Selective Tibial Neurotomy in the Treatment of Spastic Equinovarus Foot in Hemiplegic Patients: A 2-Year Longitudinal Follow-Up of 30 Cases

Combined Surgical Technique of Hyperselective and Partial Motor Neurectomies for Spastic Equinus, Equinovarus, and Claw Toe Deformities

Background

Patients with spastic equinus, equinovarus, and claw toe deformities can experience marked pain and functional limitations in the ability to weight-bear comfortably, ambulate efficiently, or mobilize independently. Seen in 80% of patients with cerebral palsy and 18% of patients with stroke (1, 2), the spastic foot and ankle deformities, and its secondary sequelae of static joint contractures, osseous changes, and chronic pain, are unfortunately common.

Methods

Adult and pediatric patients undergoing combined hyperselective and selective partial motor neurectomies for varus or claw toe deformities were reviewed. Patient demographics and complications were recorded. Pre- and postoperative Modified Ashworth Scale scores were compared.

Results

Twenty-three patients (16 adults and seven pediatric) met inclusion criteria and were included in analysis. At early 6-month follow-up, the mean preoperative Modified Ashworth Score of 2.8 in adult patients and 3.0 in pediatric patients decreased to 0.6 postoperatively. Complications in three adult patients included one patient with temporary dysesthesias to the plantar foot, one with a popliteal abscess requiring incision and drainage, and one superficial wound dehiscence that was managed conservatively.

Conclusions

A combined technique of hyperselective and partial motor neurectomies are effective in decreasing tone in the correction of spastic foot and ankle deformities in both adult and pediatric patients in short-term 6-month follow-up.

Anatomical study of the motor branches of the tibial nerve and incision design for hyperselective neurectomy

PURPOSE

Selective tibial neurotomy (STN) is a surgical procedure for treating spastic equinovarus foot. Hyperselective neurectomy (HSN) of tibial nerve is a modified STN procedure, which was rarely discussed. This study aimed to describe the branching patterns of the tibial nerve and propose an optimal surgical incision of HSN for treatment of spastic equinovarus foot.

METHODS

Sixteen lower limbs were dissected to determine the various branching patterns of the tibial nerve and categorized according to these branching patterns. The mean distances from the nerve entry points to the tip of femur's medial epicondyle were measured, as well as their percentage to the overall length of the leg. The surgical incision was designed according to the range of these nerve entry points.

RESULTS

The tibial nerve sent out proximal and distal motor branches based on their position relative to the soleus muscle's tendinous arch. For proximal motor branches, the branches innervating the medial gastrocnemius, lateral gastrocnemius and proximal soleus were categorized into types I (9/16), II (5/16) and III (2/16). Measurements from the medial epicondyle to the nerve entry points into the medial gastrocnemius, lateral gastrocnemius and proximal soleus ranged from 14 to 33 mm (4-9% of leg length), 22-45 mm (6-12%) and 35-81 mm (10-22%), respectively. Distal motor branches including the distal soleus, posterior tibialis, flexor digitorum longus and flexor hallucis longus, were classified as types A (8/14), B (4/14) and C (2/14), with the distances from their respective terminal points to the medial epicondyle were 67-137 mm (19-39%), 74-125 mm (20-35%), 116-243 mm (33-69%) and 125-272 mm (35-77%).

CONCLUSIONS

The motor branches of tibial nerve were classified into two groups and each subdivided into three types. Detailed location parameters may serve as an anatomical basis for designing incision of HSN.

Selective Tibial Neurotomy Outcomes for Spastic Equinovarus Foot: Patient Expectations and Functional Assessment

BACKGROUND

Spastic equinovarus foot (SEF) is a common dysfunctional foot posture after stroke that impairs balance and mobility. Selective tibial neurotomy (STN) is a simple but underutilized surgical option that can effectively address critical aspects of SEF and thereby provide enduring quality of life gains. There are few studies that examine both functional outcomes and patient satisfaction with this treatment option.

