Therapeutics
.jpg "Roger De la Cerna, MD photo")
Roger De la Cerna, MD
Physiatrist
Hospital Nacional Edgardo Rebagliati Martins
Lima, Lima, Peru
Gabriela Mabel Ruiz, N/A, MD
Medical resident
Hospital Nacional Dos de Mayo
Lima, Lima, Peru
Midori Chacón Cruzado, N/A, MD
Medical resident
Hospital Nacional Dos de Mayo
Lima, Lima, Peru
Spastic quadriparesis due to cerebral palsy treated with phenol and hyaluronidase
Case Description:
In a 14-year-old female adolescent with spastic quadriparesis due to cerebral palsy, refractory to botulinum toxin management and treated on an outpatient basis at a referral hospital in Peru, with physiotherapy and the use of orthoses, a decision was made to perform phenol chemodenervation, along with complementary injections of bovine testicular hyaluronidase (BTH) (used off-label and approved by a medical board). The patient’s mother signed informed consent, and under ultrasound guidance, branches of the musculocutaneous, median, and tibial nerves were targeted; 75-100 IU of BTH was injected into each of 10 muscles (elbow extensors and supinators, wrist extensors, knee extensors, and ankle dorsiflexors) in areas with a Modified Heckmatt Scale grade of 3-4. Improvements of 20-50° in passive range of motion and 1-2 points on the Modified Ashworth Scale were achieved, with progressive gains from the immediate post-procedure period trough 10 weeks of follow-up. No adverse effects were reported.
Discussions:
Regarding the mechanism of action of hyaluronidase in spasticity, hyaluronan accumulation in muscles is thought to contribute to muscle fibrosis in individuals with neurological injuries. Therefore, direct application of BTH may represent a potentially effective treatment, especially for rigidity associated with spasticity. In this case report, spasticity improved after treatment with phenol and BTH in combination with conventional management. Prior evidence includes a case series and a case report from the United States, a case report from Peru, and a cohort study from India, all supporting hyaluronidase as a promising option for spasticity management.
Conclusions:
This case shows that phenol chemodenervation combined with BTH and conventional rehabilitation can improve muscle tone, and passive range of motion in a pediatric patient with refractory spastic quadriparesis due to cerebral palsy. The favorable response supports BTH as a promising adjunctive therapy.
