Preoperative Botulinum Toxin Research Articles

Minimally invasive Venetian blinds ventral hernia repair with botulinum toxin chemical component separation.

Laparoscopic ventral repair is safe, with lower wound infection rates compared with open repair. 'Venetian blinds' technique of plication in combination with mesh reinforcement, is totally intra-corporeal, with hernia defect and sac plication to reduce seroma formation. While laparoscopic suturing of the abdominal wall can represent a technical challenge, pre-operative botulinum toxin A (BTA) injections as an adjunct can assist. This study aims to demonstrate feasibility and efficacy of this technique in abdominal wall hernia repair, with BTA adjunct in midline hernias. A single-centre case series was conducted using minimally invasive 'Venetian blinds' technique for repair of complex ventral abdominal hernias. Twelve patients (seven midline, five non-midline) underwent repair (11 laparoscopic; one robotic). Midline hernias received BTA (200-300 units Botox) 4-6 weeks prior to surgery. Repairs were mesh-reinforced following fascial closure. Twelve (10 female, two male) patients, with a median age 72 years (range 31-83) and body mass index of 27.3 kg/m2 (range 22.8-61.7) were included. The median length of operation was 133 min (range 45-290) and length of hospital stay 3 days (range 1-28). To date there has been no recurrence of hernia. A single symptomatic seroma was treated with antibiotics and did not require mesh removal. One patient developed hospital-acquired pneumonia and pseudomembranous colitis. Minimally invasive 'Venetian blinds' technique has promising early results with both midline and non-midline ventral hernias. The addition of BTA is a novel and feasible combination for repair of midline ventral hernias.

Surgical effect and electrophysiological study of patients with hemifacial spasm treated with botulinum toxin or acupuncture before microvascular decompression

ObjectiveWe investigated patients with hemifacial spasm (HFS) who received a botulinum toxin (BT) injection or acupuncture before receiving microvascular decompression (MVD) to determine whether it affects the success rate of surgery. Abnormal Muscle Response (AMR) and Compound Motor Action Potential (CMAP) are commonly used as electrophysiological monitoring methods in surgery, and we will compare the differences between these patients in this regard. Patients and methodsA total of 539 patients with HFS underwent MVD treatment in our department between January 2014 and June 2017. Among them, 83 patients had received BT injection before surgery and were recorded as BT group. Eighty-three patients underwent acupuncture before surgery and were recorded as acupuncture group. Five patients received both BT injection and acupuncture before surgery and were recorded as mixed group. A total of 368 patients who had not received any treatment before surgery were recorded as simple MVD group. We calculated the immediate and long-term remission rates after surgery. AMR and CMAP monitoring were routinely performed during surgery. ResultsImmediate remission rate after surgery was 96.4% (80/83) in BT group, 100% (83/83) in acupuncture group, 100% (5/5) in mixed group, and 95.1% (350/368) in simple MVD group, and the immediate remission rate of BT group is significantly higher than that of simple MVD group (p = 0.04). Long-term remission rate: the remission rates of the four groups were 94.0% (78/83), 97.6% (81/83), 100.0% (5/5) and 92.7%(341/368), respectively, and there is no statistical difference between them (p > 0.05). The amplitude of one branch or several branches of CMAP on the affected side was lower than the healthy side in BT or acupuncture treatment patients. ConclusionsA preoperative BT injection or acupuncture treatment do not reduce the postoperative remission rate of HFS patients treated with MVD, and the amplitude of CMAP on the affected side was lower than the healthy side.

Limitations of Electromyography in the Assessment of Abdominal Wall Muscle Contractility Following Botulinum Toxin A Injection.