OBJECTIVE

To elucidate the patient goals that motivated their decision to undergo the procedure and compare subjective and objective changes in balance and functional mobility as a consequence of surgery.

METHODS

Thirteen patients with problematic SEF who had previously failed conservative measures were treated with STN. Preoperative and postoperative (on average 6 months) assessments evaluated gait quality and functional mobility. In addition, a custom survey was conducted to investigate patient perspectives on STN intervention.

RESULTS

The survey showed that participants who opted for STN were dissatisfied with their previous spasticity management. The most common preoperative expectation for STN treatment was to improve walking, followed by improving balance, brace comfort, pain, and tone. Postoperatively, participants rated the improvement in their expectations and were, on average, 71 on a 100-point scale, indicating high satisfaction. The gait quality, assessed with the Gait Intervention and Assessment Tool, improved significantly between preoperative and postoperative assessment (M = -4.1, P = .01) with a higher average difference in stance of -3.3 than in swing -0.5. Improvement in both gait endurance (M = 36 m, P = .01) and self-selected gait speed (M = .12 m/s, P = .03) was statistically significant. Finally, static balance (M = 5.0, P = .03) and dynamic balance (M = 3.5, P = .02) were also significantly improved.

CONCLUSION

STN improved gait quality and functional mobility and was associated with high satisfaction in patients with SEF.

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.

Nerve transfer in the spastic equino varus foot: Anatomical feasibility study

PURPOSE

We want to evaluate the feasibility of transferring a motor branch of the anterior tibial muscle (ATM) to the extensor digitorum longus (EDL) to evaluate this procedure in patients with spastic equinovarus foot (EVF) following post-stroke hemiplegia.

METHODS

Ten cadaveric dissections from five fresh frozen human cadavers were performed to establish the anatomic feasibility of transferring a motor branch of the deep peroneal nerve, usually destinated to the ATM, to the branch of the EDL to manage spastic EVF.

RESULTS

Six cases (60%) presented three branches destinated to the ATM, one case (10%) presented give branches, and three cases (30%) had four branches. In all specimens, the coaptation between the motor branch to the ATM, referred as the "effector" branch, and the branch of the EDL "receiver" branch was feasible without tension and did not require any intraneural dissection.

CONCLUSION

This anatomical study confirms the feasibility of transferring a motor branch from the ATM to the EDL to correct a spastic EVF.

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.

Evaluation methods to assess the efficacy of equinovarus foot surgery on the gait of post-stroke hemiplegic patients: A literature review

Introduction

The aim of this study was to realize a systematic review of the different ways, both clinical and instrumental, used to evaluate the effects of the surgical correction of an equinovarus foot (EVF) deformity in post-stroke patients.

Methods

A systematic search of full-length articles published from 1965 to June 2021 was performed in PubMed, Embase, CINAHL, Cochrane, and CIRRIE. The identified studies were analyzed to determine and to evaluate the outcomes, the clinical criteria, and the ways used to analyze the impact of surgery on gait pattern, instrumental, or not.

Results

A total of 33 studies were included. The lack of methodological quality of the studies and their heterogeneity did not allow for a valid meta-analysis. In all, 17 of the 33 studies involved exclusively stroke patients. Ten of the 33 studies (30%) evaluated only neurotomies, one study (3%) evaluated only tendon lengthening procedures, 19 studies (58%) evaluated tendon transfer procedures, and only two studies (6%) evaluated the combination of tendon and neurological procedures. Instrumental gait analysis was performed in only 11 studies (33%), and only six studies (18%) combined it with clinical and functional analyses. Clinical results show that surgical procedures are safe and effective. A wide variety of different scales have been used, most of which have already been validated in other indications.

