Selective neurotomy of the tibial nerve for treatment of the spastic foot

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.

Nerve-Targeted Surgical Treatments for Spasticity: A Narrative Review

Spasticity is a potentially debilitating symptom of various acquired and congenital neurologic pathologies that, without adequate treatment, may lead to long-term disability, compromise functional independence, and negatively impact mental health. Several conservative as well as non-nerve targeted surgical strategies have been developed for the treatment of spasticity, but these may be associated with significant drawbacks, such as adverse side effects to medication, device dependence on intrathecal baclofen pumps, and inadequate relief with tendon-based procedures. In these circumstances, patients may benefit from nerve-targeted surgical interventions such as (i) selective dorsal rhizotomy, (ii) hyperselective neurectomy, and (iii) nerve transfer. When selecting the appropriate surgical approach, preoperative patient characteristics, as well as the risks and benefits of nerve-targeted surgical intervention, must be carefully evaluated. Here, we review the current evidence on the efficacy of these nerve-targeted surgical approaches for treating spasticity across various congenital and acquired neurologic pathologies.

Lateral Pectoral Nerve Identification through Ultrasound-Guided Methylene Blue Injection during Selective Peripheral Neurectomy for Shoulder Spasticity: Proposal for a New Procedure

Internally rotated and adducted shoulder is a common posture in upper limb spasticity. Selective peripheral neurectomy is a useful and viable surgical technique to ameliorate spasticity, and the lateral pectoral nerve (LPN) could be a potential good target to manage shoulder spasticity presenting with internal rotation. However, there are some limitations related to this procedure, such as potential anatomical variability and the necessity of intraoperative surgical exploration to identify the target nerve requiring wide surgical incisions. This could result in higher post-surgical discomfort for the patient. Therefore, the aim of our study was to describe a modification of the traditional selective peripheral neurectomy procedure of the LPN through the perioperative ultrasound-guided marking of the target nerve with methylene blue. The details of the localization and marking procedure are described, as well as the surgical technique of peripheral selective neurectomy and the potential advantages in terms of nerve localization, surgical precision and patients' post-surgical discomfort. We suggest that the proposed modified procedure could be a valid technique to address some current limitations and move the surgical treatment of spasticity toward increasingly tailored management due to the ease of nerve identification, the possibility of handling potential anatomical variability and the resulting smaller surgical incisions.

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.

Spasticity and movement disorders in cerebral palsy

PURPOSE

To review the neurosurgical treatments of children with movement disorders associated with cerebral palsy (CP) during the previous decades, up to the present day.

METHODS

An extensive literature review was undertaken to identify important publications about this subject. My experience treating children with these disorders over the past three decades was included in the individual sections.

RESULTS

Peripheral neurotomies have been developed for children with focal spasticity. For those with spastic paraparesis, selective lumbar rhizotomies were developed, and for those with spastic quadriparesis, intrathecal baclofen infusions were developed. Both effectively alleviate spasticity in the affected extremities. Generalized dystonia associated with CP has been treated with deep brain stimulation with mild improvement, but treatment with intrathecal baclofen and intraventricular baclofen improve those movements markedly. No effective treatment has been reported for children with athetoid CP. For those with choreiform CP, deep brain stimulation may be effective but intrathecal baclofen does not appear to be.

CONCLUSION

Treatment of children with movement disorders associated with CP increased slowly in the 1970s and 1980s but accelerated rapidly in the 1990s with the introduction of lumbar dorsal rhizotomies and intrathecal baclofen. In the last 30 years, tens of thousands of children with spasticity and movement disorders associated with CP have been treated by pediatric neurosurgeons, and their care has become an integral component of current pediatric neurosurgical practice.

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.

Highly selective motor nerve block and movement analysis for preoperative evaluation of complex spastic gait

BACKGROUND

Lower-extremity spasticity and impaired gait control after central nervous system injury are challenging to improve, because spasticity limits residual motor control while providing mechanical support. Highly selective partial neurectomies (HSPNs) can substantially reduce spasticity but may have greater risks in patients with complex lower-extremity spastic gait.