Purpose: Pre-operative botulinum toxin A (BTA) injection of the lateral obliques aims to facilitate the closure of large ventral hernia defects and decrease the risk of repair breakdown during the critical healing phase. The exact duration of post-operative BTA effect and top-up timing in cases at high risk of recurrence remains uncertain. This study was designed to assess the value of electromyography (EMG) in determining the appropriate time for BTA top-up.Methods: 56 patients underwent ventral hernia repair with pre-operative BTA infiltration of the lateral obliques. Eleven patients at high risk of recurrence considered suitable for BTA top-up were assessed post-operatively with both functional computed tomography (CT) and EMG. CT assessed segmental contractility of each muscle layer. Single-point EMG assessed the activity of individual muscle layers bilaterally in the anterior axillary line.Results: CT showed (i) variable contractility of anterior and posterior muscle segments prior to BTA injection; (ii) absent or incomplete muscle paralysis in over half of all segments; (iii) increased BTA effect on progress scans; and (iv) non-uniform pattern of change in BTA effect between the anterior and posterior muscle. EMG demonstrated modest voluntary activity in most muscle layers. Compared to standard of reference (CT), EMG showed moderate sensitivity (0.62), poor specificity (0.48), poor accuracy (0.57), and incorrect grading in 71% of true positive results.Conclusions: As BTA effect wanes, single-point EMG cannot reliably determine functional muscle status. A novel finding is that BTA-induced paralysis of the abdominal muscles may be remarkably non-uniform in degree, distribution and duration.

Selective muscle botulinum toxin A component paralysis in complex ventral hernia repair.

Repair of complex ventral hernia presents a significant challenge plagued by high morbidity and recurrence. Recent studies have demonstrated significant benefits achievable with preoperative Botulinum Toxin A (BTA) chemical component paralysis to the abdominal wall muscles, facilitating primary closure of complex ventral hernia defects. However, transversus abdominis is known to play an integral role in truncal stability, and its paralysis can result in unwanted physiological changes. This is the first study to report on selective administration of preoperative BTA to internal and external oblique muscles only, thus sparing transversus abdominis from paralysis. This is a prospective observational study of 46 patients who underwent either selective two-layer or standard three-layer abdominal wall muscle BTA injection prior to elective laparoscopic ventral hernia repair. Serial abdominal CT imaging was performed to compare defect size and length of the lateral abdominal musculature. 46 patients received preoperative BTA injections (23 in each group). A comparison of gains achieved from chemical component paralysis demonstrated no statistically significant difference between the two groups. Fascial closure was achieved in all cases, with no post-operative sequelae of abdominal hypertension. There are no hernia recurrences to date. Preoperative selective muscle chemical component paralysis is an effective technique to counteract the chronic muscle retraction observed in large ventral hernias. Transversus abdominis plays a significant role in truncal and spinal stability, and sparing it from paralysis preserves an important component of abdominal wall physiology and does not detract from the ability to primarily close complex defects.

Preoperative Botulinum Toxin and Progressive Pneumoperitoneum are Useful in the Treatment of Large Incisional Hernias

Preoperative Botulinum Toxin and Progressive Pneumoperitoneum are Useful in the Treatment of Large Incisional Hernias

Single port component separation: endoscopic external oblique release for complex ventral hernia repair.

Component separation (CS) is a technique which mobilizes flaps of innervated, vascularized tissue, enabling closure of large ventral hernia defects using autologous tissue. Disadvantages include extensive tissue dissection when creating these myofascial advancement flaps, with potential consequences of significant post-operative skin and wound complications. This study examines the benefit of a novel, ultra-minimally invasive single port anterior CS technique. This was a prospective study of 16 external oblique (EO) releases performed in 9 patients and 4 releases performed in 3 fresh frozen cadavers. All patients presented with recurrent complex ventral hernias, and were administered preoperative Botulinum Toxin A to their lateral oblique muscles to facilitate defect closure. At the time of elective laparoscopic repair, patients underwent single port endoscopic EO release using a single 20-mm incision on each side of the abdomen. Measurements were taken using real-time ultrasound. Postoperatively, patients underwent serial examination and abdominal CT assessment. Single port endoscopic EO release achieved a maximum of 50-mm myofascial advancement per side (measured at the umbilicus). No complications involving wound infection, hematoma, or laxity/bulge have been noted. All patients proceeded to laparoscopic or laparoscopic-open-laparoscopic intraperitoneal mesh repair of their hernia, with no hernia recurrences to date. Single port endoscopic EO release holds potential as an adjunct in the repair of large ventral hernia defects. It is easy to perform, is safe and efficient, and entails minimal disruption of tissue planes and preserves abdominal wall perforating vessels. It requires only one port-sized incision on each side of the abdomen, thus minimizing potential for complications. Further detailed quantification of advancement gains and morbidity from this technique is warranted, both with and without prior administration of Botulinum Toxin A to facilitate closure.

