Uncontrolled spasticity poses a therapeutic challenge for physicians. Managing spasticity and spasms in patients with spinal cord injuries without knowing other putative diagnoses, can lead to an inappropriate increase of antispastic drugs and sometimes to the surgical implant of intrathecal baclofen (ITB) pump.

A 48-year-old man with a Th4 AIS-A paraplegia secondary to ballistic wounds in 2004, was referred to our spasticity consultation for uncontrolled spasms despite an ITB pump, implanted in 2007 and replaced in 2012, with a satisfying relief until then.

Since 2014, he has been progressively hampered by disabling spasms, occurring mostly when fishing, or lying down. X-rays showed a catheter's top extremity reaching Th11, and an indium scintigraphy revealed an appropriate infusion of baclofen. A spine MRI showed a known and stable syringomelic cyst. Between 2014 and 2015, the ITB flow was increased to 960μg/day in continuous mode without significant change. It was decided to replace the catheter and the pump considering the strong suspicion of dysfunction of the material. The infusion mode was secondary switched to discontinuous boluses, until a maximum of 1200μg/day by the end of 2016 without any efficacy. Our clinical evaluation revealed frequent lower limbs spasms (Penn score=3), and did not retrieve any irritative factors. A direct ITB injection via lumbar puncture had no effect on his symptoms.

We got intrigued by the reported multiple awakenings caused by spontaneous spasms. We therefore conducted a nocturnal polysomnography, which results were the following: periodic limb movements (PLM) index of 56 events per hours of sleep, and PLM arousals of 15/h. A treatment with pramipexole was initiated at the daily dose of 0.18mg. Nocturnal spams and recorded PLM significantly diminished, enabling us to decreased ITB doses to 375μg/day, without any further complaints.

PLM has been described in SCI patients, but this is the first time it is identified as a differential for spasticity. Facing spasms which prevails at night or in the supine position, physicians have to think about PLM before interpreting them as a non-or-partial response to antispastic drugs, keeping in mind that spasticity and PLM can be associated.