Transcript Spasticity - Surgical Therapies

Spasticity
Surgical Therapies
Part 6 of 6
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Spasticity Slide Library Version 2.3 - All Contents Copyright © WE MOVE 2001
Intrathecal Baclofen
• Delivered via an implantable,
programmable pump
• For management of severe spasticity due to:
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Cerebral palsy
Stroke
Brain injury
Spinal cord injury
Demyelinating disease
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Potential Benefits
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Decrease spasticity
Prevent or decrease incidence of contractures
Decrease pain associated with spasticity
Ease rehabilitation
Improve mobility
Improve quality of life
Multidisciplinary health care team involved in care and goal setting
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Intrathecal Bacofen: Pharmacology
• GABAb agonist
– Decreases interneuronal firing at the spinal cord level
• Oral dose of 60 mg  lumbar concentration of
24µg/L
• Intrathecal infusion of 600 µg/day  lumbar
concentration of 1240µg/L
– cervical concentration approximately 1/4th lumbar
• Most patients maintained on 300-800µg/day
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Intrathecal Baclofen Therapy:
Programmer
ITB: Overview of System
• Pump controlled via radio-telemetry link
from an external programmer
• Allows control of rate, mode, and pattern
of infusion
• Dosage titration, schedule revision
• Preservative-free, stable in pump for
up to 90 days
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The ITB Pump
Patient Selection
• Indicated for patients with severe spasticity
in whom oral medications have proven
ineffective
• Age of 3-4 or older and at least
30-35 pounds
• Responsive to the trial dose
• Patient and family have commitment
to program
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Precautions and Contraindications
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Impaired renal function
Pregnant or breastfeeding
History of autonomic dysreflexia
Psychotic disorder
Use of depressants or alcohol
History of uncontrolled seizures
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Screening Procedure
• Bolus dose of 50-100 µg intrathecal
baclofen via lumbar puncture
• Assessments performed
– spasticity, underlying athetosis, contracture
– side effects
– vital signs
• Patient must remain supine for 24 hours
• Response does not mirror effects of ITB
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Surgical Procedure
• Pump implanted in a subcutaneous
or subfascial pouch in the abdomen
just under the rib cage
• Catheter is placed in the lumbar spine
(usually L3 or L4) with a 15 or 16 gauge
Touhy needle
• Tip placement at the T10-T11 level
is confirmed using fluoroscopy
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Pump Placement
Post-Operative Care
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4-7 day hospital stay
1-3 days supine
Pain medications delivered, if necessary
PT and OT begin
Patient and family educated regarding
wound care and surveillance for
complications
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Monitoring the Dose
• Clinical goals include:
– Maintain muscle tone at a level which permits
maximal functional ability
– Decrease the frequency and severity of spasms
• If spasticity suddenly worsens, reassess
patient before increasing the dosage
– infection, bowel or bladder problems
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Maintenance Phase
• Dose adjustments performed in office
using portable computerized programmer
via a telemetry wand
– Adjustable parameters include: drug concentration,
reservoir status, alarms, infusion rate, and pattern,
e.g., more at night and less during school
• Dose may be increased by up to 15%
on each occasion on a weekly basis
• Temporal adjustments for functional needs
• Adjustments in adjunctive therapies
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Refill Interval
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Usually every 6-12 weeks
Maximum interval is 90 days
Set alarm at or above 2.0 cc
Schedule refill before alarm date
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Side Effects
Side effects are similar to oral medication and
may be minimized by adjusting dose:
• Hypotonia
• Somnolence
• Nausea/vomiting
• Headaches
• Dizziness
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Risks and Complications
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Catheter and procedural complications
Infection
Seizure risk if pump malfunctions
Overdose potential
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Respiratory depression
Loss of consciousness
Reversible coma
Death
• May be associated with a worsening of scoliosis
in some patients
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Selective Dorsal Rhizotomy
• Interruption of reflex arc
• Sectioning of afferent nerve rootlets
L-2 to S-2
• EMG guidance, selected roots only
Treatment goals: improve gait and mobility;
facilitate care; prevent contractures
or bony deformities
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Patient Selection
• Pure spasticity
• No evidence of dystonia (fluctuating tone)
or rigidity (constant resistance to force)
• No evidence of truncal hypotonia
• Good head control
• Best age is between 4 and 6
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Exclusion Criteria
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Spasticity of spinal cord origin
Athetosis
Rigidity
Poor trunk control
Severe weakness
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Surgical Procedure
• Midline lumbar incision