Preoperative Botulinum toxin A enabling defect closure and laparoscopic repair of complex ventral hernia.

Operative management of complex ventral hernia still remains a significant challenge for surgeons. Closure of large defects in the unprepared abdomen has serious pathophysiological consequences due to chronic contraction and retraction of the lateral abdominal wall muscles. We report outcomes of 56 consecutive patients who had preoperative Botulinum toxin A (BTA) abdominal wall relaxation facilitating closure and repair. This was a prospective observational study of 56 patients who underwent ultrasound-guided BTA into the lateral abdominal oblique muscles prior to elective ventral hernia repair between November 2012 and January 2017. Serial non-contrast abdominal CT imaging was performed to evaluate changes in lateral oblique muscle length and thickness. All hernias were repaired laparoscopically, or laparoscopic-open-laparoscopic (LOL) using intraperitoneal onlay mesh. 56 patients received BTA injections at predetermined sites to the lateral oblique muscles, which were well tolerated. Mean patient age was 59.7years, and mean BMI was 30.9kg/m2 (range 21.8-54.0). Maximum defect size was 24×27cm. A subset of 18 patients underwent preoperative pneumoperitoneum as an adjunct procedure. A comparison of pre-BTA to post-BTA imaging demonstrated an increase in mean lateral abdominal wall length from 16.1cm to 20.1cm per side, a mean gain of 4.0cm/side (range 1.0-11.7cm/side) (p<0.0001). This corresponds to an unstretched mean length gain of 8.0cm of the lateral abdominal wall. Laparoscopic/LOL primary closure was achieved in all cases, with no clinical evidence of raised intra-abdominal pressures. One patient presented with a new fascial defect 26months post-operative. Preoperative BTA to the lateral abdominal wall muscles is a safe and effective technique for the preparation of patients prior to operative management of complex ventral hernias. BTA temporary flaccid paralysis relaxes, elongates and thins the chronically contracted abdominal musculature. This in turn reduces lateral traction forces facilitating laparoscopic repair and fascial closure of large defects under minimal tension.

Modified components separation technique: experience treating large, complex ventral hernias at a University Hospital.

An increasing number of patients have large or complex abdominal wall defects. Component separation technique (CST) is a very effective method for reconstructing complex midline abdominal wall defects in a manner that restores innervated muscle function without excessive tension. Our goal is to show our results by a modified CST for treating large ventral hernias. A total of 351 patients with complex ventral hernias have been treated over a 10-year period. Pre- and postoperative CT scans were performed in all patients. All ventral hernias were W3, according to the EHS classification 1. We analyzed demographic variables, co-morbidities, hernia characteristics, operative, and postoperative variables. One hundred and seventy patients (48.4%) were men; the average age of the study population was 51.6±23.2years with an average BMI of 32.3±1.3. The hernia was located in the midline in 321 cases (91.5%) versus the flank in 30 (8.5%). In 45 patients, preoperative botulinum toxin (BT) and progressive pneumoperitoneum (PPP) were needed due to giant hernia defects when the VIH/VAC ratio was>20%. Postoperative complications related to the surgical site were seroma (35.1%), hematoma (9.1%), infection (7.2%), and wound necrosis (8.8%). Complications related to the repair were evisceration in 3 patients (1.1%), small bowel fistula in 4 patients (1.5%), 11 cases of mesh infection (2.9%), and abdominal compartment syndrome (ACS) in 2 patients. There were 29 hernia recurrences (8.2%) with a mean follow-up of 31.6±8.1months. The modified CST is an effective strategy for managing complex ventral hernias that enables primary fascial closure with low rates of morbidity and hernia recurrence.