Discussion

Neuro-orthopedic surgery for post-stroke EVF is becoming better defined. However, the method of outcome assessment is not yet well established. The complexity in the evaluation of the gait of patients with EVF, and therefore the analysis of the effectiveness of the surgical management performed, requires the integration of a patient-centered functional dimension, and a reliable and reproducible quantified gait analysis, which is routinely usable clinically if possible.

Neuro-Orthopedic Surgery for Equinovarus Foot Deformity in Adults: A Narrative Review

Neuro-orthopedic surgery is an alternative to the conservative treatment of spastic equinovarus foot (SEF) in adults. The objective of the present narrative review was to summarize current practice with regard to patient assessment, the choice of treatment, the various neuro-orthopedic procedures, and the latter's outcomes. We searched literature databases (MEDLINE, EMBASE, Cochrane) for original articles or opinion papers on surgical treatment of spastic equinovarus foot in adults. Neuro-orthopedic approaches require a careful analysis of the patient's and/or his/her caregiver needs and thus relevant treatment goals. Surgical planning requires detailed knowledge of impairments involved in the spastic equinovarus foot deformity based on a careful clinical examination and additional information from diagnostic nerve blocks and/or a quantitative gait analysis. Procedures mainly target nerves (neurotomy) and tendons (lengthening, transfer, tenotomy). These procedures reduce impairments (spasticity, range of motion, and foot position), improve gait and walking function, but their impact on participation and personalized treatment goals remains to be demonstrated. Neuro-orthopedic surgery is an effective treatment option for spastic equinovarus foot in adults. However, practice is still very heterogeneous and there is no consensus on the medical strategies to be applied before, during and after surgery (particularly the type of anesthesia, the need for immobilization, rehabilitation procedures).

Highly Selective Partial Neurectomy for Lower-Extremity Spasticity: 2-Dimensional Operative Video

Spasticity is a common debilitating condition after central nervous system injury. The principal therapies-sedating antispasticity medications and focal therapies (eg, botulinum toxin)-may not provide sufficient reduction in tone, have intolerable side effects, and lose efficacy over time. Selective neurectomy is a surgical option for durable reduction in tone.1-6 Although commonly performed internationally, neurectomies are used less often within the USA. We present the surgical case of a 23-yr-old woman with cerebral palsy and severe spastic diplegia. Medications, injections, and tendon surgeries had failed to relieve her spastic lower extremities. She presented with crouch gait, adductor scissoring, and bilateral equinovarus. She had previously benefitted significantly from bilateral hamstring and obturator neurectomies, with improvement in mobility. She desired tibial neurectomies for her bilateral equinovarus, which impacted her gait substantially. To reduce unwanted plantarflexion and internal rotation tone, selective neurectomies of the motor nerves to the medial and lateral gastrocnemius, soleus, and posterior tibialis muscles were performed. The surgical video details a technique for longitudinally opening the epineurium, separating small nerves into their individual fascicles, and subdividing submillimeter fascicles by approximately 50% to 60% of the fascicle cross-sectional area. She reported significant improvement in gait, her modified Ashworth score dropped from 3 to 0, and her motor power remained unchanged, which is equivalent or better than most published results.2,7 Neurectomies are a highly effective procedure for focal extremity spasticity. Additional clinical series or trials would help establish the appropriate indications and durability and quantify the risks and benefits. The patient consented to treatment and publication.

Location of motor branches of tibialis posterior muscle and its relation in treatment of spastic equinovarus foot: a cadaveric study

Background and objectives

Nerve block or neurolysis is an important approach in the treatment of spastic equinovarus foot. To illustrate the accurate location of the nerve branch to the tibialis posterior muscle (TP) in clinical practice, 21 adult cadavers were dissected and 14 complete both lower limb specimens were obtained. A total of 28 lower limbs were included.

Methods

We measured the length of the motor branch nerve (LM) of the tibialis posterior muscle, the length of the fibula (LF), the vertical distance (D1) from the midpoint of LM to the fibula tip as well as the horizontal distance (D2) from the midpoint of LM to the inner edge of the fibula.

