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CHAPTER 31
Khalili & Betts, 1967). This method to eliminate the predominant spastic muscles is used
mainly in incomplete lesions with good voluntary or reflex bladder and sexual function.
The technique is simple. The peripheral nerve or motor point is first located externally,
using a surface monopolar electrode. A needle electrode coated with teflon, except for
its tip, is then inserted and an electric stimulator is used to identify the respective nerve
fibres or motor point. The needle is in the desired position when the least intensity
of the electric current elicits the maximum contraction of the muscle to be blocked. Some
authors inject first a test solution of 1-2 ml of 0-5 to i per cent procaine or xylocaine
before injecting 2 ml of 40 or 60 per cent alcohol (Lacombe
et al.)
or 0-3 to 0-5 ml
of 2, 3 or 6 per cent aqueous phenol solution (Apolinario, Cain, Khalili). There is
immediate relief of spasticity of the muscle innervated by the blocked nerve fibres. The
duration of the beneficial effect varies, and repeated injections at varying intervals are
often necessary to achieve longer lasting results. From all these observations, it can be
concluded that these peripheral nerve and motor point blocks are of considerable value
in reducing spasticity in selected cases, especially if surgical procedures for one reason
or another are not contemplated.
(2) Intrathecal alcohol or phenol blocks
It is well known that chemical agents injected intrathecally for spinal anesthesia or for
relief of pain due to malignant tumours may result in paraplegia.
In early 1946,1 studied the effect of intrathecal injection of alcohol into the thoraco-
lumbar junction of the cord for transforming the spastic paraplegia into a flaccid motor
lesion in complete cord lesions with intractable spasticity and flexion contractures of the
legs. Although, at first, only small doses (i to 2 cc) of 80 per cent alcohol were used, the
immediate effect in abolishing the most violent flexor spasms and giving relief to the
patient was most striking, and the first results were reported at the Neurological Section
of the Royal Society of Medicine (Guttmann, 1946). However, it was found that the
effect was only temporary, and, in due course, larger doses (6-10 cc at the maximum)
were injected intrathecally to block the spinal roots of the cauda equina, as this procedure
is technically simpler than the blind, intra-medullary injection. Canadian and American
authors (Gingras, 1948; Sheldon & Bors, 1948) confirmed the striking effect of the alcohol
block on intractable spasticity, using larger doses (10-15 cc), and, in due course, the
intrathecal alcohol block has been widely used by other workers in this field. The idea of
this procedure was to replace the surgical procedures on the spinal cord, previously
mentioned, by the chemical relief of spasticity, in particular in those patients with
intractable spasticity suffering from septic conditions due to pressure sores, where larger
operations necessitating laminectomy and general anaesthesia would constitute too great
a risk.
Technique.
The patient is placed in lateral, tail-up position (40°) having regard to the
lighter specific gravity of the alcohol, to avoid its running too far headwards. A lumbar
puncture is performed, without anaesthetic, as a rule, between the first and second or
second and third lumbar vertebrae, using a fine needle. Only in special cases, where
excessive abdominal spasms are present in addition to the intractable spasticity of the
