Neuro-orthopedic deformities managment: A multidisciplinary approach

Introduction Dystonic and dyskinetic syndromes produce musculotendinous retractions, subluxations and hip or shoulder dislocations. Most of the time, deep brain stimulation and pallidotomy cannot be used in secondary syndromes as they are in primitive forms. Drug treatments have frequent side effects. Very often these treatments are inadequate to prevent musculoskeletal deformities, which have an impact on pain, nursing, positioning and quality of life. Observation We followed a 45-year-old man with a spastic tetraparesia and a generalised dystonic and dyskinetic syndrome residual of a cerebral anoxia due to a heart arrest. His initial treatment was oral baclofen, anticholinergics and secondary intratechal baclofen. His symptoms increased progressively: pain, communication and nursing difficulties, mispositioning, elbow crease mycosis, as a consequence of musculoskeletal deformities. The patient had triple flexion of his upper limbs, antero inferior irreducible left shoulder dislocation, bilateral flessum of the knees. Multidisciplinary management has been provided, initially surgical then medical. Surgery included rotator cuff desinsertion of the left shoulder, needle percutaneous tenotomies of left elbow flexors, biceps femoris and semitendinus and plaster cast immobilisation. The medical treatment included twice-daily bolus of intratechal baclofen with dose-increase, botulinum toxin injection (left semimembranosus, right shoulder retractor muscles), phenolyc neurolysis (bilateral ansa pectoralis, left musculocutaneous nerve), physiotherapy and occupational therapy. The pain relief allowed a progressive morphinic doses decrease. Both armchair and bed positioning have been improved. Dyskinetic movements disappeared and verbal communication became easier. Discussion Neuro-orthopedic deformities management in patients with dystonia and dyskinesia may allow a decrease of dyskinetic movements and improve their comfort. It consists of multidisciplinary medicosurgical approach with tenotomies in association with oral or intratechal baclofen, botulinum toxin, chemical neurolysis and rehabilitation.