Results

The LM was higher (35.74 ± 7.28 mm) in male than in female (30.40 ± 6.88 mm) specimens but there was no significant correlation between LM and gender (p > 0.05). Additionally, among male specimens, the LM on the right side was longer than that on the left (p ≤ 0.05) while among female specimens, the D1 on the left side was longer than that on the right (p ≤ 0.05). The LF in male specimen was significantly longer than that in female (p ≤ 0.05). The midpoint of the nerve to the motor branch of the tibialis posterior muscle was about 50 mm distal to the fibular head and 10 mm at the inner edge of the fibula.

Conclusion

Using this coordinate, the midpoint of the nerve branch to the TP could be accurately located.

Cryoneurotomy as a Percutaneous Mini-invasive Therapy for the Treatment of the Spastic Limb: Case Presentation, Review of the Literature, and Proposed Approach for Use

Objective

To provide a proof-of-concept study demonstrating that the decades old procedure of cryoneurotomy, used traditionally for analgesia, is a safe adjunctive and effective treatment for limb spasticity.

Design

Case series.

Setting

Publicly funded outpatient hospital spasticity clinic and community interventional anesthesia clinic.

Participants

Patients (N=3) who had plateaued with standard of care spasticity treatments including botulinum toxin. Two hemiplegic stroke patients with elbow spasticity and 1 pregnant patient with multiple sclerosis and a spastic equinovarus foot for whom botulinum toxin was now contraindicated.

Interventions

Selective anesthetic diagnostic motor nerve blocks with ultrasound and e-stimulation with 1cc of 1% lidocaine to the motor nerve to the targeted spastic muscle were performed to either the musculocutaneous nerve to brachialis, radial nerve to the brachioradialis or the tibial nerve. If the benefits included improved active and passive range motion and or decreased clonus, a percutaneous cryoneurotomy was performed.

Main Outcome Measures

Active and passive range of motion were measured using the Modified Tardieu Scale. The change in resistance to passive stretch was measured using the Modified Ashworth Scale (MAS). Videos of the before and after treatment were collected.

Results

Both elbows’ treatments resulted in MAS improving from a 3 to a 1+. Greatly improved active range of motion was noted at 94 and 64 degrees, respectively, as well as improvements in passive range on the Modified Tardieu Scale. The tibial nerve cryoneurotomy resulted in improvements in all parameters with a much improved gait. Results were maintained up to 17 months of follow-up.

Conclusion

Cryoneurotomy as a treatment for spasticity is a novel safe adjuvant treatment. Our initial results suggest patients can achieve significantly increased active and passive range of motion in the upper extremity and decreased clonus, and improved gait after tibial nerve cryoneurotomy.

Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques

Since ancient times, the aim of orthopedic surgery has been to correct limb and joint deformities, including those resulting from central nervous system lesions. Recent developments in the treatment of spasticity have led to changes in concepts and management strategies. The increase in life expectancy has increased the functional needs of patients. Orthopedic surgery, along with treatments for spasticity, improves the functional capacity of patients with neuro-orthopaedic disorders, improving their autonomy. In this paper, we describe key moments in the history of orthopedic surgery regarding the treatment of patients with central nervous system lesions, from poliomyelitis to stroke-related hemiplegia, from the limbs to the spine, and from contractures to heterotopic ossification. A synthesis of the current surgical techniques is then provided, and the importance of multidisciplinary evaluation and management is highlighted, along with indications for medical, rehabilitation and surgical treatments and their combinations. We explain why it is essential to consider patients' expectations and to set achievable goals, particularly before surgery, which is by nature irreversible. More recently, specialized surgical teams have begun to favor the use of soft-tissue techniques over bony and joint procedures, except for spinal disorders. We highlight that orthopedic surgery is no longer the end-point of treatment. For example, lengthening a contractured muscle improves the balance around a joint, improving mobility and stability but may be only part of the problem. Further medical treatment and rehabilitation, or additional surgery, are often necessary to continue to improve the function of the limb. Despite the recognized effectiveness of orthopedic surgery for neuro-orthopedic disorders, few studies have formally evaluated them. Hence, there is a need for research to provide evidence to support orthopedic surgery for treating neuro-orthopedic disorders.

