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

2. 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 )

3. 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

4. Investigation

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

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

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

8. 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+

9. 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

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