Penetrating head injury: A rare case of spastic paraparesis Dr Anand Sharma Dr Yashbir Dewan

Introduction PBI is leading or second leading cause of head injury Paraparesis following gunshot penetrating brain injury is not mentioned in available English literature Discuss spastic paraparesis following gunshot injury with brief review of literature upon management and role of intrathecal baclofen pump (ITB )

Case report 32-year-male presented with spastic paraparesis H/O Gunshot injury with paraparesis 6 years back, Underwent primary debridement with closure of scalp wound Spastic paraparesis was resistant to all conservative management O/E Conscious, Oriented Power : UL 5/5, LL: Right 3/5, Left 4/5 Tone : MAS –Right LL 3, Left LL 3, No bladder / Bowel dysfunction

Investigation

MANAGEMENT Risk and prognosis were explained for removal of retained bony fragments INTRATHECAL BACLOFN PUMP 50 microgram injection Continuous infusion intrathecal baclofen pump

SURGICAL STEPS Lumber puncture and incision Insertion of thecal end Insertion of abdominal end through trocar

SURGICAL STEPS Abdominal pouch and placement of ITB Fixation of ITB pump with closure

RESULT Preoperative After Trial Immediate post operative ITB MAS GRADE MUSCLE Spasm DTR Preoperative 3 Present 4+ After Trial 3+ Immediate post operative 1 Follow up 3 month Absent 2+

Discussion First case report of spastic paraparesis following gunshot BI Mechanism2 : Hyperpolarization of motor horn cells Use of ITB was associate with reduced spasticity, muscle spasm and deep tendon reflexes (DTR) Meythaler JM et al in his double- blind, placebo-controlled trial (1999) reported similar effect with continuous infusion ITB in acquired BI ITB improved functional strength by a reduction in motor tone leads to effective use of muscle power

TAKE HOME MESSAGE Paraparesis can be occur with cerebral injury Continuous infusion Intrathecal baclofen can be use in resistant cases Cost 3 -5 lac