INDICES> phenol injection? (2)

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INDICES> phenol injection? (2)
----------------------------------------

> We have a query from a doctor who is attending to a spinal injury
> patient with muscular spasm which generally responds to baclofen. He
> wants to inject phenol in glycerin or phenol in arachis oil/almond
> oil. We know about phenol 5% or 10% in oil for varicose veins or
> hemmorhoids but would like to know if anyone has any knowledge of
> phenol for this purpose. There's a little in an older Martindale and
> little on drugdex/medline.

Dear Joe,

I am passing on a reference from drugdex. I have found some more references
on
medline. But the drugdex one is more helpful as it also describes the
preparation procedure for injection.

Also check out  " Muscle & Nerve" Volume 20, Issue S6, 1997. This whole
issue is
on spasticity and its therapy. I am attaching the abstract of a review from
this
issue also with this mail.

First reference from Drugdex

The use of PHENOL for NERVE BLOCK has been documented in numerous clinical
trials. Investigators have described the use of various concentrations of
phenol
and different vehicles for nerve block, which include phenol 5% in oil
(Doyle,
1982), phenol 3% in water (Mullin, 1980), phenol 7% in water (Nomoto et al,
1987), phenol 3% in glycerine (Garland et al, 1982), and phenol 6% in 0.9%
sodium chloride (Racz et al, 1982). But the compounding procedure and
stability
of the phenol solution used in these studies have not been described .
A thorough search of the literature did not reveal specific data on the
preparation of phenol for injection (Lit Search, 1990).
Solubility data of phenol is available and may be useful in the
determination of
a compatible preparation. The SOLUBILITY of phenol is good in water (1:15),
and
superior in glycerol (3:1) (Wade, 1977). The miscibility of phenol in water
may
be increased by the addition of glycerin; a solution of 10% phenol, 75%
water,
and 15% glycerin achieves complete dissolution of phenol (Matyba et al,
1975).
 STERILIZATION of phenol solutions containing glycerin has been performed by
exposing hermetically sealed containers to 150 degrees C heat for one hour,
and
aqueous solutions have been autoclaved to achieve sterilization (Wade,
1977).
Specific information on storage requirements could not be located (Lit
Search,
1990), but general recommendations include storage in airtight containers
and
protect from light (Wade, 1977).
CONCLUSION:
No specific data on the preparation or stability of phenol solutions used as
an
injection could be found in the medical literature; however, phenol 3% to 7%
in
water, oil, 0.9% sodium chloride, or glycerin used as an injection for nerve
block has been described by several investigators. Heat has been recommended
in
the sterilization of phenol solutions for injection.
REFERENCES:
1. Doyle D: Nerve blocks in advanced cancer. Practitioner, 1982 226:539-544.
2. Garland DE, Lilling M & Keenan MA: Percutaneous phenol blocks to motor
points
of spastic forearm muscles in head-injured adults. Arch Phys Med Rehabil
1984;
65:243-245.
3. Garland DE, Lucie RS & Waters RL: Current uses of open phenol nerve block
for
adult acquired spasticity. Clin Orthop 1982; 165:217-222.
4. Literature Search: Medline 1960-1990.
5. Matyba ER et al: Can Pharm J (per abstract) 1975; 90:438.
6. Mullin V: Brachial plexus block with phenol for painful arm associated
with
pancoast's syndrome. Anesthesiology 1980; 53:431-433.
7. Nomoto Y, Fujita T & Kitani Y: Serum and urine levels of phenol following
phenol blocks. Can J Anaesth 1987; 34:307-310.
8. Racz GB, Sabonghy M, Gintautas J et al: Intractable pain therapy using a
new
epidural catheter. JAMA 1982; 579-581.
9. Wade A (Ed): Martindale: The Extra Pharmacopoeia. 27th ed. The
Pharmaceutical
Press, London, UK 1977.


