Weird ortho case

[Crybaby]

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One of the total joint guys I work closely with asked my opinion on a weird case he has. He specifically wanted to know if I could use botox.

The case is a woman with multiple back surgeries and bilateral hip replacements with chronic dislocations. He has revised left hip and she did well. Now months later he revised the right hip (a few days ago) and she has since developed significant gastroc spasm and pain in RLE . She is now admitted in hospital

The case was not a complicated revision per him, no length added, not difficult in OR.

Spasm is focal to gastroc/soleous- I am unable to dorsiflex at all- muscle is hard and flexed- other tissues soft.

He has done CT of hip- no hematoma- MRI waiting- I have asked him to consult neuro. No DVT. No history of MS. I don't have a ton of details as I really just was curbsided.

I mentioned adding baclofen and sciatic nerve block. Block seemed to help and he was able to dorsiflex foot past neurtral. Now wearing off with return of spasm.

My recs to him were to get neuro consulted and reblock with catheter for comfort. If looks chronic I do not mind botox- but I would really like to have a reason she has developed such a focal spasm.

Anyone see anything like this?

 

[adiradirim]

Any dopamine blocker medications given to her during or after the surgery? Metoclopramide? Unusual for a calf, but dystonia can be in any muscle. Usually anticholinergics work well in those cases.

 

[Ferrismonk]

I also would do a trigger point before I would do Botox.

 

[SSdoc33]

agree that you have to know why you have the focal spasm before you botox. any weird history of neuro disorders? myotonia?

i probably would stick a needle in there (EMG) to see what it shows.

my gut says that time, heat, and stretching will make this go away.

 

[kstarm]

Is there a radicular component? Would consider potential issues related to positioning during surgery. With hx of back surgery and response to sciatic block may consider imaging of her back if pelvis MRI is negative.

 

[Crybaby]

Any dopamine blocker medications given to her during or after the surgery? Metoclopramide? Unusual for a calf, but dystonia can be in any muscle. Usually anticholinergics work well in those cases.

I will ask

 

[Crybaby]

Is there a radicular component? Would consider potential issues related to positioning during surgery. With hx of back surgery and response to sciatic block may consider imaging of her back if pelvis MRI is negative.

MRI of lumbar spine shows hardware T11-S1
other than that and the artifact no new herniation, foramen appear patent enough

 

[jayel]

Any UMN signs on exam?

 

[deleted875186]

This is bizarre .... I would have them consult neuro first and get the EMG. In the meantime try baclofen and TPI.

 

[deleted875186]

Apparently there is a “stiff limb syndrome”, as I was reading in uptodate. Seems like it is thought to be CNS mediated, less GABA activity. Apparently they have a marked response to diazepam .... probably worth a shot.

 

[deleted875186]

Also, love these things, makes this forum worth while to here weird stuff like this.

 

[clubdeac]

Common things are common. He injured or irritated the sciatic nerve during the revision. This is more common in revisions than primary THA and the temporary relief from the sciatic block would confirm this. EMG (although may be too soon to see anything) and pelvic Magnetic Resonance neurography (MRN)

 

[Crybaby]

No UMN signs

There is a small nondisplaced posterior column fx noted on CT scan of hip- but they think that is unlikely to cause spasm

The spasms have improved catheter out since yesterday morning.

Surgeon called me yesterday and asked me if this could be due to her dilaudid pump, haha. No where in any notes was it mentioned that she had one. Pump will be interrogated today- I am highly doubtful that this is any of the cause.

Spasms are resolving, Hospital Neurology team has been too busy to see. From notes patient is beginning to look a little bit more leaning towards psych....

Will update if anything is found. I really do appreciate opinions of all who contributed. I know I learn a lot from other similar discussions

 

[SommeRiver]

Dilaudid pump! Ha!

Ortho are quick to push pts to you if anything weird happens.

Here's a fantastically amazing story full of severely extreme drama:

We used to have this total hip and knee guy. He is no longer in our practice.

This ***** has a pt with severe stenosis (maybe L4-5 canal or something)...He's doing a total knee and is worried she won't be able to do post op PT so can I do a pre op epidural 7d prior? She has no pain other than the knee that I'm replacing.

...well, no...I won't do a "prophylactic epidural" for you, but I'll see her.

She comes in the clinic and she's legit. Bad back pain with radiation into the hamstrings.

I do a TFESI bilaterally with dex and saline. NO LOCAL. This is a week before her TKR.

No issues. Huge improvement with the pain, and she gets that TKR. Within 12 hrs of surgery she has drop foot.

Tells the surgeon who says, "THE EPIDURAL DID THAT!"

I confronted him and showed him my procedure note. No local. No drop foot IN THE WEEK BEFORE THE F'ING SURGERY...Don't worry dude, it will resolve over the next few months and it did.

Edit - Oh, to sum it up - "Don't do that."