Resultado de la aplicación preoperatoria de toxina botulínica A en el tratamiento de hernias incisionales gigantes

IntroductionThe giant incisional hernias are characterized by complex ventral hernias, associated with such an important parietal loss that cannot be repaired with a simple suturing technique as in other hernias, they are associated with loss of domain, muscle atrophy and chronically decreased intra-abdominal volume.There are 2 surgical strategies for the treatment of giant parietal defects that are not suitable for the reaproximation of tissues under tension: one option is to bridge the defect, with grafts from the patient's native tissue or with synthetic products; the second option is to close the defect by preparing the aponeurosis with many preoperative techniques that promote progressive tissue expansion.The objective of this study is to evaluate the results of the transient muscular relaxation obtained by the application of preoperative botulinum toxin type A. MethodsA retrospective study was undertaken in 14 patients with giant incisional hernia between March 2012 and February 2014. The patients took a basal abdominal computed tomography, and were infiltrated with 50iu of botulinum toxin type A in each side of the abdominal wall; 4 weeks later they were submitted to surgery. ResultsWe found a reduction in the larger hernia diameter in 50% of the patients, without a significant reduction in the measures with a difference of 0.30cm (CI 95% -1.05 to 1.65, p=0.615), the total hernia area posterior to the infiltration had a reduction in 50% of the patients, with a difference of -34.21cm2 (CI 95% of -22.2 to 90.6, p=0.195). There have not been recurrences por 15 months. ConclusionsThe application of preoperative botulinum toxin type A for the management of complex ventral hernia is of great utility, but there is only one prospective study in which the benefit was statistically significant. Still, there are no randomized studies to establish the botulinum toxin type A doses, the application technique and the timing for surgery; these are features that we recommend to standardize with more studies to obtain better results.

Long-term surgical outcomes of cervical myelopathy with athetoid cerebral palsy

To understand the long-term surgical outcomes and prognostic factors for the operative treatment of cervical myelopathy (CM) in patients with athetoid cerebral palsy (ACP). We retrospectively reviewed 24 patients with ACP who underwent surgery for CM at our hospital between March 2002 and June 2008. All patients had more than 5 years follow-up. Anterior fusion (11 patients), posterior fusion (1 patient), or combined anterior and posterior (AP) fusion (7 patients) and C1-2 fusion (5 patients) surgeries were performed. Surgical outcomes (average follow-up 102 months), as assessed using modified JOA (mJOA) scores, the Neck Disability Index (NDI), and a visual analog scale (VAS) were compared between the preoperative and postoperative states. Preoperatvie cervical kyphosis decreased mJOA scores significantly. Long-term follow-up clinical outcomes demonstrated that 10 patients showed favorable (excellent and good) outcomes and 11 patients had non-favorable (fair and worse) outcomes. According to the mJOA scores, patients showed postoperative improvement (7.10-10.45). NDI decreased from 68.46 to 31.66. A second operation was done in seven cases due to instrument failure, progressive kyphotic deformities and adjacent segment degeneration. A preoperative botulinum toxin injection significantly decreased (p < 0.05) the incidence of a second operation. Patients with ACP have high incidence of instrument failure. Strong surgical fixation, bone fusion and perioperative immobilizations using botulinum toxin injection should be carefully planned preoperatively.