Second Reference from Muscle & Nerve

Traditional pharmacological treatments for spasticity part I: Local
treatments

Jean-Michel Gracies, MD, PhD 1 *, Elie Elovic, MD 2, John McGuire, MD 3,
David
Simpson, MD 4
1Department of Neurology, The Mount Sinai Medical Center, New York, NY
2Center for Head Injuries, JFK Johnson Rehabilitation Institute, Edison NJ
3Rehabilitation Institute of Chicago, Chicago, IL
4Departments of Neurology and Clinical Neurophysiology, The Mount Sinai
Medical
Center, New York, NY
 Keywords
 spasticity; muscle overactivity; local anesthetic; lidocaine; bipuvicaine;
etidocaine; neurolysis; ethyl alcohol; phenol; botulinum toxin
Abstract
Spasticity is a velocity-dependent increase in stretch reflex activity. It
is
one of the forms of muscle overactivity that may affect patients with damage
to
the central nervous system. Spasticity monitoring is relevant to function
because the degree of spasticity may relect the intensity of other disabling
types of muscle overactivity, such as unwanted antagonistic co-contractions,
permanent muscle activity in the absence of any stretch or volitional
command
(spastic dystonia), or inappropriate responses to cutaneous or vegetative
inputs. In addition, spasticity, like other muscle overactivity, can cause
muscle shortening, which is another significant source of disability.
Finally,
spasticity is the only form of muscle overactivity easily quantifiable at
the
bedside. Under the name pharmacological treatments of spasiticity, we
understand
the use of agents designed to reduce all types of muscle overactivity, by
reducing excitability of motor pathways, at the level of the central nervous
system, the neuromuscular junctions, or the muscle. Pharmacologic treatment
should be an adjunct to muscle lengthening and training of antagonists.
Localized muscle overactivity of specific muscle groups is often seen in a
number of common pathologies, including stroke and traumatic brain injury.
In
these cases, we favor the use of local treatments in those muscles where
overactivity is most disabling, by injection into muscle (neuromuscular
block)
or close to the nerve supplying the muscle (perineural block). Two types of
local agents have been used in addition to the newly emerged botulinum
toxin:
local anesthetics (lidocaine and congeners), with a fully reversible action
of
short duration, and alcohols (ethanol and phenol), with a longer duration of
action. Local anesthetics block both afferent and efferent messages. The
onset
of action is within minutes and duration of action varies between one and
several hours according to the agent used. Their use requires resuscitation
equipment available close by. When a long-lasting blocking agent is being
considered, we favor the use of transient blocks with local anesthetics for
therapeutic tests or diagnostic procedures to answer the following
questions:
Can function be improved by the block? What are the roles played by
overactivity
and contracture in the impairment of function? Which muscle is contributing
to
pathologic posturing? What is the true level of performance of antagonistic
muscles? A short-acting anesthetic can also serve as preparation to casting
or
as an analgesic for intramuscular injections of other antispastic treatment.
Alcohol and phenol provide long-term chemical neurolysis through destruction
of
peripheral nerve. Experience with ethanol is more developed in children
using
intramuscular injection, while experience with phenol is greater in adults
with
perineural injection. In both cases, there are anecdotal reports of efficacy
but
studies have rarely been controlled. Side effects are numerous and include
pain
during injection, chronic dysesthesia and chronic pain, and episodes of
local or
regional vascular complications by vessel toxicity. In the absence of
controlled
studies, a theoretical comparison of neurolytic agents with botulinum toxin
is
proposed. Neurolytic agents may by preferred to botulinum toxin on a number
of
grounds, including earlier onset, potentially longer duration of effect,
lower
cost, and easier storage.
Conversely, pain during injection, tissue destruction with chronic sensory
side
effects, and lack of selectivity on motor function with neurolytic agents
may
favor the use of botulinum toxin. Neurolytic agents and botulinum toxin may
be
used in combination, the former for larger proximal muscles and the latter
for
selective injection into distal muscles. In the future, neurolytic agents
may
prove more appropriate in very severely affected patients for whom the
purposes
of the block are comfort and hygiene. Conversely, botulinum toxin may be
better
indicated in patients for whom there is hope for functional improvement in
the
affected limb, since the integrity of sensory afferents is indispensable.
Controlled comparative studies between neurolytic agents and botulinum toxin
are
needed in specific patient populations to help determine the most
appropriate
applications of each. © 1997 John Wiley & Sons, Inc. Spasticity: Etiology,
Evaluation, Management, and the Role of Botulinum Toxin Type A, MF Brin,
editor.
Muscle Nerve 1997; 20 (suppl 6):S61-S91.

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*Correspondence to Jean-Michel Gracies, Department of Neurology, The Mount
Sinai
Medical Center, One Gustave L. Levy Place, New York, NY 10029


I hope this helps?

Ayesha Ahmed
Drug Information Helpline



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