506 - Elective lower extremity amputation for management of severe, refractory spasticity

Case Diagnosis: Left lower extremity spasticity

Case Description: A 55 year old male with a history of spastic paraplegia secondary to an incomplete T8 spinal cord injury from a spinal cord stroke at the age of 18 developed worsening left lower extremity spasticity over the past several years. His spasticity was refractory to conservative measures, botulinum toxin injections, and increasing doses of oral baclofen and tizanidine. His symptoms, including episodes of clonus severe enough to pull him out of his manual wheelchair, were hindering his ability to complete transfers, work as a tattoo artist, and contributed to his chronic mechanical low back pain, non-healing lower extremity ulcers, and depression. Given his concerns about the risks of an intrathecal baclofen pump, the patient expressed interest in a lower extremity amputation to manage his refractory spasticity. He was referred to orthopedic surgery where he ultimately opted for an elective left lower extremity knee disarticulation.

Discussions: Management of spasticity in patients with spinal cord injuries primarily involves conservative and pharmacologic measures. This includes physical therapy and orthoses, muscle relaxants like oral baclofen, as well as procedural interventions like botulinum toxin injections or intrathecal baclofen therapy. Surgical options for spasticity are limited, and spasticity is generally not an indication for amputation.

Conclusions: The patient underwent an elective, uncomplicated left lower extremity knee disarticulation. Post-operatively, he noted significant improvements in his spasticity, depression, and overall quality of life at a follow up with his PCP. In select patients with severe, refractory lower extremity spasticity, amputation may serve as a last resort option to help with overall quality of life.