Continuing Medical Education Questions: August 2013

Questions: Which one of the following statements is true about the epidemiology, pathogenesis, or natural history of achalasia? A. Because there is a higher prevalence of achalasia in men than in women, and particularly in the Caucasian population, these patients with dysphagia should undergo prompt investigation for achalasia, whereas other patient populations should be observed and treated with a more aggressive regimen of PPI therapy. B. The end result of the inflammatory process in achalasia is that of upregulation of cholinergic activity, which subsequently overpowers the inhibitory neurotransmitters nitrous oxide and vasoactive peptide (VIP). This results in an imbalance between excitatory and inhibitory neurons, leading to incomplete relaxation of the lower esophageal sphincter (LES) and aperistalsis. C. Because there is a higher prevalence of achalasia in men than in women, and particularly in the Caucasian population, screening for esophageal squamous cell carcinoma should begin at the onset of diagnosis and subsequently every 2 years. D. Owing to poor esophageal emptying and stasis inflammation, patients with achalasia are at an increased risk of not only esophageal squamous cell carcinoma but also adenocarcinoma, although the latter carries a substantially lower risk than that for squamous cell carcinoma. Which one of the following statements is true about confirming a diagnosis of achalasia? A. The endoscopic finding of a strong resistance at the esophagogastric junction (EGJ) when intubating the stomach should lead the physician to a very high suspicion for achalasia; however, motility testing is still needed to confirm a diagnosis of achalasia. B. A barium esophagram demonstrating a dilated esophagus, a “bird-beak” appearance, aperistalsis, and poor emptying of barium has a very high sensitivity and specificity for making a diagnosis of achalasia, and thus, confirmation with esophageal manometry may be redundant. C. A barium esophagram demonstrating a dilated esophagus, aperistalsis, and poor emptying of barium can help confirm a diagnosis of achalasia in cases where esophageal manometry may have indeterminate findings. D. In patients with high clinical suspicion of achalasia, the absence of a mechanical obstruction on endoscopy or esophagram is sufficient evidence to make a diagnosis of achalasia with > 95% accuracy. In the following clinical scenarios, which treatment recommendation is the appropriate therapy for patients with achalasia? A. For all patients with a new diagnosis of achalasia, oral pharmacologic therapies (e.g., calcium channel blockers or long-acting nitrates) should be the initial therapy because they are effective and the least invasive options. B. For medically fit patients, either graded pneumatic dilation or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy because both methods provide good relief of symptoms with comparable success rates. C. In the patients who are undergoing surgical myotomy, preoperative Botulinum toxin therapy should be given to improve surgical outcomes. D. For patients who develop “end-stage” achalasia characterized by megaesophagus or sigmoid esophagus and significant esophageal dilation and tortuosity, per-oral esophageal myotomy (POEM) should be recommended because it has been shown to be a more effective treatment option than surgical esophagectomy in a randomized prospective trial.

The use of postoperative botulinum toxin injection in large angle childhood esotropia

IntroductionThis study aimed to assess the influence of preoperative botulinum toxin (BT) injection upon the surgical correction of large angle esotropia (ET) in children and the stability of alignment following subsequent strabismus surgery.MethodsA retrospective review of children younger than 14 who had received BT prior to surgery for large angle ET (>50Δ) from January 2002 to April 2012 was undertaken. 27 patients who met inclusion criteria and had been treated with BT to both medial recti were identified. The angles for near and distance fixation, preBT, 3 months post BT, at last follow-up prior to surgery and at last postoperative follow-up were analyzed.Results3 months post BT the mean angle of deviation had reduced from 60Δ to 38Δ. This stayed stable (42Δ) after a mean follow-up of 11.8 months. 20 of the 27 patients (74%) had undergone or were awaiting 2-muscle surgery. Of those operated (n = 15), 11 were satisfactorily aligned but 4 exhibited a residual postoperative esotropia of 20Δ or more at final follow-up (range, 3 months to 3 years).DiscussionThe use of preoperative BT reduced the angle of deviation in children with large angle ET and enabled the use of less aggressive 2-muscle (instead of 3 or 4 muscle) strabismus surgery.ConclusionsBT injection prior to planned surgery in large-angle ET is an effective strategy for reducing the angle of esotropia to be surgically managed. We believe this is beneficial for the long term management of these patients who may require further strabismus procedures in their lifetime IntroductionThis study aimed to assess the influence of preoperative botulinum toxin (BT) injection upon the surgical correction of large angle esotropia (ET) in children and the stability of alignment following subsequent strabismus surgery. This study aimed to assess the influence of preoperative botulinum toxin (BT) injection upon the surgical correction of large angle esotropia (ET) in children and the stability of alignment following subsequent strabismus surgery. MethodsA retrospective review of children younger than 14 who had received BT prior to surgery for large angle ET (>50Δ) from January 2002 to April 2012 was undertaken. 27 patients who met inclusion criteria and had been treated with BT to both medial recti were identified. The angles for near and distance fixation, preBT, 3 months post BT, at last follow-up prior to surgery and at last postoperative follow-up were analyzed. A retrospective review of children younger than 14 who had received BT prior to surgery for large angle ET (>50Δ) from January 2002 to April 2012 was undertaken. 27 patients who met inclusion criteria and had been treated with BT to both medial recti were identified. The angles for near and distance fixation, preBT, 3 months post BT, at last follow-up prior to surgery and at last postoperative follow-up were analyzed. Results3 months post BT the mean angle of deviation had reduced from 60Δ to 38Δ. This stayed stable (42Δ) after a mean follow-up of 11.8 months. 20 of the 27 patients (74%) had undergone or were awaiting 2-muscle surgery. Of those operated (n = 15), 11 were satisfactorily aligned but 4 exhibited a residual postoperative esotropia of 20Δ or more at final follow-up (range, 3 months to 3 years). 3 months post BT the mean angle of deviation had reduced from 60Δ to 38Δ. This stayed stable (42Δ) after a mean follow-up of 11.8 months. 20 of the 27 patients (74%) had undergone or were awaiting 2-muscle surgery. Of those operated (n = 15), 11 were satisfactorily aligned but 4 exhibited a residual postoperative esotropia of 20Δ or more at final follow-up (range, 3 months to 3 years). DiscussionThe use of preoperative BT reduced the angle of deviation in children with large angle ET and enabled the use of less aggressive 2-muscle (instead of 3 or 4 muscle) strabismus surgery. The use of preoperative BT reduced the angle of deviation in children with large angle ET and enabled the use of less aggressive 2-muscle (instead of 3 or 4 muscle) strabismus surgery. ConclusionsBT injection prior to planned surgery in large-angle ET is an effective strategy for reducing the angle of esotropia to be surgically managed. We believe this is beneficial for the long term management of these patients who may require further strabismus procedures in their lifetime BT injection prior to planned surgery in large-angle ET is an effective strategy for reducing the angle of esotropia to be surgically managed. We believe this is beneficial for the long term management of these patients who may require further strabismus procedures in their lifetime

