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Thread: Chad had a phenol nerve block today

  1. #1
    Senior Member zillazangel's Avatar
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    Chad had a phenol nerve block today

    Chad is a C4 complete quadriplegic, injured 18 years ago (anniversary was last Sunday in fact). He has had much trouble with spasticity over the years and he had such massive severe spasticity last Sept that was initially triggered by a seizure that he was hospitalized for over a week for them.

    The muscle relaxants, when taken in high enough doses to control the spasms sufficiently ("al dente" pasta body - not rigid, not limp) quite literally causes his blood pressure to plummet so low that he loses consciousness on a regular basis whilst sitting up. So he had to be weaned to a much lower dose, which caused ... you got it - spasms and then PAIN.

    For the pain, he was put on OxyContin, which actually for the first time in 18 years, helped massively with his quality of life because it actually addressed many underlying pain issues beyond just the spasms that he didn't even know he had.... until the pain was gone! But the spasms were still there. For his own reasons, he is adamantly opposed to a baclofen pump.

    After researching the remaining options, his doctor and we decided on a phenol block. Given the high level of his injury, the "oldness" of his injury and his wishes to not have a pump implanted, and the unfeasibility of Botox with his all over body spasms, the doctor thought this was the best option.

    So today, he was injected behind the knee with 4 mL (?? I believe this is the right measurement, I was eavesdropping on that part) of phenol. Phenol denatures the nerve - it strips the nerve of the myelin sheath, it's coating so that it cannot communicate information as effectively up or down. This should reduce his spasms dramatically his doctor said because it will interrupt the "discussion" his body has with itself when having a spasm (this is my spin on it!).

    It will take a few days to take full effect they said, but I could already tell a difference putting him in bed tonight. Normally when I pull his legs up to put the foot plate on his wheelchair, his calves shake very hard and kick. Tonight, they had just a very light shiver to them.

    Chad had one odd sensation of a buzzing feeling "somewhere" below his injury site, but that was it. Otherwise it was quite interesting to watch as a spectator!

    I'll keep anyone here updated if you are interested on how this works. They said it should work from 6 months to a year, and it's posswible he may need to come back to tweak the med amount, but hopefully not if we're lucky. They gave him a relatively high dose they said due to the intensity of the spasms and his inability to tolerate muscle relaxants at higher doses.

    Anyway, just wanted to share in the collective interest of the CC community.

    Ami (igotafriend@nc.rr.com - email me with any questions instead of private topics, I tend to be sporadic around here!), wife of Chad

  2. #2
    What wonderful results! I hope this relief continues for along time.
    Thanks for sharing this information with others.
    It shows me that it pays to be inquisitive,persistent and to explore all your options.

    Having a wonderful wife as an advocate helps too!

    AAD

  3. #3
    zillasangel,

    It is interesting that the doctor suggested a phenol block. This is an old method that use to be used much more (in the 1970's) and I had thought that it was largely abandoned with the availability of the baclofen pump and botox for specific muscle spasticity/spasms. Because phenol damages the peripheral nerve, I decided to do a literature review to see if there are any recent studies on the subject, to see if there are any long term results.

    McCrea, et al. (2004) examinated the 12-week effects of phenol blocks, finding that phenol injections into a person with chronic elbow flexor spasticity following a stroke reduces spasticity and also paradoxically increased the strength of the muscle (perhaps due to increased use of the elbow after reduction of spasticity.

    Wong, et al. (2004) compared botox and phenol block on gait in children with cerebral palsy. They tested 27 ambulatory children with spastic cerebral palsy and found that the adverse effects of botox were less severe compared with phenol.

    Ofluoglu, et al. (2003) found that phenol blocks improved hip adductor overactivity in 24 patients without complications. Viel, et al., (2003) likewise reported that phenol or alcohol blocks were "accurate, fast, simple, highly successful and reproducible".

