4. How do you treat spasm? Should we do tenotomies?
Answer:
Spasticity is common in patients with spinal cord injuries. It is believed that loss of supraspinal inhibitory pathways is the mechanism of spasm in these patients. The incidence varies with the level of injury. The more proximal the lesion, the higher the incidence of spasm: near 100% in the cervical region, 75% in the thoracic region, and 50% in the thoracolumbar region. If spasm is not eliminated prior to any surgical procedure, the pressure sore will inevitably recur.
Medications are available to reduce spasm. One option is Valium, 10 mg, given every 8 hours or in combination with baclofen. Baclofen is usually started at 10 mg every 6 hours and may be increased to as much as 25 mg every 6 hours. Also available is dantrolene, 25 mg every 12 hours. Some caution should be used because hepatic toxicity has been reported, and serum transaminases should be monitored. If patients fail to respond to medical therapy, surgical intervention may be indicated.
The surgical management of spasm includes peripheral nerve blocks, epidural stimulators, baclofen pumps, and rhizotomy. Rhizotomy can be surgical or medical, the latter using subarachnoid blocks with phenol (phenol rhizotomy). Since clinical improvement can occur up to 18 months after injury, surgical rhizotomy is not performed during this period. In addition, some spinal cord lesions are not complete, and rhizotomy must be used with care to avoid exacerbating the injury.
In patients with longstanding denervation, joint contractures may occur. Unless an aggressive program of physical therapy is initiated early, these patients will have a significant problem. Contractures occur because of tightening of both muscles and joint capsules. Because the hip flexors are so strong, contractures are common in this region, contributing to the formation of trochanteric, knee, and ankle ulcers. Patients with significant hip and/or knee contractures should have every attempt made to treat the contractures prior to surgery. If not, the pressure sores are sure to recur. If the patient is placed in an alternative position, then the pressure will only be redistributed, and a different area will be at risk for breakdown. If physical therapy is unsuccessful at relieving the contractures, tenotomies are performed. In mobile, wheelchair bound patients, however, releasing the hip contractures can lead to a flail extremity, which may interfere with transferring.