Botulinum toxin injections for blepharospasm prior to ocular surgeries

PurposeThe aim of this study was to show the efficiency of preoperative botulinum toxin A (Botox A) in patients with benign essential blepharospasm who were to undergo ocular surgery with local anesthesia.Materials and methodsTwenty-eight benign essential blepharospasm patients who were administered unilateral Botox A prior to ocular surgery between January 2004 and May 2011 were included in this study. Eleven cases had pterygiums, ten had cataracts, and four had glaucomas, while the remaining three had aphakia. All cases’ severity of spasm (stage 0–4) and eyelid closing forces (stage 1–4) were evaluated according to the Jankovic scale prior to the injection, at 3 days, 14 days, 1 month, and 3 months after Botox A injection.ResultsOf the patients enrolled in the study, 16 were female and 12 were male, with an average age of 55.52 ± 1.53 years (52–65). Average onset of the Botox injection’s effect was 2.8 ± 0.9 (2–5) days. Its effect lingered for about 11.5 ± 3.6 (8–22) weeks. The severity of spasm and eyelid closing forces of all the patients enrolled were compared prior to the injection at 3 and 14 days and the first and third months after the injection. There were statistically significant differences between prior to the injection and 3 days (P = 0.001), 14 days (P < 0.001) and 1 month after the injection (P < 0.001). There was no statistically significant difference between prior to the injection and 3 months after the injection (P = 0.513). Fourteen days following the injection, the surgeries were successfully performed.ConclusionBotox A administered prior to ocular surgery will control both blepharospasm and lower the risks that can be encountered before and during surgery, thus increasing the comfort of the patient and the surgeon.

Pre-operative Botulinum Toxin Injection for Movement Disorder-induced Cervical Spondylosis

Movement disorder is characterized by unique, unusual movements that are repetitive, and involuntary cervical motion has been well established to cause cervical spondylosis. The purpose of this study was to investigate the management of neurological and orthopedic complications in patients with movement disorder induced cervical spondylosis by botulinum toxin injection to provide immobilization of neck. In this retrospective study, 6 patients during the period from 2003 to 2010 were diagnosed with movement disorder-induced cervical spondylosis by neurologists. Each patient received botulinum toxin injection with a total dosage of 500-600U in the sternocleidomastoid, trapezius, splenius capitis, levator scapulae one week prior to surgery. Patients' demographics, diagnoses, injected dosage of botulinum toxin, and operative methods are retrospectively collected. All patients had a repeat cervical spine X-ray to assess the fusion and integrity of the construct. The clinical outcomes were assessed by using modified Rankin scale (mRS). The duration of follow-up was measured from the date of operation to the date of the last clinic visit. The mean age of our patients was 47.2 years ranging from 31 to 64 years. There was a male gender predilection with a male/female ratio of 4:2. The causing diseases prior to cervical spondylosis in our six patients were as follows: cerebral palsy in 3 patients, spasmodic torticollis in 2, and tardive dyskinesia in 1. At the mean follow-up of 56.5 months, all patients had improvement in their daily activities, and the average ratio of improvement in mRS was 41%. Cervical spine X-ray series showed no evidence of implant failure in any of the patients. Intramuscular injection of botulinum toxin provided post-operative immobilization of the neck for treatment of movement disorder-induced cervical spondylosis. These patients need long-term follow up for monitoring of adjacent segmental degeneration.