    Most of the above studies are not randomized clinical trials. In 2002, van Kuijk, et al. did a literature search for randomized clinical trials (RCT) of neuronal and neuromuscular blockade, finding 4 RCTs for Botox and none for phenol. Although the evidence suggest that botox is safe, convincing evidence of efficacy was found only in two groups of patients: (1) patients with mild spasticity and a potential for voluntary extensor activity and (2) patients with severe spasticity suffering from problems of positioning.

    Wolf & English (2000) studied the effects of peripheral nerve phenol block in rats and showed that it denervated muscle spindles (the sensors for muscle stretch) of both afferent (sensory) and gamma (motor control) fibers. After 6 weeks, most of the spindles (90%) showed return of the afferent fibers but only about a third (38%) showed return of gamma innervation.

    Finally, the following article gives a fairly comprehensive description of various neuromuscular blocking agents including phenol injections http://www.global-help.org/publicati...spasticity.pdf According to this article, there are several advantages of phenol over botox: rapid action, longer duration, low cost, no antibody formation. The disadvantages are relatively painful injection, chronic dysesthesia and pain (this should not be a problem if the injection is done in a motor nerve), peripheral edema and deep venous thrombosis (avoidable by limiting dose), reversible sensory loss (this should not be a problem in a person with sensory loss). Its effects are said to range from 2 to 36 months.

    Wise.



    REFERENCES

    McCrea PH, Eng JJ and Willms R (2004). Phenol reduces hypertonia and enhances strength: a longitudinal case study. Neurorehabil Neural Repair 18: 112-6. Phenyl alcohol blocks are used to relieve spasticity. Such nerve conduction blocks result from phenol-induced axonotmesis and could potentially affect muscle properties related to the ability to generate, maximize, and reduce force. This study assessed the 12-week longitudinal effect of phenol on position (stiffness) and velocity (damping) components of hypertonia, in addition to strength (peak torque and times to generate and reduce torque) in an individual with chronic elbow flexor spasticity following stroke. Phenol motor point injections of flexor muscles paradoxically increased the magnitude of flexion torque and decreased the times required to generate and reduce flexion and extension joint torques, in addition to reducing elbow extension stiffness and damping. Large reductions in the velocity-related component of hypertonia (damping changes > 90%) occurred immediately following injection, which is a finding that supports the velocity-dependent definition of spasticity. Although the changes in damping were large and transient, changes in stiffness and strength variables were small, slower to occur, and maintained. This suggests secondary changes following nerve block, possibly facilitated by regular elbow use subsequent to spasticity reduction. Department of Mechanical Engineering, University of BC, Vancouver, Canada. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=15228807

    Wong AM, Chen CL, Chen CP, Chou SW, Chung CY and Chen MJ (2004). Clinical effects of botulinum toxin A and phenol block on gait in children with cerebral palsy. Am J Phys Med Rehabil 83: 284-91. OBJECTIVE: To compare the treatment effectiveness of botulinum toxin type A (BTX-A) and phenol blocks in managing lower limb spasticity and gait dysfunction in children with cerebral palsy. DESIGN: This is a case-controlled study that took place in a tertiary center's gait laboratory. A total of 27 ambulatory children with cerebral palsy spastic diplegia, aged from 3 to 7 yrs, and 20 normal children were recruited into this study. Sixteen children with cerebral palsy received BTX-A injections, and 11 received phenol motor point blocks. Gait analyses were assessed by a portable computer-assisted system (Computer DynoGraphy, Infotronic, The Netherlands). Both the BTX-A and phenol groups received gait analysis at 1 wk before and 2 mos after injection treatments. RESULTS: Significant improvements in gait variables of velocity and cadence were noted in children with cerebral palsy after BTX-A injections as compared with the phenol block group. Gaitline and cyclogram patterns also improved significantly in the BTX-A group. The adverse clinical effects of BTX-A injections were less severe as compared with phenol injections. CONCLUSIONS: BTX-A injections demonstrated superior treatment effects in improving gait variables and patterns in children with spastic diplegia as compared with phenol blocks. BTX-A injections also revealed fewer clinical side effects and were well tolerated by children with cerebral palsies. Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Kwei-Shan, Tao-Yuan, Taiwan. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=15024330

