RU2454170C1 - Method of treating muscle spasticity in patients with vertebral and spinal cord injury - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurology, and can be used in treatment of muscle spasticity in patients with spinal cord injury. For this purpose botulotoxin is introduced into iliolumbar muscle under control of X-ray computer tomography. Introduction of preparation is performed by dorsal access into proximal part of iliolumbar muscle at the level of LII-LIII vertebrae, 2-3 cm more laterally than spinous process. Depth of introduction is 8-10 cm.

EFFECT: method makes it possible to ensure efficient relief of local spasticity of iliolumbar muscle with absence of botulotoxin effect on other groups of muscles due to accurate introduction of preparation into definite region of said muscle.

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Description

The present invention relates to medicine, in particular to methods for treating spasticity due to injuries and diseases of the central nervous system.

As a prototype, a method of treating patients with a spinal cord injury was chosen, which consists of introducing botulinum toxin into the distal ileo-lumbar muscle 3-4 cm lateral to the femoral artery and 1-2 cm distal to the inguinal ligament to a depth of 2-4 cm (see Wolfgang Jost / Pictorial Atlas of Botulinum Toxin Injection, UK, Quintessence books, 2008, p. 103).

However, the introduction of the drug into the distal part of the muscle is unsafe due to the close location of the neurovascular bundle. In addition, the spastic state of the iliopsoas muscle causes flexion and rotation of the trunk, limiting the ability to maintain vertical posture and movement, therefore, the introduction of the drug into the distal part of the muscle does not allow correction of the resulting deformation of the trunk due to the small amount of muscle mass in the projection of the injection point of botulinum toxin.

The task of the invention is to ensure the safety of the drug and increase the effectiveness of the procedure.

The problem is solved due to the fact that the introduction of botulinum toxin is performed by dorsal access to the proximal part of the iliopsoas muscle at the level of the LII-LIII vertebra, 2-3 cm lateral to the spinous process to a depth of 8-10 cm under the control of X-ray computed tomography.

A method for the treatment of muscle spasticity in patients with spinal cord injury is as follows. An x-ray computed tomography of the lumbar spine is performed, the point of botulinum toxin injection into the ileum-lumbar muscle is determined at the level of the LII-LIII vertebra, 2-3 cm lateral to the spinous process to a depth of 8-10 cm. At this point, the proximal part of the ileum-lumbar muscle is controlled CT injected drug.

Clinical example 1. Patient S., 20 years old, was admitted for treatment to the rehabilitation department of the NNIIIT on 01.01.2008 with a diagnosis of vertebral-spinal cord injury: comminuted comminuted fracture of the C6 vertebra with contusion and compression of the spinal cord, late period, spastic tetraparesis, neurogenic bladder, heterotopic ossificates of the left thigh; condition after operations - anterior decompression of the spinal cord, spinal fusion with an allograft and an implant made of nickel-titanium.

Complaints upon admission of a violation of self-care, mobility, difficulty maintaining a vertical posture and movement due to painful contractions of the muscles of the back and lower extremities, pain in the left thigh.

Anamnesis. Injury received while diving into a reservoir on 06.16.06. Operated on 06/21/06: decompression corpectomy of the C6 vertebra and adjacent discs, anterior interbody fusion with an allograft and a nickel-titanium implant. In the postoperative period, strength in the upper extremities increased, active movements in the legs, voluntary urination and defecation appeared. In 2006-2007, he received courses of rehabilitation treatment in rehabilitation clinics with a positive trend in the regression of motor disorders, pelvic disorders, and improved self-care.

Objective examination data. C-shaped scoliotic deformity in the thoracolumbar spine II st. Pronounced tension of the long muscles of the back in the lower thoracic and lumbar regions. Palpation of the spine is painless. There is no pathological mobility. Tilts "back", "left" in the lumbar are impossible due to spastic muscle tension, "forward" and "right" are limited to 50% of the norm. When you try to take a vertical position, an irresistible bending of the body occurs with a left turn. Reflexes with the triceps, biceps muscles of the shoulder and brachioradius muscle are normal, d = s. Knee and Achilles reflexes are elevated, d = s, clonus of the feet and patella. Abdominal reflexes are absent, cremasteric and anal reflexes are preserved. Muscle tone in the upper extremities is slightly increased (2 points according to Ashfort), muscle tone in the lower extremities is significantly increased (up to 4 points) in the distal regions and roughly in the proximal. Significantly limited internal and external rotation, adduction and abduction in the left hip joint. Active movements in the remaining joints of the upper and lower extremities in full. The motor score according to ASIA of the key muscles of the upper extremities is 46, the lower extremities - 42 points. Movement is possible in a wheelchair.

Self-assessment was carried out using the Functional Rating Scale for patients with spinal cord injury. The points on the points of the scale were: moving in bed - 23, eating - 30, moving within the room - 53, moving - in a wheelchair 75, personal hygiene - 34, dressing - 34, performing social skills - 41 points. Walking using support means is not possible.

Botulinum toxin was injected with dorsal access into the proximal part of the iliopsoas muscle on the left at the level of the LII-LIII vertebra, 2-3 cm lateral to the spinous process to a depth of 8 cm.The procedure was performed to reduce the muscle tone of the iliopsoas muscle and to allow independent walking. The introduction was carried out under the control of computed tomography.

Dynamics. The patient felt the effect seven days after the introduction of botulinum toxin, the completely violent flexion of the body when walking disappeared after 14 days and no longer resumed within two years of observation.