Preoperative botulinum toxin test injections before muscle lengthening in cerebral palsy

BackgroundMuscle weakening is a well-known side effect of muscle-tendon lengthening. Botulinum toxin A (BTX-A) weakens the muscle temporarily by blocking the neuromuscular junction. Hence application of the drug is a logical step to test whether weakness deteriorates function prior to an operation. In the present study, BTX-A application is used to test preoperatively whether the gait pattern depends on the strength of the tested muscle. Since 1999, instrumented gait analysis, including kinematic, kinetic, and dynamic electromyographic data, is routinely used to define the individual surgical program. MethodsIn our series of 110 consecutive patients with cerebral palsy (CP) considered for surgical muscle lengthening from 1999 to 2008, BTX-A was applied to identify patients at risk for functional deterioration. Gait analysis was repeated 6 weeks (maximum effect of BTX-A) and 12 weeks (follow-up) after the test injection to check for loss of joint control (excessive ankle dorsiflexion, knee flexion, increased anterior pelvic tilt). ResultsIn all, 20.9% (n = 23) showed deterioration in gait after preoperative BTX-A test injections (n = 112, two patients had two test trials) in all muscles considered for lengthening. As a consequence, their lengthening surgery was canceled. A total of 68 patients underwent surgery as planned, and in none of them did gait function deteriorate. These clinical data were compared to those of a historical group (n = 105) before this test, where 18% showed functional deterioration after surgery. The similar percentage of patients filtered out by the test suggests that there could be a context to the number of poor results in the historical group. ConclusionsWe conclude that preoperative BTX-A test injection is a reliable tool for filtering out patients with risk of deterioration after muscle lengthening surgery in patients with CP and can be helpful to avoid poor outcomes.

Cervical myelopathy in athetoid and dystonic cerebral palsy: retrospective study and literature review

The early onset of degenerative cervical lesions has been well described in patients suffering from athetoid or dystonic cerebral palsy. Myelopathy can occur and aggravate of their unstable neurological status. Diagnosis and treatment are delayed and disrupted by the abnormal movements. This retrospective study was implemented to evaluate the symptoms, the anatomical findings, and the surgical management of seven patients from 20 to 56 years old suffering from cervical myelopathy and athetoid or dystonic cerebral palsy. The mean delay in diagnosis was 15 months and the mean follow-up was 33 months. The initial symptoms were spasticity, limbs weakness, paresthesias and vesico-sphinteric dysfunction. In addition to abnormal movements, imaging demonstrated disc herniation, spinal stenosis and instability. All patients were managed surgically by performing simultaneous spinal cord decompression and fusion. Two patients benefited from preoperative botulinum toxin injections, which facilitated postoperative care and immobilization. Strict postoperative immobilization was achieved for 3 months by a Philadelphia collar or a cervico-thoracic orthosis. All patients improved functionally with a mean Japanese Orthopaedic Association score gain of 1.5 points, in spite of the permanent disabilities of the myelopathy. Complications occurred with wound infection, metal failure and relapse of cervical myelopathy at an adjacent level in one case each. All the previous authors advised against isolated laminectomy but no consensus emerged from the literature analysis. Spinal fusion is usually recommended but can be complicated by degenerative adjacent deterioration. Surgical management provides good outcomes but requires a long-term follow-up.