    Ofluoglu D, Esquenazi A and Hirai B (2003). Temporospatial parameters of gait after obturator neurolysis in patients with spasticity. Am J Phys Med Rehabil 82: 832-6. OBJECTIVE: The management of spasticity should be implemented with the most appropriate pharmacologic agents. Ideally, these agents should provide functional improvement with minimal adverse effects. The aim of this study was to evaluate the width of the base of support and the velocity of gait before and after obturator nerve block. Blocks were performed with aqueous phenol solution in patients with unilateral hip adductor muscle overactivity that resulted in scissoring gait. The goal was to analyze functional improvement and quantify outcomes and to attempt to document adverse effects. DESIGN: This retrospective study analyzed data from 24 patients' files. Inclusion criteria included subjects whose main functional complaint was an adducted gait pattern. All subjects were able to consent for and to undergo unilateral obturator neurolysis with 7% phenol solution. Temporospatial parameters of gait were obtained using the Gait Mat II before and after obturator nerve injection. RESULTS: The analysis showed no statistical change in the walking velocity or step length. However, the width of the base of support was significantly increased after injection. No postblock complications were reported. CONCLUSION: Obturator neurolysis with 7% phenol solutions is an effective procedure to decrease hip adductor muscle overactivity without reported complications. In the studied population, improvement was found in the width of the base of support without immediate change in walking velocity or step length. Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=14566149

    Viel E, Pelissier J, Pellas F, Boulay C and Eledjam JJ (2003). [Alcohol neurolytic blocks for pain and muscle spasticity]. Neurochirurgie 49: 256-62. Peripheral nerve blockade is one of the therapeutic options for spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents efficient rehabilitation. Neurolytic blocks are possible in most of motor nerves of the upper and lower limbs and main indications are spastic sequelae of stroke and spinal trauma but also of multiple sclerosis, cerebral palsy and chronic coma. The use of percutaneous nerve stimulation allows accurate location and four nerves are more frequently treated: pectoral nerve loop, median, obturator and tibial nerves. In patients with spasticity of the adductor thigh muscles, nerve blocks are performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. No complications occur and minor side effects are transient painful phenomena during injection. These approaches have proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures, should be performed as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurons. Departement d'Anesthesie et Centre de la Douleur, Faculte de Medecine de Montpellier-Nimes. eric.viel@chu-nimes.fr http://www.ncbi.nlm.nih.gov/entrez/q..._uids=12746700

    van Kuijk AA, Geurts AC, Bevaart BJ and van Limbeek J (2002). Treatment of upper extremity spasticity in stroke patients by focal neuronal or neuromuscular blockade: a systematic review of the literature. J Rehabil Med 34: 51-61. Studies published from January 1966 until October 2000 on the clinical effects of focal neuronal and neuromuscular blockade in post stroke upper limb spasticity were identified. Twelve studies were included and evaluated on 13 methodological criteria. Ten studies on Botulinum toxin type A (BTX-A) treatment were found (of which 4 were randomised controlled trials (RCTs) and 6 were uncontrolled observational studies) as well as one uncontrolled observational study on phenol blockade of the subscapular muscle and one on alcohol blockade of the musculocutaneus nerve. The homogeneity of the patient groups with regard to diagnosis and their comparability with regard to functional prognosis and other sources of bias were generally unsatisfactory. Only two RCTs met predetermined criteria of minimal validity. There is evidence of effectiveness of BTX-A treatment on reducing muscle tone (varying between 0.8 and 2.0 points on the modified Ashworth scale) and improving passive range of motion at all arm-hand levels in chronic stroke patients for approximately 3-4 months. There is also preliminary evidence of a synergistic effect of concomitant electrostimulation. Taking into account a critical maximum dose of 100 MU Botox" (300-500 MU Dysport) for preserving active finger flexion, BTX-A treatment seems to be a safe focal spasmolytic treatment. Effectiveness of BTX-A treatment on improving functional abilities could not be convincingly demonstrated, although two subgroups may be identified that might specifically benefit at a functional level: (1) patients with mild spasticity and a potential for voluntary extensor activity and (2) patients with severe spasticity suffering from problems with positioning and taking care of the affected arm and hand. Larger controlled studies are needed to compare the effectiveness of BTX-A with other focal spasmolytic techniques paying special attention to individual goal assessment, the (duration of) functional benefits, co-treatment and aftercare, side-effects and cost-effectiveness. Department of Rehabilitation Medicine, Sint Maartenskliniek, Nijimegen, The Netherlands. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=12019580