OBJECTIVE

To examine the potential of ultrasound- and stimulation-guided highly selective motor nerve blocks (HSMNBs) to assess the potential impact of reduced spasticity on gait.

METHODS

In this retrospective series, six patients underwent HSMNBs with movement assessment before and after the block. Range of motion, strength, position angles, surface electromyography, lower limb kinematics, and patient satisfaction were assessed.

RESULTS

Pre- and post-HSMNB movement analysis yielded dichotomous gait kinematics, which facilitated surgical decisions. Of the 59 metrics evaluated, 82% demonstrated a positive improvement post-block (62% improved more than one standard deviation (SD) of typically developing means, 49% improved > 2 SD) and 16% demonstrated a negative change (2% worsened > 1 SD).

CONCLUSION

HSMNB provided clear efficacy in changing clinical, surface electromyography, and gait parameters. Movement analysis provided clear and robust objective and patient-centered evidence for surgical guidance. This protocol may provide utility in evaluation of patients being considered for HSPNs for complex spastic gait patterns.

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.

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).

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).

Contralateral C7 nerve transfer in the treatment of upper-extremity paralysis: a review of anatomical basis, surgical approaches, and neurobiological mechanisms

The previous three decades have witnessed a prosperity of contralateral C7 nerve (CC7) transfer in the treatment of upper-extremity paralysis induced by both brachial plexus avulsion injury and central hemiplegia. From the initial subcutaneous route to the pre-spinal route and the newly-established post-spinal route, this surgical operation underwent a series of innovations and refinements, with the aim of shortening the regeneration distance and even achieving direct neurorrhaphy. Apart from surgical efforts for better peripheral nerve regeneration, brain involvement in functional improvements after CC7 transfer also stimulated scientific interest. This review summarizes recent advances of CC7 transfer in the treatment of upper-extremity paralysis of both peripheral and central causes, which covers the neuroanatomical basis, the evolution of surgical approach, and central mechanisms. In addition, motor cortex stimulation is discussed as a viable rehabilitation treatment in boosting functional recovery after CC7 transfer. This knowledge will be beneficial towards improving clinical effects of CC7 transfer.

Nerve transfer in the spastic upper limb: anatomical feasibility study

PURPOSE

Nerve transfers represent an innovative tool in the surgical treatment of upper limb paralysis. Well-documented for brachial plexus sequalae and under evaluation for tetraplegic patients, they have not yet been described for spastic upper limbs. The typical spastic deformity involves active and spastic flexor, adductor and pronator muscles, associated with paralysed extensor and supinator muscles. Experience with selective neurectomy has shown an effective decrease in spasticity together with preservation of muscle strength. We conceptualized a combination of neurectomy and nerve transfer, by performing a partial nerve transfer from a spastic elbow flexor muscle to a paralyzed wrist extensor muscle, hypothesizing that this would reduce the spasticity of the former and simultaneously activate the latter.

METHODS

Ten cadaveric dissections were performed in order to establish the anatomic feasibility of transferring a motor branch of the brachioradialis (BR) onto the branch of the extensor carpi radialis longus (ECRL) or brevis (ECRB). We measured the emergence, length, muscle entry point and diameter of each branch, and attempted the transfer.

RESULTS

We found 1-4 motor nerve for the BR muscle and 1-2 for the ECRL muscle. In all cases, the nerve transfer was achievable, allowing a satisfactory coaptation. The ECRB branch emerged too distally to be anastomosed to one of the BR branches.

CONCLUSION

This study shows that nerve transfers from the BR to the ECRL are anatomically feasible. It may open the way to an additional therapeutic approach for spastic upper limbs.

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.

How I do it: selective tibial neurotomy

BACKGROUND

Selective neurotomy is known as an effective method to reduce focal spasticity when medical treatment including botulinum toxin is not sufficient. The tibial nerve can be targeted to treat spastic equinovarus foot with (or without) claw toes.