O003 Preoperative botulinum toxin to avoid poor surgical results of muscle lengthening in patients with cerebral palsy

Botulinum toxin type-A (Bot-A) is a commonly used drug for both cosmetic and therapeutic purposes. The effects of Bot-A on skin and muscle flaps and the related mechanisms have been described previously. In this study, we used a rat transverse rectus abdominis musculocutaneous (TRAM) flap model to examine the effects of Bot-A on the skin island, which is perfused by the rectus abdominis muscle according to the angiosome concept.Forty female rats were divided into five groups, including control and sham groups. In the control group, a TRAM flap was raised and sutured back after inserting a silicone sheath underneath the flap. In the sham group, the flap was raised 1 month after injecting saline into the muscle. In the chemical delay group, the flap was raised 1 month after injecting 10 IU of Bot-A. In the surgical delay group, the flap was raised 2 weeks after ligating the cranial epigastric artery. In the surgical and chemical delay group, a Bot-A injection was performed initially, a cranial epigastric artery was ligated after 2 weeks, and a TRAM flap was raised after the first month. In all groups, laser Doppler examination, photographic documentation, and analysis of the flap survival rates were performed. In the histopathological evaluation, the diameter measurements of the caudal epigastric vessels, vascular density measurements using CD31 stain, and apoptotic rate estimation using the Tunnel method were performed.The necrosis ratios, arterial cross-sectional diameters, and microvascular density measurements were significantly superior compared to those of control and sham groups; however, there was no significant difference between the delay groups. There was also no difference in the laser Doppler measurements between the groups and the zones of the TRAM flaps.An injection of Bot-A increases muscular circulation and flap survival of TRAM flaps in rats.

Intérêt de la toxine botulique pour les suites opératoires en chirurgie des membres chez l’enfant infirme moteur cerebral

Purpose of the study Spasticity can be the cause of pain in cerebral palsy (CP) children who may suffer increased postoperative pain after orthopedic surgery. Moreover, symptoms can be worsened by abnormal movements, cast immobilization or anxiety. Spasticity must therefore be treated after surgery in CP children. A randomized study has demonstrated that when these children undergo surgical tenotomy, preoperative injections of botulinum toxin have a beneficial effect in terms of pain relief. The aim of this study was to assess the benefit regarding pain and comfort provided by preoperative use of botulinum toxin in total-body CP children undergoing bone surgery. Material and methods Two successive groups of nine total-body CP children were compared in a retrospective study. All patients underwent an orthopedic surgery involving a bone or a multilevel procedure. The second group was treated before surgery with multisite injections of botulinum toxin. The main outcome criteria studied were: efficiency and adverse effects of botulinum toxin, duration of hospital stay and pain, length of level III analgesic treatment (morphine), sleep quality, and skin lesions under cast immobilization. The two groups were similar for mean age (8.7 ± 2.04 versus 10.9 ± 4.37 years) and mean body weight (20 ± 5.6 versus 26 ± 7.7 kg). Mean botulinum toxin (Botox ®/kg) in the second group was 11.6 U (range 9.7 - 14.8). Average time from preoperative botulinum toxin injections to surgery was 27 days (range 23-31). Results There was no significant difference between the two groups, except for the botulinum toxin treatment. The Aschworth scale confirmed the clinical efficiency of the preoperative injections, with no adverse effects. After the surgical procedure, all patients but two had cast immobilization (orthopedic traction, in botulinum group). The mean duration was six weeks in both groups. There was no significant difference in duration of the hospital stay: 7.33 ± 1.5 versus 7.88 ± 1.7 days and duration of level III analgesic treatment (4.33 ± 1.9 versus 4.16 ± 2.5 days). The duration of pain symptoms decreased significantly from 6.87 ± 2.9 to 2.22 ± 1.7 days and sleep quality improved from 7/9 to 1/9 patients with disturbed sleep. Four under-cast skin lesions were noted in the first group but none in the bolulinum group. Discussion We cannot confirm that botulinum toxin before bone surgery induces lesser consumption of analgesic drugs. Our results do however support the hypothesis that treatment of spasticity using preoperative injections of botulinum toxin decreases the duration of postoperative pain and improves the children's comfort. Moreover, postoperative under-cast skin lesions can be prevented. This work suggests that improved patient comfort and pain relief could be achieved by using multisite botulinum toxin injections before orthopedic surgery in spastic total-body CP children.