Neurosurgery for spasticity

[Anatomical cartography of the radial nerve at the elbow level for intraradial nerve transfers for finger extension reconstruction in spastic upper limb - A cadaveric study]

INTRODUCTION

Upper limb spasticity is a surgical challenge, both in diminishing agonists spasticity and reconstructing antagonist function. Brachioradialis (BR) is often involved in elbow flexors spasticity. Finger extension is often impaired in spastic patients. This study aims to demonstrate the feasibility of BR motor branch to posterior interosseous nerve (PIN) during BR selective neurectomies, and to describe fascicles topography inside the radial nerve to facilitate PIN dissection.

MATERIAL AND METHOD

Ten upper limbs from 10 fresh frozen anatomical specimens were dissected. Motor branches to the BR, wrist extensors, supinator, PIN and radial sensory branch were identified. BR to PIN transfer was realized and its feasibility was studies (donor length, tensionless suture).

RESULTS

BR to PIN transfer was achievable in 9 out of 10 cases. The position of the sensory branch of the radial nerve was inferior or medial in all cases. The position of the PIN was lateral in 90% of the cases.

CONCLUSION

BR to PIN nerve transfer is achievable in most cases (90%). The lateral topography of the PIN and the inferomedial topography of the sensory branch in most cases allows for an easier intraoperative finding of the PIN when stimulation is not possible.

LEVEL

IV, feasibility study.

Cervical dorsal rhizotomy for upper limbs spasticity. Case report

Spasticity is a prevalent symptom of upper motor neuron syndrome, becoming debilitating when hindering voluntary movement and motor function and causing contractures and pain. Functional neurosurgery plays a crucial role in treating severe spasticity. Despite extensive literature on SDR for lower limb spasticity, there is a scarcity of papers regarding the procedure in the cervical region to alleviate upper limb spasticity. This case report details a cervical dorsal rhizotomy (CDR) performed for upper limb spasticity, resulting in significant improvement in spasticity with sustained outcomes and low complication rates. Neuroablative procedures like CDR become an option to treat spasticity.

Neurectomies for treatment of stroke-related upper extremity spasticity

Limb spasticity due to central nervous system lesions can lead to substantial functional impairment. This is particularly challenging when the patient retains control of limb movements. This intraoperative video demonstrates selective neurectomies to improve spasticity. The case of a patient with left spastic hemiplegia after stroke who requested peripheral neurectomies for durable treatment of left elbow flexion spasticity is shown. The patient had substantial improvement in resting tone and achieving a relaxed, near-full extension at rest. He retains elbow flexion, which has improved in subsequent clinical follow-up evaluation. Highly selective partial denervation surgery can successfully reduce spasticity. The video can be found here: https://stream.cadmore.media/r10.3171/2022.9.FOCVID22106.

Assessment, goal setting, and botulinum neurotoxin a therapy in the management of post-stroke spastic movement disorder: updated perspectives on best practice

INTRODUCTION

Post-stroke spastic movement disorder (PS-SMD) appears up to 20% in the first week following stroke and 40% in the chronic phase. It may create major hurdles to overcome in early stroke rehabilitation and as one relevant factor that reduces quality of life to a major degree in the chronic phase.

AREAS COVERED

In this review, we discuss predictors,early identification, clinical assessments, goal setting, and management in multiprofessional team, including Botulinum neurotoxin A (BoNT-A) injection for early and chronic management of PS-SMD.

EXPERT OPINION

The earlier PS-SMD is recognized and managed, the better the outcome will be. The comprehensive management in the subacute or chronic phase of PS-SMD with BoNT-A injections requires detailed assessment, patient-centered goal setting, technical-guided injection, effective dosing of BoNT-A per site, muscle, and session and timed adjunctive treatment, delivered in a multi-professional team approach in conjunction with physical treatment. Evidence-based data showed BoNT-A injections are safe and effective in managing focal, multifocal, segmental PS-SMD and its complications. If indicated, BoNT-A therapy should be accompanied with adjunctive treatment in adequate time slots. BoNT-A could be added to oral, intrathecal, and surgical treatment in severe multisegmental or generalized PS-SMD to reach patient/caregiver's goals, especially in chronic PS-SMD.

A Case of Dentatotomy for Pain and Spasticity and Systematic Review

BACKGROUND

Surgical interventions for spasticity aim to improve motor function and pain in cases that are refractory to medical treatment. Ablation of the cerebellar dentate nucleus (dentatotomy) may be a useful alternative.

CASE REPORT

A 55-year-old male patient with spasticity, secondary to a traumatic cervical spinal cord injury with quadriparesis, had bilateral lumbar DREZotomy with an improvement that lasted for 6 years. Ten years after the DREZotomy, a progressive increased spasticity manifested as spastic diplegia (Ashworth 4) and spontaneous muscle painful spasms (Penn 4), as well as spasticity in the upper extremities, predominantly on the right side (Ashworth 3). A right radio frequency dentatotomy was performed with intraoperative electrophysiological monitoring. Spasticity scales were applied at the following times: preoperative and at 1 and 8 months after surgery. During the first month, the patient presented a clear decrease in spasticity ipsilateral to the side of lesioning (Ashworth 1) and of painful spasms in the lower extremities (Penn 1). After 8 months, spasticity ipsilateral to the injury decreased even more to Ashworth (0), but a progressive increase in muscle spasms of lower extremities was observed (Penn 2).