METHOD

Tibial nerve trunk is dissected in the popliteal fossa. Sensitive and motor branches are identified using electrical stimulation to monitor motor responses. The muscular nerves corresponding to the targeted muscles are partially sectioned according to a preoperative chart. A postoperative rehabilitation program is mandatory.

CONCLUSION

Precise and rigorous selective neurotomy provided a definitive and safe treatment for spastic equinovarus foot.

Three consecutive neurotomies in one patient for the treatment of spastic hemiplegia: Spinal, median, and foot toes common flexor

Background

Neurotomies were one of the first procedures performed in the field of functional neurosurgery. Microstimulators and microscopes facilitate the performance of neurotomies to treat focal spasticity. This report shows how three different consecutive neurotomies were performed in one patient with chronic left upper/lower extremity spasticity.

Case Description

A 65-year-old male with intractable epilepsy underwent a right temporal lobectomy for seizure control. Postoperatively, he developed left upper/lower extremity spasticity attributed to a postoperative right internal capsule infarct. The severe spasticity persisted despite the administration of conventional drugs, rehabilitation efforts, and botulinic toxin injections. Three sequential selective neurotomies (e.g., spinal, median, and foot common flexor nerves) were next performed. Postoperatively, the neurotomies resulted in significant symptomatic long-term improvement, 6 years after spinal neurotomy, 7 years after median neurotomy, and 9 years after common flexor neurotomy. Spasticity scores diminished from 4 to 0 points on the Ashworth scale and from 4 to 0 points on the Held-Tardieu scale for each muscular region.

Conclusion

Multiple regional neurotomies were effective in the management of left-sided postoperative spasticity in a patient who underwent a temporal lobectomy for seizure control with a resultant postoperative right internal capsule infarct.

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.

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.

Long-term neuromechanical results of selective tibial neurotomy in patients with spastic equinus foot

BACKGROUND

The neuromechanical consequences of tibial neurotomy have not been extensively studied.

METHODS

Fifteen patients were evaluated before and after selective tibial neurotomy (after 2 months and after 15 months) by means of clinical, neurophysiological [tendon (T) reflexes, Hoffmann (H) reflexes and maximum motor response, Mmax] and mechanical parameters (passive stiffness of plantar flexors at the ankle). The neurotomy concerned the soleus (100 % of cases), gastrocnemius (20 % of cases), posterior tibial (60 % of cases) and flexor digitorum longus (47 % of cases) nerves.

RESULTS

Neurotomy provided more than 90 % improvement of clinical spasticity scores, 20 % improvement of walking scores and the angle of passive dorsiflexion (APDF) of the ankle (mean angle: 7°), temporary reduction of the soleus Mmax (18 % at 2 months with return to the preoperative value at 15 months), and lasting reduction of the soleus Hmax/Mmax (68 % at 2 months, 78 % at 15 months) and T/Mmax (84 % at 2 months, 80 % at 15 months). M and H responses of the gastrocnemius (whether or not they were included in the neurotomy) were not modified, while T/Mmax decreased to the same degree as for soleus. Passive stiffness was lastingly decreased from 64.0 Nm/rad to 49.0 Nm/rad (2 months) and 49.5 Nm/rad (15 months).

CONCLUSION

Selective tibial neurotomy of the soleus nerve induces long-term reduction of reflex hyperexcitability and passive stiffness of plantar flexors in spastic patients, with no lasting impairment of motor efferents. In parallel, it modifies the tendon reflexes of synergistic muscles (gastrocnemius) not concerned by the neurotomy.

Outcome of selective motor fasciculotomy in the treatment of upper limb spasticity

OBJECTIVE

The objective was to assess the outcome of selective motor fasciculotomy in relieving upper limb harmful resistant spasticity and thereby to improve motor functions in persons with cerebral palsy.

MATERIALS AND METHODS

Twenty people having cerebral palsy (12 females and 8 males) with age ranging from 5 to 35 (mean 12.85) years with upper limb resistant spasticity due to spastic hemiplegia (n=7), triplegia (n=6), and quadriplegia (n=7) were assessed using Modified Ashworth Scale, Selective Voluntary Control Grade, Wee FIM Scale and hand function evaluation. Selective motor fasciculotomy was performed on the musculocutaneous nerve (n=13) for elbow flexors spasticity, median nerve (n=24) for pronators and radial wrist flexors spasticity and ulnar nerve (n=3) for ulnar wrist flexors spasticity. Pre- and post-op therapeutic exercises were performed.

