ERECTOR SPINAE PLANE AS AN ALTERNATIVE ROUTE FOR MESENCHYMAL STEM CELL DELIVERY IN ALS: ANATOMICAL RATIONALE, TECHNIQUE AND CLINICAL CASE

Abstract

Introduction. Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized by high mortality and the absence of effective etiological therapy. Modern experimental approaches, particularly the use of mesenchymal stem cells (MSCs), demonstrate significant neuroprotective and immunomodulatory properties; however, the optimal route for delivering cells into the central nervous system remains unresolved. Invasive methods (intrathecal and intramedullary administration) carry procedural risks, whereas the epidural approach results in limited penetration of cells into the subarachnoid space. Given the anatomical continuity between fascial compartments and the epidural canal, the erector spinae plane (ESP) is considered a potentially viable alternative pathway for transporting cellular preparations toward CNS structures. Objective. To substantiate the anatomical and clinical feasibility of administering mesenchymal stem cells into the erector spinae plane as an alternative method of cell delivery in ALS and to demonstrate its applicability through a clinical case. Materials and Methods. An analysis was performed of the pathogenetic mechanisms of ALS, current MSC delivery routes to the CNS, anatomical features of the ESP compartment, and its potential connection with the epidural space. The technique of ultrasound-guided high-thoracic ESP injection of MSCs (Th2– Th5) is described, including equipment preparation, patient positioning, needle insertion technique, aspiration control, test injection, main injection of the cellular product, temperature conditions, and infusion rate. The MSC preparation used had a concentration of 10 million cells/mL, with 20 mL administered on each side bilaterally. Clinical Case. A 37-year-old patient with ALS, predominantly affecting the lower motor neuron and resulting in flaccid tetraparesis, was evaluated. During combined cell therapy (intrathecal + intravenous), partial clinical improvement was observed, including enhanced gait stability and fine motor function. On examination, muscle strength was reduced mainly in the lower extremities (1–4 points depending on the segment), with impaired coordination, instability in the Romberg position, and partial preservation of self-care abilities. An ultrasound-guided bilateral ESP injection of MSCs at the upper thoracic level was performed. The procedure confirmed adequate cranial spread of the cellular preparation along the fascial plane. All conditions necessary to maintain MSC viability were ensured during administration. Conclusions. The erector spinae plane may be considered a potentially safe and less invasive route for delivering mesenchymal stem cells to central nervous system structures. The anatomical relationship between the ESP compartment and the epidural canal provides a basis for partial migration of cells toward the subarachnoid space, potentially enhancing the efficacy of cell therapy in ALS. The presented clinical case demonstrates the technical feasibility and possible clinical relevance of this approach. Further studies are required to evaluate its therapeutic effectiveness and to determine optimal parameters for MSC administration via the ESP.