CONCLUSION

Stereotactic dentatotomy may be an effective surgical alternative for management of spasticity associated with painful spasms in selected patients.

The therapeutic effects of ablative neurosurgical procedures on the spinal cord for intractable spinal spasticity

STUDY DESIGN

This research is a retrospective study.

OBJECTIVE

To study the therapeutic effects of operative procedures, including dorsal longitudinal myelotomy (DLM) and dorsal root entry zone lesion (DREZL) on spasticity and associated aspects.

SETTING

Tertiary university hospital in Bangkok, Thailand.

METHODS

Eighteen patients with refractory spasticity of spinal origin who underwent the operations were recruited. Clinical parameters for evaluating severity of spasticity and ambulatory status were compared between before and after surgery, and between surgeries.

RESULTS

A statistically significant reduction of spasticity as measured by the Modified Ashworth Scale (MAS), Adductor Tone Rating Scale (ATRS) and Penn Spasm Frequency Scale (PSFS) was found after surgeries and in the overall analysis (p < 0.05). Chronic pressure ulcers disappeared postoperatively in 11 cases. All of 7 bed-ridden subjects experienced improvement in their ambulatory status postoperatively. DLM was found to be more effective than DREZL in reduction of spasticity.

CONCLUSION

Ablative neurosurgery on the spinal cord is still valuable in situations when intrathecal baclofen is unavailable. These operations are potentially effective in the treatment of intractable spasticity of spinal origin.

Computed Tomography-guided Percutaneous Trigeminal Tractotomy-nucleotomy

Objective:

The destruction of the descending trigeminal tractus in the medulla is known as trigeminal tractotomy (TR), whereas the lesioning of the nucleus caudalis is known as trigeminal nucleotomy (NC). Trigeminal TR and/or NC procedures can be used in a large group of pain syndromes, such as glossopharyngeal, vagal, and geniculate neuralgias, atypical facial pain, craniofacial cancer pain, postherpetic neuralgias, and atypical forms of trigeminal neuralgia.

Methods:

In this study, anatomic and technical details of the procedure and the experience gained from 65 patients over the course of 20 years are discussed. Patients’ pain scores and Karnofsky Performance Scale scores were evaluated pre- and postoperatively (postoperative Day 1).

Results:

The best results were obtained in the second-largest group (vagoglossopharyngeal neuralgia, n = 17) and in geniculate neuralgia (n = 4). Patients with atypical facial pain (n = 21; 13 women, eight men) accounted for the largest group to undergo computed tomography-guided TR-NC surgery; pain relief was achieved in 19 of these patients. In the third-largest group (craniofacial and oral cancer pain, n = 13), 11 of 13 patients were successfully treated with TR-NC. Four of five patients with failed trigeminal neuralgia were also effectively treated with TR-NC.

Conclusion:

We propose that computed tomography-guided TR-NC provides direct visualization of the target-electrode relation and can be considered a first-step procedure in patient management. In view of its high efficacy, low complication rate, and minimal invasiveness, computed tomography-guided trigeminal TR-NC is a safe and effective procedure in the treatment of intractable facial pain syndromes.

Long term results of microsurgical dorsal root entry zonotomy for upper extremity spasticity

OBJECTIVE

The purpose of the present study is to assess the long-term results of microsurgical dorsal root entry zonotomy (MDT) for the treatment of medically intractable upper-extremity spasticity.

METHODS

The records of nine adult patients who underwent MDT by one operating neurosurgeon from March 1999 to June 2004 were retrospectively reviewed by another investigator who had no role in the management of these patients. In all patients, MDT was performed on all roots of the upper limb (from C5 to T1) for spasticity of the upper extremity. The degree of spasticity was measured by the Modified Ashworth Scale (grade 0-4). Severity of the pain level was determined using the Numeric Rating Scale (NRS, score 0-10). Also, patient satisfaction of the post-operative outcome was assessed.

RESULTS

Comparing the preoperative and postoperative spasticity using the Modified Ashworth Scale, we observed improvement in all patients, particularly in five of the nine patients (55.6%) who improved by three grades over an average of 66.4 months (range, 40-96). Regarding patient satisfaction, seven patients (77.8%) had affirmative results. None of the patients experienced severe, life-threatening, postoperative complications. We observed a decrease in the intensity of painful spasms to less than three scores as measured by NRS in all four patients with associated pain.

CONCLUSION

This study shows that MDT provides significant, long-term reduction of harmful spasticity and associated pain in the upper limbs.

Intrathecal antispastic drug application with implantable pumps: results of a 10 year follow-up study

Since 1986, more than 300 patients received an intrathecal baclofen (ITB) pump for the treatment of severe spasticity. Chronic ITB administration is a safe and effective method, which significantly decreases pathologically exaggerated muscle tone and improves the quality of life in most patients. This therapy is indicated in severe spasticity of cerebral or spinal origin that is unresponsive to oral antispastic medications. It is also useful in patients who may experience intolerable side effects when they receive orally effective baclofen doses. The therapeutic dose required to treat spasticity of cerebral origin is about three times higher than in spasticity of spinal origin. In carefully selected patients who suffer from spasticity, pump implantation is a cost-effective treatment which improves their quality of life. In our series with a follow-up period of 10 years, the ITB dose remained constant and no development of tolerance was observed in most patients. Destructive procedures such as myelotomy are no longer performed in our department in order to treat spasticity.