Objective-To confirm the apparent effectiveness of botulinum toxin (BTX) in hemiparetic patients with ankle plantar flexor and foot invertor spasticity. Methods-Twenty three hemiparetic patients with spasticity of the ankle plantar flexors and foot invertors were included in a randomised double blind, placebo controlled study with BTX. Patients were examined on days 0, 30, 90, and 120 and received one injection of BTX and one of placebo in a random order at day 0 and day 90. Results-Patients reported a clear subjective improvement in foot spasticity after BTX (P = 0-0014) but not after placebo. Significant changes were noted in Ashworth scale values for ankle extensors (P < 0.0001) and invertors (P = 0.0002), and for active ankle dorsiflexion (P = 0-0001). Gait velocity was slightly but not significantly (P = 0-0731) improved after BTX injections. The severity of spasticity did not modify treatment efficacy, but BTX was less effective in patients with longer duration of spasticity (P = 0-0081). Conclusion-The efficacy of BTX injections in the treatment of spastic foot suggests that BTX may be particularly useful during the first year after a stroke.

We retrospectively analyzed the charts of 13 athletes (18 limbs) who had sural nerve entrapment localized in the passage of the nerve through the superficial sural aponeurosis. There were 11 men and 2 women (average age, 43 years; range, 31 to 59). All patients reported chronic calf pain that was exacerbated during physical exertion. Delay to diagnosis averaged 9 months (range, 5 to 24). Tenderness in the calf was identified along the course of the sural nerve in all cases. In 10 patients (15 limbs) electrodiagnostic testing before surgery was positive. After failure of nonoperative treatment, surgery was conducted under local anesthesia. Neurolysis was performed by incising the superficial sural aponeurosis and the fibrous band in it through which the nerve passes. The results of the operation were evaluated in terms of residual symptoms, ability to return to the former sport, and degree of patient satisfaction. A final follow-up examination was performed an average of 14 months (range, 6 to 30) after the operation. The final result was excellent in 9 limbs (2 bilateral), good in 8 limbs (2 bilateral), and fair in 1 case. The differential diagnosis of sural nerve entrapment in athletes is discussed. Increase in sural muscle mass or development of local fibrous scar tissue compromised the sural nerve in its course through the unyielding and inextensible superficial sural aponeurosis.

We studied the e cacy of endoscopic injection of Botulinum A toxin (150 I.U. Dysport 1 ) in the treatment of detrusor-sphincter dyssynergia in 17 patients with spinal cord disease. One month after the injection, the postvoiding residual urine volume (7176 ml, P50.001), the bladder pressure on voiding (719 cm water, P50.01), and the urethral pressure (724 cm water, P50.001) were signi®cantly decreased. The modality of voiding was improved in 10 patients (ie micturition by suprapubic tapping was easier to induce, discontinuation of indwelling catheter use, or decrease in frequency of intermittent catheterizations). The tolerance of the treatment was excellent. The therapeutic e ect lasted 2 to 3 months on the average. The low doses used in this study probably explain in part why the treatment sometimes failed. Botulinum A toxin could become an alternative treatment for detrusorsphincter dyssynergia in certain patients, notably in those who are refractory to sphincterotomy or in patients, such as those who are tetraplegic, and who are incapable of performing intermittent self-catheterization.

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Critical illness polyneuropathy (CIP) is a reported cause of varying degrees of neuromuscular weakness in patients with multiple organ failure. Little is known concerning predictive factors of neurological recovery. The critical care conditions, neurological explorations and 2-year clinical follow-up of 19 patients who suffered from severe forms (quadriplegia or quadriparesis) of CIP were analyzed. Characteristics of patients who recovered clinically were compared with those of patients who did not. Two patients died within 2 months, 11 recovered completely, 4 remained quadriplegic and 2 remained quadriparetic. All patients suffered from sepsis, multiple organ dysfunction syndrome and a catabolic state before the onset of CIP. Outcome appears difficult to predict with clinical or electrophysiological data. Three parameters were significantly correlated with poor recovery: longer length of stay in the critical care unit, longer duration of sepsis and greater body weight loss. A relationship seems to exist between the severity of CIP and that of sepsis and its associated hypercatabolism. The favorable outcome usually attributed to CIP must be reconsidered. The authors recommend aggressive measures against sepsis to limit CIP and its sequelae.