Objective examination data: scoliosis is absent in an upright position, movements in the lumbar spine in all directions make up 50% of the norm. The patient can be upright for up to one hour, walk with support on "Canadian" clubs up to 400 meters without rest. Self-service assessment in dynamics demonstrated the achievement of the maximum possible indicators on all points: moving in bed - 25, eating - 30, moving within a room - 60, moving - 75, personal hygiene - 35, dressing - 40, performing social skills - 45 points. Currently, the patient moves with the support of a cane. The quality of his life has significantly improved - the patient is fully self-serving, mobile.

Clinical example 2. Patient P., 24 years old, was admitted for treatment to the rehabilitation department of the NNIIIT on September 13, 2010 with a diagnosis of spinal cord injury: compression fracture of the C5 vertebra with contusion and compression of the spinal cord, late period, spastic tetraparesis, neurogenic urinary bladder, postoperative condition: anterior decompression of the spinal cord, spinal fusion with an allograft and a cage.

Complaints upon admission to limiting movements in the upper and lower extremities, impaired self-care, mobility, difficulty maintaining a vertical posture and the inability to move due to painful contractions of the muscles of the back and lower extremities.

Anamnesis. Injury received while diving in a reservoir 07/24/08. Operated on 07/25/08: decompression of the spinal cord, anterior interbody fusion with an allograft and cage. In the postoperative period, strength in the upper extremities increased, active movements in the legs, voluntary urination and defecation appeared. In 2008-2009, he received courses of rehabilitation treatment in the rehabilitation department with a positive trend in the regression of motor disorders, pelvic disorders, and improved self-care. In 2008, in order to reduce the tone of the iliopsoas muscle, botulinum toxin was injected into the distal part of the muscle according to the well-known method (WolfgangJost, 2008) - the dynamics of spasticity changes was minimal (the tone of the hip flexors was 4 points according to Ashfort).

Objective examination data. C-shaped scoliotic deformity in the thoracolumbar region, III tbsp. Pronounced tension of the long muscles of the back in the lower thoracic and lumbar regions. Palpation of the back muscles is painful. There is no pathological mobility. Tilts "back", "left" in the lumbar are impossible due to spastic muscle tension, "forward" and "right" are limited to 75% of the norm. When you try to take a vertical position, an irresistible bending of the body occurs with a left turn. The position of "lying on his stomach" takes with difficulty due to involuntary bending of the trunk and left thigh. Reflexes with the triceps, biceps muscles of the shoulder and brachioradius muscle are normal, d = s. Knee and Achilles reflexes are elevated, d = s, clonus of the feet and patella. Abdominal reflexes are absent, cremasteric and anal reflexes are preserved. Muscle tone in the upper extremities is slightly increased (2 points according to Ashfort), muscle tone in the lower extremities is significantly increased (up to 4 points) in the distal sections and roughly (5 points) in the proximal. Significantly limited internal and external rotation, adduction and abduction in the hip joints, more to the left. Active movements in the remaining joints of the upper and lower extremities in full. The motor score according to ASIA of the key muscles of the upper extremities is 40, the lower extremities - 36 points. Movement is possible in a wheelchair.

Self-assessment was carried out using the Functional Rating Scale for patients with spinal cord injury. The points on the points of the scale were: moving in bed - 19, eating - 28, moving within the room - 24, moving - in a wheelchair 50, personal hygiene - 28, dressing - 20, performing social skills - 34 points. Walking using support means is not possible.

The introduction of botulinum toxin was made by dorsal access to the proximal part of the iliopsoas muscle at the level of the LII-LIII vertebra, 2-3 cm lateral to the spinous process to a depth of 10 cm.The procedure was performed to reduce the muscular tone of the iliopsoas muscle and to enable independent walking. The introduction was carried out under the control of computed tomography.

Dynamics. The patient felt the effect eight days after the introduction of botulinum toxin: back pain stopped, the completely violent flexion of the trunk when taking a vertical posture disappeared after 20 days and did not resume within four months of observation.

Objective examination data: in a vertical position scoliosis of 0/1 degree, movements in the lumbar spine in all directions make up 50% of the norm. The patient can be upright for up to one hour, walk with support on a walker up to 100 meters with rest. Self-service assessment in dynamics demonstrated an increase in indicators for all items:

moving in bed - 22, eating - 30, moving within the room - 40, moving in a wheelchair - 60, personal hygiene - 31, dressing - 30, performing social skills - 39 points.

The proposed method for treating muscle spasticity in patients with spinal cord injury with dorsal access under the control of X-ray computed tomography is safe and effective. So, in the case when the spasticity of the muscle limited the patient’s rehabilitation capabilities, the introduction of botulinum toxin made it possible to remove the local spasticity of the iliopsoas muscle in the absence of influence on other muscle groups, and to improve the patient’s self-care and mobility.

The proposed method is simple, affordable and requires only a neurologist with specialization in botulinum therapy and x-ray computed tomography.

Claims (1)

A method of treating muscle spasticity in patients with a spinal cord injury, which involves administering botulinum toxin to the ileum-lumbar muscle, characterized in that the drug is administered by dorsal access to the proximal part of the iliopsoas muscle at the level of the LII-LIII vertebra, by 2-3 cm lateral to the spinous process to a depth of 8-10 cm under the control of x-ray computed tomography.