements were, SCI 0.11cm, AB 0.23cm, and the ED CSA were SCI 0.13cm, AB 0.29cm. The MDC of the ECR CSA measurements were, SCI 0.16cm, AB 0.33cm, and the ED CSA were SCI 0.19cm, AB 0.41cm. Conclusions: The current study has established excellent reliability for the use of ultrasound in evaluating muscle CSA in individuals with SCI. The findings are highly relevant to this population considering the magnitude of skeletal muscle atrophy following SCI. The current study will help further investigations of adaptations of the musculoskeletal system following SCI.

Poster 437 Nontraumatic Spinal Cord Injury Secondary to Anterior Spinal Infarction in a Patient Taking Sildenafil for Erectile Dysfunction: A Case Report

wheelchair mobility. However, ongoing truncal instability has resulted in a decline in functional mobilities. Program Description: Charcot spine is a degenerative arthropathy due to analgesia below the level of injury in chronic spinal cord injury and results in joint destruction and instability. The most common clinical findings are back pain, spinal deformity, and audible sounds with motion. This case report presents a patient with chronic spinal cord injury and with progressively ascending sensory loss as the sole presentation of Charcot arthropathy. Setting: Acute inpatient rehabilitation. Results: Computed tomography and magnetic resonance imaging of the spine was interpreted as L2-L3 diskitis and/or osteomyelitis, however, with repeated computed tomographic–guided needle biopsies, there was no evidence of infection or neoplastic pathology. On further investigation, the above imaging was noted to have bony debris, and subsequent radiographic flexion and extension views showed lumbar vertebral shift. Given imaging findings and the above exclusions, a diagnosis of Charcot arthropathy was made. We hypothesize that spinal cord traction in the setting of the above vertebral destruction led to sensory deficits. It was recommended that the patient undergo spinal stabilization via fusion and instrumentation of involved vertebrae. Discussion: The limited descriptions of this disease, relative to other diagnoses prevalent in the spinal cord population, lends this process to be underdiagnosed to a certain extent. In this case report, there was a delay in diagnosis secondary to an unusual presentation of cephalad sensory loss and imaging findings that initially suggested an underlying infectious process. Conclusions: The isolated symptom of cephalad sensory loss, although nonspecific, may aid in making the diagnosis with associated radiographic findings, particularly in the setting of benign infectious and neoplastic workup. Such early recognition of Charcot spinal arthropathy may help expedite surgical intervention and subsequently improve patient functional status.