RESULTS

Statistical analysis using the Wilcoxon Signed Ranks test showed significant reduction in spasticity and improvement in selective voluntary control, hand functions (grasp to hold a 2 inch rod), and Wee FIM (self-care domain in particular). There was no recurrence in spasticity and complications following surgery.

CONCLUSIONS

The selective motor fasciculotomy of musculocutaneous, median, and ulnar nerves significantly reduces spasticity in the affected muscle groups and thereby improves the self-care (motor) functions in selected people with cerebral palsy who have harmful resistant spasticity without any organic shortening of the muscles. The procedure is safe and the spasticity does not recur.

Direct neurectomy of the motor branches of the tibial nerve in hemiplegic adults: an assessment with a mean follow-up period of 11 years

INTRODUCTION

Neurectomy of the tibial nerve plays a major role in the relief of disabling spasticity, which is refractory to drug treatment and physiotherapy. Although the immediate postoperative results are generally satisfactory, few evaluations of the procedure's long-term efficacy have been published.

OBJECTIVE

To estimate the long-term efficacy of total or partial neurectomy of the motor branches of the tibial nerve (combined with additional orthopaedic surgery in some cases).

METHOD

A descriptive, retrospective study of 25 brain-damaged patients having undergone neurectomy at least 4 years ago.

RESULTS

The mean post-neurectomy follow-up period was 11 years. Twenty patients became less dependent on the use of walking aids. Of the 18 patients unable to walk barefoot before surgery, 11 could do so after surgery. Of the 12 patients unable to walk on uneven ground before surgery, seven could do so afterwards. The walking distance increased for 20 patients. In 22 cases, the spasticity disappeared immediately after the operation and did not reappear in the long-term. In three other cases, spasticity persisted postoperatively and, in the long-term, affected the soleus (the denervation of which had been incomplete or not performed). Eighty-three percent of the patients were satisfied with the operation's outcome.

CONCLUSIONS

The observed maintenance of the benefits of total or partial neurectomy after an average follow-up period of 11 years confirms the value of this procedure. The few mediocre outcomes (observed in cases of partial neurectomy of the soleus) are in agreement with literature reports and emphasize the role of the soleus in this pathology.

Long-term results of microsurgical selective tibial neurotomy for spastic foot : comparison of adult and child

OBJECTIVE

Selective neurotomy is generally a safe, effective, and long-lasting treatment for patients with spastic equinovarus foot deformity. We retrospectively analyzed the results of microsurgical selective tibial neurotomy (STN) for spastic feet in adults and children.

METHODS

A neurosurgeon selected 32 patients with 45 spastic feet (adults : 13, children : 32) to undergo microsurgical STN between October 1998 and September 2007. A physician of rehabilitation assessed spasticity pre- and postoperatively, that was based on the Ashworth scale, ankle clonus, and the amplitude of ankle dorsiflexion. The mean postoperative follow-up period was 36.7 months in adults and 42.5 months in children.

RESULTS

Spastic components of the feet were corrected immediately after surgery in both the adult and child groups. The mean Ashworth's grade changed from 3.6 +/- 0.40 to 1.6 +/- 0.70 in adults and from 3.7 +/- 0.69 to 1.4 +/- 0.49 in children. Mean ankle clonus decreased markedly, from 1.6 +/- 0.79 to 0.3 +/- 0.42 in adults and from 1.7 +/- 0.65 to 0.3 +/- 0.56 in children. The mean amplitude of ankle dorsiflexion was improved, but eight (adults: 4, children: 4) contracted feet needed complementary orthopedic correction for acceptable results.

CONCLUSION

STN can be effective in the long-term for improving lower limb function and reduction of equinovarus deformity. Our results demonstrate that STN might be an effective procedure for treating localized harmful spastic feet in adults and children.

