|LETTER TO THE EDITOR
|Ahead of print publication
Multiple solitary plasmacytoma, spasticity, and botulinum toxin
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
Department of Medicine, Federal University of Santa Maria, Santa Maria, RS, Brazil
|Date of Submission||03-Jan-2020|
|Date of Decision||03-Nov-2020|
|Date of Acceptance||03-Nov-2020|
Jamir Pitton Rissardo,
Rua Roraima, Santa Maria, Rio Grande do Sul
Source of Support: None, Conflict of Interest: None
We read the article entitled “Multiple Solitary Plasmacytoma of the Spine with Compressive Cervical Myelopathy: A Rare Case Report and Review of Literature” on the esteemed “Medical Journal of Dr. D. Y. Patil Vidyapeeth” with a great interest. Maheshwari et al. reported a case of an elderly male who presented with insidious onset neck pain. On neurological examination, spastic quadriparesis was observed. After a thorough examination, he had a diagnosis of multifocal plasmacytoma. What most called our attention was the spastic movements that even though the patient had significantly subsided and was ambulant without support about 6 weeks after surgery; this good prognosis is not for every patient. In some patients, the development of a definitive upper motor lesion can lead to spasticity.
Spasticity is an important form of movement disorder marked by a velocity-dependent increase in the muscle tone or tonic stretch reflexes associated with hypertonia. It can present in a variety of forms from acute to chronic and affects many diseases, which include multiple sclerosis, stroke, and cerebral palsy. Spasticity negatively influences the quality of life and is related to social impairment where embarrassment and social stigma lead the individual to self-isolation. It is believed that spasticity is a part of a disabling upper motor neuron syndrome, in which a lesion decreases the inhibitory drive in the corticospinal tract causing spasticity. The management of spasticity is with medication and multidisciplinary care; one of the drugs commonly used to spasticity is botulinum toxin injections.
Herein, we would like to discuss the on a botulinum toxin A (BOTOX) for lower limb spasticity in children approved by the Food and Drug Administration (FDA) in October 2019. It is important to highlight that the BOTOX was already approved for the treatment of movement disorders in upper and lower limb spasticity in adults, cervical dystonia in adults, and blepharospasm associated with dystonia. In addition, the BOTOX was approved for pediatric upper limb spasticity in early 2019. The approval by FDA comes after studying with more than three hundred participants. The inclusion criteria of the study were children aged 2–17 years with cerebral palsy, equinus foot position, ambulatory, and the intensity of muscle tone ≥2 in affected lower limb, as measured on the Modified Ashworth scale. On the other hand, the exclusion criteria were fixed contracture; previous phenol, alcohol injection, or surgical intervention; other neurological/neuromuscular disorders; and severe athetoid or dystonic movements. An interesting fact was that the medication was approved from aged 2 to 17 years but excluding spasticity from cerebral palsy due to marketing issues. The approved recommended dose per session is a maximum of 8 units/kg divided among affected muscles, or 300 units, whichever is lower. Furthermore, when treating both lower limbs or upper and lower limbs in combination, the total dose should not exceed 10 units/kg, or 340 units, whichever is lower during a period of 3-month interval. Common adverse events include injection site pain, tiredness, local allergy, pain in extremity, muscular weakness, cough, oropharyngeal pain, rhinorrhea, nausea, and vomiting.
Studies about the use of botulinum toxin in cerebral palsy have yet not provided good results. A recent Cochrane systematic review about BOTOX in the treatment of lower limb spasticity in children with cerebral palsy selected only randomized controlled trials of children with cerebral palsy younger than 19 years assessed a total of more than 1500 individuals. The studies found compared BOTOX with physiotherapy, placebo or sham, serial casting, or orthoses. They conclude that there is limited evidence about the efficacy of the drug, but the percentage of side effects between BOTOX and placebo was almost the same.
In sum, spasticity affects a significant portion of the population, and the development of new therapies alleviating the discomfort of those sensible individuals is important. Moreover, even though BOTOX was already approved for adults, this recent approval for the lower limb spasticity in children modifies years of common oral therapy.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Maheshwari V, Islam SU, Narang A, Mukherjee A. Multiple solitary plasmacytoma of the spine with compressive cervical myelopathy: A rare case report and review of literature. Med J Dr DY Patil Vidyapeeth 2019;12:452.
Delauche-Cavallier MC, Laredo JD, Wybier M, Bard M, Mazabraud A, Le Bail Darne JL, et al
. Solitary plasmacytoma of the spine. Long-term clinical course. Cancer 1988;61:1707-14.
Das S. Multiple solitary plasmacytoma of the spine. Med J Dr DY Patil Vidyapeeth 2019;12:456.
Bhimani R, Anderson L. Clinical understanding of spasticity: Implications for practice. Rehabil Res Pract 2014;2014:279175.
Blumetti FC, Belloti JC, Tamaoki MJ, Pinto JA. Botulinum toxin type A in the treatment of lower limb spasticity in children with cerebral palsy. Cochrane Database Syst Rev 2019;10:CD001408.