Preoperative intramuscular injection of botulinum toxin prior to hip surgery in a patient with cerebral palsy

Background: We report on a 47-year-old man with tetraspasticity due to cerebral palsy requiring total hip joint endoprosthesis because of hip dysplasia in whom botulinum toxin A was applied preoperatively to reduce the high risk of postoperative luxation due to an increased flexor and adductor muscle tone at the right hip.

Methods: Performance of one-time CT-controlled injections of botulinum toxin A (overall 300 Units) in a patient with increased flexor tone in M. iliopsoas after cerebral palsy. The primary outcome measure was self-reported pain relief, muscle tone and limb position. The tone of the right hip flexor and adductor muscles was evaluated with the use of the five-point Ashworth Scale.

Results: There were no major or minor adverse events associated with injection of botulinum toxin A. After botulinum toxin A injection an improvement of spasticity, disability and pain was observed. The primary outcome measure was self-reported pain relief, muscle tone and limb position. After a period of seven to ten days the patient was free of pain. The spastic joint position in the right hip improved 7 to 10 days after injection of botulinum toxin A from 45° to 20° in the flexor muscle and from 20° to 10° in the spastic adductor muscle. The tone of the right hip flexor and adductor muscles improved from four to two points with the use of the five-point Ashworth Scale within seven days.

Conclusion: Intramuscular injections of botulinum toxin A is a safe procedure and reduces spasticity of limb muscles and associated disability and pain in a patient with tetraspasticity due to cerebral palsy. This unique case demonstrated a new indication for botulinum toxin A treatment in the preoperative setting to allow total hip joint endoprosthesis in patients with an increased flexor and adductor muscle tone at the right hip and thus reducing the risk of postoperative luxation. However further studies regarding optimal timing of age, muscles selection, techniques of muscle localization, dosing and dilution volume and long-term effects of botulinum toxin A injections are required to help optimize the injection strategy for botulinum toxin A in the management of spasticity in patients with cerebral palsy.