Pronator teres selective neurectomy in children with cerebral palsy

The objective of this study was to evaluate the results after selective pronator teres (PT) neurectomy in children with spastic hemiplegia. Patients with PT spasticity without contracture and an active supination improvement after PT botulinum toxin injection were included. Hand function and deformities were evaluated with the House score, Gschwind and Tonkin pronation deformity classification and Zancolli's classification. Twenty-two patients (mean age 11.6 years) were included in this study. The average follow-up was 32.6 months. All but one patient improved their supination with a preoperative mean active supination of 5° (range -80-70°) and postoperative of 48° (range 10-90°). Active pronation was always maintained at the last follow-up. PT selective neurectomy appears to improve active and passive forearm supination and should be included in a global strategy of treatments to improve upper limb function in children with cerebral palsy.

LEVEL OF EVIDENCE

IV.

Botulinum toxin type A or selective neurotomy for treating focal spastic muscle overactivity?

OBJECTIVE

To discuss the effectiveness, indications, limitations and side effects of botulinum toxin type A and selective neurotomy for treating focal spastic muscle overactivity to help clinicians choose the most appropriate treatment.

METHODS

Expert opinion based on scientific evidence and personal experience.

RESULTS

Botulinum toxin type A can decrease muscle tone in different types of spastic muscle overactivity, which allows for treating a large variety of spastic patterns with several etiologies. The toxin effect is sometimes insufficient to improve functional outcome and is transient, thereby requiring repeated injections. Selective neurotomy is a permanent surgical treatment of the reflex component of the spastic muscle overactivity (spasticity) that is effective for spastic equinovarus foot. The neurotomy provides a greater and more constant reduction in spasticity. However, the long-lasting effect on the non-reflex muscle overactivity, especially dystonia, is doubted. The effectiveness, clinical indications, advantages, side effects and limitations of both techniques are discussed.

CONCLUSION

Botulinum toxin type A has the highest level of evidence and the largest range of indications. However, the botulinum toxin effect is reversible and seems less effective, which supports a permanent surgical treatment such as selective neurotomy, especially for the spastic foot. Further research is needed to compare the effect of botulinum toxin type A and selective neurotomy for the different types of spastic muscle overactivity and clinical patterns.

Modified Lambrinudi Arthrodesis for the Acute Treatment of Neurogenic Clubfoot: A Case Report

Neurogenic contracture often results in spastic, nonreducible equinovarus deformity. Rigid contracture leads to pain, instability, and bracing difficulties. This case report details the utilization of the modified Lambrinudi triple arthrodesis intended to create a plantigrade, functional limb that is amenable to an extremity brace in a case of an acquired neurologic clubfoot.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case Report.

Establishing reconstructive neurosurgery as a subspecialty

Neurosurgery is experiencing the emergence of a new subspecialty focused on function restoration. New, evolving, and reappraised surgical procedures have provided an opportunity to restore function to many patients with previously undertreated disorders. Candidates for reconstruction were previously limited to those with peripheral nerve and brachial plexus injuries, but this has been expanded to include stroke, spinal cord injury, and a host of other paralyzing disorders affecting both upper and lower motor neurons. Similar to the recent evolution of the well-established subdisciplines of spinal and vascular neurosurgery, reconstructive neurosurgery requires the adaptation of techniques and skills that were not traditionally a part of neurosurgical training. Neurosurgeons—as the specialists who already manage this patient population and possess the requisite surgical skills to master the required techniques—have a unique opportunity to lead the development of this field. The full development of this subspecialty will lay the foundation for the subsequent addition of emerging treatments, such as neuroprosthetics and stem cell–based interventions. As such, reconstructive neurosurgery represents an important aspect of neurosurgical training that can ameliorate many of the deficits encountered in the traditional practice of neurosurgery.

