Neurotomy as a treatment for intractable triple flexion spasms of the lower limb in patients with spinal cord injury: Two case reports

Abstract

Spasticity is a frequent complication after spinal cord injury (SCI). A subtype consists of flexion spams of the lower limb. There are several treatment options, ranging from physical therapy over oral pharmacological interventions, injection techniques, to intrathecal baclofen and surgery. The purpose is to describe two cases of SCI patients who underwent a neurotomy of radix L2 and the sciatic nerve as a minimally invasive treatment for flexion spasms in the lower limb. Case report. We describe two men, 38 and 40 years old who suffered a traumatic spinal cord injury T4 AIS A, respectively 13 and 14 years earlier. Despite oral pharmacological and intrathecal baclofen treatment (ITB), flexion spasms were insufficiently controlled in both patients. An attempt to block these spasms was made by injecting 100 Units of onabotulinumtoxinA in the psoas muscle in patient 1. This injection provided a clear relief of spasms for 3 weeks. As we aimed for a more permanent cost-effective treatment, a nerve block with 0.5 mL Chirocaïne 0.5% of radix L2, was performed in both patients to mimic neurotomy. The positive results supported the decision to perform a minimal invasive extraforaminal L2 neurotomy. Preoperatively patient 1 scored 3 on frequency and 3 on severity on the Penn Spasm Frequency Scale (PSFS) in comparison to 2 + 1 postoperatively. Patient 2 scored 4 + 3 preoperatively, 3 + 1 postoperatively and 2 + 3 after 2 years. Both patients regained functionality and comfort. Patient 1 wanted to stop ITB-therapy to scuba-dive to greater depths. As spasms in the hamstrings reappeared after lowering his ITB-dose, he received bilateral sciatic nerve block and subsequent selective neurotomy of hamstring branches of the sciatic nerve. 2 years postoperatively, without ITB-therapy he scores 1 + 2. A minimally invasive neurotomy is technically feasible and can be an efficient method for reducing intractable flexion spams in the lower extremities, after successful nerve block.