How I do it: selective tibial neurotomy

Selective Tibial Neurotomy for Spastic Equinovarus Foot: Operative Technique

BACKGROUND AND OBJECTIVES

Spastic equinovarus foot (SEF) is a common complication of stroke and other upper motor neuron injuries. It is characterized by a plantigrade and inverted foot, often with toe curling, causing significant disability from pain, gait, and balance difficulties. Management includes physical therapy, antispasticity drugs, orthoses, chemical neurolysis, or botulinum toxin, all of which may be insufficient, sedating, or transient. Selective tibial neurotomy (STN) provides a surgical option that is effective and long-lasting. Our goal is to provide a concise description of our technique for performing the STN for treatment of SEF. We discuss the standard posterior approach with surgical variations used by other groups and a medial approach, should the posterior approach be insufficient.

METHODS

A posterior leg approach allows access to the tibial nerve and its branches to the bilateral gastrocnemius muscles, soleus, posterior tibialis, and extrinsic toe flexors. A medial approach is used if the toe flexors cannot be accessed sufficiently from the posterior approach. Nerve branch targets identified by preoperative functional assessment are carefully exposed and fully neurolysed distally to identify all terminal branches to each muscle of interest before neurotomy.

RESULTS

The STN is a powerful tool for treating SEF, with an immediate and lasting effect. Approximately 80% of the target muscle should be denervated to ensure long-term efficacy while maintaining adequate function of the muscle through collateral innervation.

CONCLUSION

The STN is a safe and effective outpatient procedure that can be performed by an experienced nerve surgeon to improve balance and ambulation and reduce pain for patients with SEF. Large clinical trials are necessary to further establish this underutilized procedure in the United States.

Evaluation of Selective Tibial Neurotomy for the Spastic Foot Treatment Using a Personal Goal-Centered Approach: A 1-Year Cohort Study

BACKGROUND

Selective tibial neurotomy (STN) has already demonstrated its effectiveness to reduce foot deformities and spasticity, but assessment according to a goal-centered approach is missing.

OBJECTIVE

To evaluate the effectiveness of STN associated with a postoperative rehabilitation program for the treatment of the spastic foot, according to a goal-centered approach.

METHODS

Interventional study (before-after STN and rehabilitation program) with observational design including consecutive adult patients with spastic foot, who received STN followed by a rehabilitation program, was performed. The primary outcome measure was the achievement of individual goals at the 1-year follow-up using the Goal Attainment Scaling methodology (with T-score). The secondary outcomes measures were the Modified Ashworth Scale and the modified Rankin Score.

RESULTS

A total of 104 patients were included. At the 1-year follow-up, 228/252 (90.5%) goals were achieved: 62/252 (24.6%) were achieved as initially expected, 86/252 (34.1%) were achieved better than initially expected, and 80 (31.7%) were achieved much better than initially expected. The mean T-score was significantly increased at the 1-year follow-up (61.5 ± 10.5) compared with the preoperative period (38.1 ± 2.9, P < .00001), and 95/104 (91.3%) patients had a T-score ≥50, meaning that these patients have achieved their goals. At follow-up, spastic deformities were all significantly decreased ( P < .0001), the Modified Ashworth Scale was significantly lower for each muscle targeted ( P < .0001), and the modified Rankin Score was significantly decreased ( P < .0001) allowing the patient population to improve from a moderate to a slight disability status.

CONCLUSION

This study showed that STN, associated with a postoperative rehabilitation program, successfully achieve personal goals in patients with spastic foot.

Pain Relief Following Selective Tibial Neurotomy for Spastic Equinus Foot Secondary to Stroke and Traumatic Brain Injury

OBJECTIVE

Selective tibial neurotomy (STN) has been indicated for spastic equinus foot (SEF); however, the impact of this procedure on quality of life and activities of daily living has not been evaluated in detail. This study aimed to evaluate the surgical outcomes of STN and its effect on SEF accompanied by pain.

METHODS

We evaluated 26 patients (mean age: 59.6 ± 15.2 years; 14 men and 12 women) who underwent STN for SEF, 10 of whom complained of spontaneous pain preoperatively. We used the following scales for clinical evaluation: the Modified Ashworth Scale, Medical Research Council (MRC), 10-m walking test, Functional Independence Measure, and numeric rating scale for pain. These scales were evaluated preoperatively and postoperatively. Differences in clinical characteristics were compared between the 10 patients with pain and the 16 patients without pain.

RESULTS

Significant differences were observed in all evaluation scale scores except for the Functional Independence Measure, and no serious adverse events were reported. Pain intensity was significantly improved from 6.4 ± 2.0 to 2.7 ± 2.3 (P < 0.05). An analysis showed that the preoperative mean Medical Research Council score of ankle movement was significantly lower in patients with pain but recovered to the same level postoperatively at the 6-month follow-up.

CONCLUSIONS

Our study showed significant improvements in spasticity and its associated symptoms, and STN effectively addressed spastic pain and motor weakness. Among various treatment modalities, STN may be positively indicated for patients with spastic pain in the lower leg.

Combined selective peripheral neurotomy in the treatment of spastic lower limbs of spinal cord injury patients

Objective

To explore the therapeutic effect of combined selective peripheral neurotomy (cSPN) on the spasm of the lower limbs after spinal cord injury.

Methods

A prospective intervention (before-after trial) with an observational design was conducted in 14 spinal cord injury patients with severe lower limbs spasticity by cSPN. Given the severe spasm of hip adductor, triceps surae, and hamstring muscles in these patients, a total of 26 obturator nerve branches, 26 tibia nerve branches, and 4 sciatic nerve branches partial neurotomy were performed. The modified Ashworth scale, composite spasticity scale, surface electromyography, gait analysis, functional ambulation category, spinal cord independence measure, and modified spinal cord injury–spasticity evaluation tool were used before and after surgery.

Results

Compared with preoperative, the spasm of the hip adductor, triceps surae, and hamstrings of the lower limbs in the postoperative patients decreased significantly. The abnormal gait of knee flexion and varus in the standing stage were significantly reduced. The grading of walking ability and activities of daily living were significantly improved.

Conclusions

Combined selective peripheral neurotomy can significantly reduce the spasm of lower limbs post spinal cord injury, improve abnormal gait, and improve motor function and activities of daily living.

Trial registration

ChiCTR1800019003 (2018–10-20).