Botulinum toxin BT before orthopaedic surgery in cerebral palsy children CP, What are the benefits

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Botulinum toxin (BT)before orthopaedic surgery
in cerebral palsy children (CP),What are the
benefits?

• Bruno Dohin, Christophe Garin, Rémi Kohler.
• Department of Pediatric Surgery,
• Edouard Herriot hospital, Lyon, France.

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Introduction

• BT is widely used in CP children mainly for
  treatment of spasticity.
• Some authors reported that BT acts on pain
  (either if pain is in relation with spasticity or
  not) Wissel J (J Pain Symptom Manage 2000)
• Barwood S (Dev Med Child Neurol 2000) reported
  in a randomized trial that BT treatment before
  tenotomies reduce both pain and hospital stay.
• The aim of the study was assessment of benefits
  of BT treatment before bone and soft tissues
  surgery in total body involved CP children.

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Methods

• Retrospective study 2 similar groups of patients
• 9 cases without botulinum toxin (BT-) before 2003
• 9 cases with botulinum toxin (BT) after 2003
• Inclusion criteria
• Total body involved CP children
• Spasticity Modified Aschworth Scale, 3 or 4
  points
• Hip surgery and/or multi site surgery (bone and
  soft tissues)
• Post-operative spica cast or traction
• Pain evaluation
• Any reported pain by family or nurses was take
  into account as a painful day
• Duration of level 3 analgesic treatment (days)
  was noted
• Sleep quality
• Any sleepless night was noted

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BT group administering BT

• BOTOX mean dose 11,6 U/kg ( 9,7 - 14,8 )
• Both sides multi site injections
• In all cases adductors, rectus femoris,
  medial hamstrings plus lateral hamstrings (one
  case), ilio-psoas (one case)
• Mean delay before surgery 27 days (23-31)

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Results BT efficiency

• In all patients of BT group, spasticity
  decrease of at least 1 point on Modified
  Aschworth Scale(examination just before
  surgery)
• No adverse effect was reported

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Results

• No difference between the 2 groups for duration
  of hospital stay
• No difference between the 2 groups for duration
  of level 3 analgesic treatment

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Results

• In BT group, duration of post-operative pain
  decrease from a mean of 7 days to a mean of 2
  days.

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Results

• In BT group, none patient presented skin
  injuries under cast, while 4 lesions were
  reported in BT- group.
• Only one patient had sleepless night in BT
  group, while 7 patients in BT- had restless
  nights.

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Discussion - Conclusion

• Nolan J (Anaesthesia 2000) reported that
  spasticity treatment is of importance for post
  operative care. We tested efficiency of BT in
  this study.
• No difference between the 2 groups was found for
  analgesic consumption and hospital stay contrary
  to reported results of Barwood S (Dev Med Child
  Neurol 2000). Nevertheless in this study,
  benefits of BT treatment before surgery were
  less duration of pain, improvement of sleep
  quality and decrease of skin lesions.
• In this study, the 2 groups were similar and BT
  treatment before orthopedic surgery improved
  patients confort during the post-operative
  period. We advocate the use of BT for prevention
  of disconfort after orthopedic surgery.