    Wolf JH and English AW (2000). Muscle spindle reinnervation following phenol block. Cells Tissues Organs 166: 325-9. Infusion of phenol into peripheral nerves is used clinically to manage spasticity. It produces relief of symptoms by chemical denervation. We simulated the clinical procedure by bathing the lateral plantar nerve of rats in 7% phenol solution for 20 min. We studied the innervation of muscle spindles in the plantar lumbrical muscles of untreated rats and in rats 4 and 6 weeks after a single phenol block. Spindles were identified by the immunoreactivity of nuclear bag(1) fibers to slow tonic myosin (antibody ALD 19). The integrity of the sensory and motor reinnervation of spindles was evaluated using a monoclonal antibody specific for a high molecular weight neurofilament protein. Four weeks after phenol block, muscle spindles were difficult to find, as their immunoreactivity to antibody ALD 19 was reduced. In those spindles studied, most (>80%) were completely denervated. The remainder of which were innervated by afferents only. None received efferent (gamma) innervation. After 6 weeks, spindles were readily identified and nearly all (>90%) received recognizable afferent innervation. A much smaller number (38%) received gamma innervation. Phenol block thus results in a complete denervation of muscle spindles, followed by a fairly rapid sensory reinnervation. Reinnervation by gamma motor neurons is either incomplete or significantly delayed. Department of Cell Biology, Emory University School of Medicine, Atlanta, GA 30322, USA. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=10867433

    [This message was edited by Wise Young on 05-27-05 at 01:14 AM.]

  4. #4
    Senior Member zillazangel's Avatar
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    Thanks Dr. Wise, I had seen most of those articles, but not of them, so thank you for posting them (and for the benefit of others considering this procedure).

    This actually not something I'd recommend for most people - I was/am in favor a baclofen pump, but Chad has an absolute opposition to have "something under my skin". It completely and totally freaks him out. I don't understand that, but then again, I am frightened beyond words of beetles. So, I guess I do understand phobias. But I was so hoping that I could convince him to get the pump, but after realizing that was truly not an option, we started looking for alternatives.

    Our physiatrist said that he is going to use phenol initially for the big huge muscles, then use Botox to knock out any residual spasms in smaller areas. The concern really was practical unfortunately. Botox, he said, lasts only 3 months and he estimated that Chad would need $10,000 worth of it to control the level of spasms he has. That's $40,000 out of pocket for us ..... now while we are finally doing well enough to pay our attendant out of pocket, $10,000 a quarter for Botox is a bit out of reach still.

    Also, we realize 100% that phenol over time does irreparable harm to the nerves. This would prevent him from walking in the case of a cure. But, we have realistically looked at the odds of that, his age (only 37 mind you) vs. the quality of life it would bring him now and decided to go forward with phenol.

    So it was an informed decision and one that although not at all appropriate for nearly all other SCInjured persons, it was right for us. I hope that explains a bit more behind our thinking.

    I'll PM you our physician's name and our location to see if you know of him. He is the chair of Phys Med/Rehab at a major teaching hospital, so we're hopeful that we're in good hands, but I'd be curious to know if you know of him.

    Many, many thanks for the information you posted!

    Ami

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