• Laminae are reflected but not resected
• Dura is opened to expose nerve rootlets
from L1-S2
• Motor responses monitored by placing needle
electrodes into quadriceps, adductors, hamstrings,
gastrocnemius and tibialis anterior muscles
• Electrode placed in anal sphincter
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Surgical Procedure, cont’d
• The correct level is found by identifying the
largest nerve root (S1)
• The dorsal roots are identified, dissected into
individual nerve rootlets and stimulated
– normal response is decremental over 1 second
of stimulation
– abnormal response can be incremental
– some controversy regarding utility of EMG
identification
• If the response is abnormal, the rootlet is cut
• This sequence is completed at each level
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Surgical Procedure, cont’d
• Usually selective
• 25-40% of nerve rootlets are cut
at each level
• Lamina replaced
– protect the dura
– theoretically decrease the incidence of lumbar
lordosis from continued anterior spinal growth
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Post-Operative Management
• Pain management very important
• Physical therapy
– Intensive PT within one week
– 3-5 times per week depending on the center
• Ambulatory patients begin walking
as soon as possible
• Strengthening is a key component
after rhizotomy
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Single-Blind Trials
• Steinbok et al., 1997
– SDR plus PT superior to PT alone
– Gross Motor Function Measurement, spasticity, ROM
• Wright et al., 1998
– SDR plus PT superior to PT alone
– GMFM, knee and ankle tone, ankle dorsiflexion, foot-floor contact
• McLaughlin et al., 1998
– No functional benefit to SDR plus PT vs. PT alone
– No differences in GMFM
– Spasticity reduced in the SDR group
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DREZ-otomy
• Afferent fibers divided at the
Dorsal Root Entry Zone
• Penetrates ventrolateral aspect of DREZ
• Destroys nociceptive and myotatic fibers
• Primarily indicated for severely affected
patients
• Limited experience
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Orthopedic Surgery
• Increase function by:
– maintaining appropriate length of muscles via
musculotendinous lengthenings
– providing power via tendon transfers
– improving the mechanics of gait via rotational
osteotomies
– providing stability via selective joint fusions
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Effect on Spasticity
• Spasticity reduction rationale
– Lengthening of the tendon may disrupt the
Golgi tendon bodies within the tendon which
inhibits the stretch response
– An overall shortening of the sarcomeres after
tendon lengthening alters the stretch on the
intrafusal stretch receptors in muscle
– Overall weakness of the muscle contributes
to the decrease in observable spasticity
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Musculotendinous Procedures
• Lengthening of the tendon
– Tendo Achilles lengthening
– Hip adductor tenotomy
• Lengthening of the musculotendinous
junction or fascia
– Strayer, Vulpius, or Baker lengthenings
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Tendon Transfers
• Spastic muscles may be weakened and
their spasticity may be utilized to perform
a different function.
• Common targets:
– Rectus femoris to hamstrings for stiff-knee gait
– Split anterior or posterior tibial tendon transfers
for varus feet
– Flexor carpi ulnaris transfer for wrist flexion
deformity
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Bony Surgery for
Rotational Abnormalities
• Fixed rotational abnormalities contribute
to abnormal stress on the muscle
(lever arm dysfunction)
– Surgeries designed to improve these problems
include:
• Varus derotational osteotomies of the femur
• Tibial and fibular osteotomies
• Calcaneal osteotomies for severe pes valgus
(flat foot)
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Post-Operative Management
after Musculoskeletal Surgery
• Short or no immobilization after surgery
• Patient begins motion immediately
• Immediate PT/OT, especially in tendon
transfers
• Early gait training
• Short braces, e.g., AFOs
– fixed, articulated or dynamic
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The Spasticity Slide Set Faculty
Spasticity Slide Library Version 2.3 - Updated September, 2001
• Henry G. Chambers, MD
Children's Hospital and Health
Center
San Diego, California
• Lauren Seeberger, MD
Medical Co-Director, Movement
Disorder Center
Colorado Neurological Institute
Englewood, Colorado
• Jean-Michel Gracies, MD, PhD
Assistant Professor of Neurology
Mount Sinai School of Medicine • Chris O'Brien, MD
New York, New York
Vice President Medical Affairs
Elan Pharmaceuticals
South San Francisco, CA
• Judy Leach, P.T.
Physical Therapy Consultant
San Diego, CA
• David M.Simpson, MD
Associate Professor of
• Patricia Nance, MD, FRCPC
Neurology
Associate Professor in Residence
Director, Clinical
University of California Irvine
Neurophysiology
Orange, CA
Mount Sinai School of Medicine
New York, New York
Original Contributing Authors
Spasticity Slide Library originally produced and distributed by WE MOVE 1999
• Kathleen Albany, P.T., M.P.H.
Physical Therapy Consultant
Mahwah, NJ
• W. Zev Rymer, M.D.
Rehab Institute of Chicago
Chicago, IL
• Judith Blazer, M.S.
Executive Director, WE MOVE
New York, NY
• Saud Sadiq, M.D.
Department of Neurology
St. Luke's Roosevelt Medical
Center
New York, NY
• Mitchell F. Brin, M.D.
Past-President and Founder, WE
MOVE
Professor, Department of
Neurology
Mount Sinai Medical Center
New York, NY
• Tom Cava, M.D.
Director Rehab, “PC-Rehab”
West Orange, NJ
• Karen Wauters, O.T.
Kessler Rehabilitation Center
East Orange, NJ