79 Spasticity after Cord Injury

Remi Nader

Clinical Presentation

A 64-year-old man presents 6 years after having sustained a motor vehicle accident.

The patient is a recovered C4 partial quadriplegic who underwent a C4 corpectomy and C5–6 anterior cervical diskectomy and fusion about one year ago.

He now presents with some upper extremity pain and bilateral shoulder pain.

He has some persistent spasticity in both upper and lower extremities, unsteady gait, and difficulties with bladder control.

Hyperreflexia and muscle atrophy are seen diffusely on examination.

He has been taking baclofen, tramadol, and diazepam, but the effect of the medications seems to have worn offdespite a recent increase in dosage.

Magnetic resonance imaging (MRI) of the entire spine is done, and the only pertinent positive findings are shown in Fig. 79.1.

Fig. 79.1 Magnetic resonance imaging of the cervical spine: (A) T2-weighted images with midsagittal section and (B) a xial sec tion through C4–5 level.

Questions

Interpret the MRI scan.
How do you manage the syrinx?
What are some other causes of spasticity?
Describe a grading system for spasticity.
What are some other medical options to treat spasticity in this patient?
Name five surgic al options commonly employed to treat spasticity.
What are the main complications of pump placements?
What are the main selection criteria for placement of baclofen pumps?

Answers

Interpret the MRI scan.

T2-weighted sagittal image (Fig. 79.1A) shows a previous C3 to C6 anterior diskectomy and fusion.

Cord atrophy at the level of the upper cervical cord is noted.

A small syrinx is seen at the level of C4–5, but it is not causing any pressure on the cord or any compression of neural elements.

Cerebrospinal fluid (CSF) spaces are wide open around the spinal cord.

There is some straightening of the normal lordosis.
How do you manage the syrinx?
- The syrinx is managed expectantly.
- No treatment for the syrinx is needed as it does not cause any pressure on the spinal cord or neural elements.
What are some other causes of spasticity?
- Multiple sclerosis
- Cerebral palsy
- Spinal dysraphism
- Amyotrophic lateral sclerosis
- Traumatic brain injury
- Stroke
Describe a grading system for spasticity.
- Ashworth grading system^1,2:
  1. No increase in tone
  2. Slight increase in tone with small “catch” when moving affected limb
  3. More marked increase in tone with easy passive movements
  4. Significant increase in tone with hard passive movements
  5. Rigid affected part
What are some other medical options to treat spasticity in this patient?
- Dantrolene³
  - Decreases calcium influx in sarcoplasmic reticulum
  - Decreases muscle contractions
- Progabide³
  - GABA A and B activator
Name five surgical options commonly employed to treat spasticity.^1–3
- Baclofen and morphine pumps⁴
- Electrical stimulation via epidural electrodes
- Selective posterior rhizotomies⁵
- Intramuscular phenol neurolysis
- Myelotomies
- Stereotactic thalamotomy
What are the main complications of pump placements?
- Mechanical⁴
  - Underinfusion
  - Catheter occlusion, kinking, dislodgment, break
- Wound problems⁴
  - Erosion of pocket
  - Infection
  - Local pain
  - Seroma/hematoma
  - CSF collection
What are the main selection criteria for placement of baclofen pumps?
- Selection criteria for baclofen pump are described below⁴:
  - Age 18 to 65, able to give informed consent
  - Severe chronic spasticity >6 months
  - Spasticity refractory to oral medications
  - Ashworth scale at least 3
  - No CSF block
  - Positive response to intrathecal baclofen test dose
  - No implantable device
  - Nonpregnant patient
  - No allergy to baclofen
  - No history of stroke, renal insufficiency, severe liver or gastrointestinal disease