Neurotomy of the rectus femoris nerve: Short-term effectiveness for spastic stiff knee gait: Clinical assessment and quantitative gait analysis

BACKGROUND

Stiff knee gait is a troublesome gait disturbance related to spastic paresis, frequently associated with overactivity of the rectus femoris muscle in the swing phase of gait.

OBJECTIVE

The aim of this study was to assess the short-term effects of rectus femoris neurotomy for the treatment of spastic stiff-knee gait in patients with hemiparesis.

PATIENTS AND METHODS

An Intervention study (before-after trial) with an observational design was carried out in a university hospital. Seven ambulatory patients with hemiparesis of spinal or cerebral origin and spastic stiff-knee gait, which had previously been improved by botulinum toxin injections, were proposed a selective neurotomy of the rectus femoris muscle. A functional evaluation (Functional Ambulation Classification and maximal walking distance), clinical evaluation (spasticity - Ashworth scale and Duncan-Ely test, muscle strength - Medical Research Council scale), and quantitative gait analysis (spatiotemporal parameters, stiff knee gait-related kinematic and kinetic parameters, and dynamic electromyography of rectus femoris) were performed as outcome measures, before and 3 months after rectus femoris neurotomy.

RESULTS

Compared with preoperative values, there was a significant increase in maximal walking distance, gait speed, and stride length at 3 months. All kinematic parameters improved, and the average early swing phase knee extension moment decreased. The duration of the rectus femoris burst decreased post-op.

CONCLUSION

This study is the first to show that rectus femoris neurotomy helps to normalise muscle activity during gait, and results in improvements in kinetic, kinematic, and functional parameters in patients with spastic stiff knee gait.

Effects of tibial nerve neurotomy on posture and gait in stroke patients: A focus on patient-perceived benefits in daily life

OBJECTIVE

To evaluate the objective and subjective functional effectiveness of tibial nerve neurotomy (TNN) in post-stroke spastic equinovarus foot (SEF).

METHODS

In an open study, 23 hemiplegic patients were assessed immediately before TNN and then 5months after TNN. The main outcome measure was the Lower Limb Function Assessment Scale (LL-FAS), which provided an ecologic assessment of impairments in standing and walking (i.e. kinematic abnormalities) and their impacts on activities of daily living. Patients were also assessed for global clinical impression of change, fear of falling, neuromotor impairments, spatiotemporal and video gait parameters and walking capacities.

RESULTS

TNN had a very marked effect on the level of spasticity and the range of motion in dorsiflexion (p<10(-3)). These changes resulted in better foot positioning when standing and walking (particularly in stance), which was perceived very favorably by the patients. There was a clear, patient-perceived improvement in activities performed when standing and walking (LL-FAS (p<0.01)), the global clinical impression of change (p<10(-3)) and the fear of falling (p=0.022) that was not revealed by conventional, objective measurements (New Functional Ambulation Classification, Rivermead Mobility Index).

CONCLUSION

TNN is an effective treatment for post-stroke SEF; it is associated with a patient-reported improvement in standing and walking abilities during activities of daily living. Further research must now assess the long-term subjective efficacy of TNN.

Treatment of dystonia in extensor hallucis longus and digitorum muscles with neurotomy of the branches of the deep fibular nerve: Preliminary results

INTRODUCTION

Dystonia in extensor hallucis and/or digitorum muscles can be observed in pyramidal and extrapyramidal lesions and results in pain in these toes, spontaneous or when walking, problems and discomfort when putting on shoes and socks, and cutaneous lesions on the toes. The objective of this study was to assess the efficacy and safety of deep fibular nerve neurotomy for the extensor hallucis longus (EHL) and/or the extensor digitorum longus (EDL) branches in the treatment of extension dystonia of the hallux and/or other toes.

