Disclosures: Kristen Courtney, DO: No financial relationships or conflicts of interest

Case Diagnosis: 31-year-old Caucasian male with spastic thoracolumbar deformity due to relapse-remitting multiple sclerosis (RR-MS).

Case Description or Program Description: Patient demonstrated substantial thoracolumbar deformity and lower extremity dystonia despite multiple lower extremity tenotomies and extensive bracing (LS KAFO) with progressive lumbar obliquity. Patient was on maximal dose of oral baclofen and not a candidate for intrathecal due to infection risk with disease modifying therapy. He underwent trigger-point (TrP) localization approach (due to inability to tolerate prone positioning for EMG-guided technique) of botulinum toxin injection into right quadratus lumborum (QL) using 100 units. Localization of QL was obtained in lateral recumbent position on uninvolved side with patient reaching overhead to elevate rib cage; palpation of crest of ilium where it meets paraspinal mass near the level of L4 transverse process. Pressure was applied superior to the iliac crest, anterior to paraspinals, and needle directed toward the tip of L4 transverse process. At 6 weeks post-procedure, an estimated 30-degree reduction of spinal curve with Modified Ashworth Scale (MAS) reduction from 4 to 2 was noted.

Setting: Outpatient

Assessment/Results: Palliative goals of improved positioning and hygiene, reduced caregiver burden, and improvement of respiratory status with reduced lateral flexion were achieved. There were no further surgeries for contracture release and brace discontinued.

Discussion (relevance): Our patient demonstrated severe truncal spasticity and deformity that was not reduced by oral baclofen, which is considered gold-standard treatment for central nervous system spasticity. From literature review, currently there are no guideline-directed resources for the dosing of botulinum toxin for thoracolumbar spine dystonia or targeted injection approach for QL spasticity. Injection technique was extrapolated from an TrP approach of localizing the thickest region of QL muscle.

Conclusions: We present a novel treatment approach to RR-MS spastic thoracolumbar deformity with botulinum toxin injection via TrP localization approach to QL.

Level of Evidence: Level V

« Back to AAPM&R Annual Assembly 2022

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/novel-treatment-of-thoracolumbar-spasticity-with-botulinum-toxin-injection-to-quadratus-lumborum/