PATIENTS AND METHODS

A deep fibular nerve neurotomy was performed in 20 patients (n=19 for the EHL, n=6 for the EDL). We retrospectively analyzed the treatment's efficacy and safety and assessed the patients' self-reported improvement and overall treatment satisfaction.

RESULTS

Dystonia totally disappeared in 15 cases (75%); it persisted at a minimal level in the other patients. The patients reported a decrease in pain (P<0.01) and fewer difficulties putting on shoes and socks (P<0.001) and had a high median level of satisfaction (8.5/10). Adverse effects were rare and transient. The identification of the nerve branches was sometimes difficult.

DISCUSSION

Deep fibular nerve neurotomy for the EHL and/or EDL branches seems to be an effective treatment for extension dystonia of the hallux and/or other toes and its consequences for the adult neurological patient. However, these encouraging preliminary results should be confirmed by prospective, longer-term studies.

Comparison between tibial nerve block with anaesthetics and neurotomy in hemiplegic adults with spastic equinovarus foot

OBJECTIVE

The aim of the study was to compare the effect of diagnostic motor nerve block with anaesthetics and of selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic adults.

METHODS

In this prospective observational study, 30 hemiplegic adults with spastic equinovarus foot benefited from a diagnostic nerve block with anaesthetics followed by a selective tibial neurotomy performed at the level of the same motor nerve branches of the tibial nerve. Spasticity (Ashworth scale), muscle strength (Medical Research Council scale), passive ankle dorsiflexion (ROM), gait parameters (10 meters walking test) and gait kinematics (video assessment) were assessed before and after the nerve block and two months and two years after selective tibial neurotomy.

RESULTS

The decrease in spasticity and the improvement in gait kinematics were similar after the diagnostic nerve block and two months and two years after neurotomy. The diagnostic nerve block did not revealed the slight increase in gait speed and in tibialis anterior muscle strength that was observed two years after neurotomy.

CONCLUSION

This study suggests that diagnostic nerve block with anaesthetics and selective neurotomy equally reduce spasticity and improve gait in case of spastic equinovarus foot in hemiplegic adults. Diagnostic nerve block can be used as a valuable screening tool before neurotomy.

A Randomized Controlled Trial of Selective Neurotomy Versus Botulinum Toxin for Spastic Equinovarus Foot After Stroke

Background. Selective neurotomy is a permanent treatment of focal spasticity, and its effectiveness in treating spastic equinovarus of the foot (SEF) was previously suggested by a few nonrandomized and uncontrolled case-series studies. Objectives. This study is the first assessor-blinded, randomized, controlled trial evaluating the effects of this treatment. Methods. Sixteen chronic stroke patients presenting with SEF were randomized into 2 groups: 8 patients underwent a tibial neurotomy and the remaining 8 received botulinum toxin (BTX) injections. The soleus was treated in all patients, and the tibialis posterior and flexor hallucis longus were treated in about half of patients. The primary outcome was the quantitative measurement of ankle stiffness (L-path), an objective measurement directly related to spasticity. Participants were assessed by a blind assessor before their intervention and at 2 and 6 months after treatment. Evaluations were based on the 3 domains of the International Classification of Functioning, Disability and Health (ICF). Results. Compared with BTX, tibial neurotomy induced a higher reduction in ankle stiffness. Both treatments induced a comparable improvement of ankle kinematics during gait, whereas neither induced muscle weakening. Activity, participation, and quality of life were not significantly modified in either group. Conclusions. This study demonstrates that the tibial nerve neurotomy is an effective treatment of SEF, reducing the impairments observed in chronic stroke patients. Future studies should be conducted to confirm the long-term efficacy based on the ICF domains.