Shoulder external rotator selective neurotomy in cerebral palsy: anatomical study and preliminary clinical results

Shoulder external rotation posturing in patients with cerebral palsy can severely impair bimanual activities and lead to painful shoulder instability. We performed an anatomical study to describe the surgical approach to the shoulder external rotators nerves. Using this technique, we performed a selective neurotomy in five shoulders with external rotator shoulder spasticity. Ashworth scale dropped from 2 or 3 to 0 and active internal rotation increased from 0-10 to 60-70 degrees . This is a short series but preliminary results are encouraging and allow us to extend the study to a greater number of patients.

The innervation of extensor hallucis longus muscle: an anatomical study for selective neurotomy

OBJECTIVE

This study is aimed to describe the observable anatomical variants of the innervation of extensor hallucis longus muscle (EHLM) in order to have the surgical coordinates to perform neurotomy on the targeted branches of its innervation and to give a valuable alternative to the commonly used technique of fascicular subepineurial neurotomy in patients affected by toe hyperextension dystonia.

METHODS

In 15 fresh cadavers of adults, 29 lower limbs (14 right and 15 left) were studied. Anatomical dissections to isolate the innervating branches of EHLM were performed. Each branch from EHLM was analyzed by microscopical opening of the epineurium to observe the number of nerve fascicles. Various measurements were made to obtain anatomical coordinates for surgery.

RESULTS

The distance between the most prominent point of the head of the fibula and the origin of the nervous branches innervating the EHLM is not proportional to the length of the leg. In 72.4% of the studied legs, the distance between the origin of the first branch innervating the EHLM and the origin of the deep peroneal nerve is 7 +/- 2 cm. In 80% of legs, the distance between the origin of the second branch and the origin of the deep peroneal nerve is 10 +/- 1.1 cm. In only one limb with double innervation, two fascicles were found, while in six limbs (25%) only one fascicle was found.

CONCLUSIONS

This anatomical study traced some valuable surgical coordinates useful for the execution of a selective peripheral neurotomy on the nerve branch innervating the EHLM.

Intrathecal administration of GABA agonists in the vegetative state

Gamma aminobutyric acid (GABA) is an inhibitor neurotransmitter that plays many important roles in the central nervous system. Because the half-life time of GABA is very short in vivo, GABA itself is not used for clinical practice. An analogue of GABA, baclofen, is an agonist of GABA-B receptor, and has very strong antispastic effect by acting to the posterior horn of the spinal cord. However, baclofen poorly crosses through the blood brain barrier, and the antispastic effect is modest when administered orally. Therefore, direct continuous infusion of small doses of baclofen into the cerebrospinal fluid (intrathecal baclofen therapy, ITB) has become an established treatment for control of otherwise intractable severe spasticity. Spasticity is clinically defined as hypertonic state of the muscles with increased tendon reflexes, muscles spasm, spasm pain, abnormal posture, and limitation of involuntary movements. Spasticity is a common symptom after damage mainly to the pyramidal tract system in the brain or the spinal cord. Such damage is caused by traumatic brain injury, stroke, spinal cord injury, multiple sclerosis, and so on. Patients in persistent vegetative state (PVS) usually have diffuse and widespread damage to the brain, spasticity is generally seen in such patients. Control of spasticity may become important in the management of PVS patients in terms of nursing care, pain relief, and hygiene, and ITB may be indicated. Among PVS patients who had ITB to control spasticity, sporadic cases of dramatic recovery from PVS after ITB have been reported worldwide. The mechanism of such recovery of consciousness is poorly understood, and it may simply be a coincidence. On the other hand, electrical spinal cord stimulation (SCS) has been tried for many years in many patients in PVS, and some positive effects on recovery of consciousness have been reported. SCS is usually indicated for control of neuropathic pain, but it has also antispastic effect. The mechanism of SCS on pain is known to be mediated through the spinal GABA neuronal system. Thus, ITB and SCS have a common background, spinal GABA neuronal mechanism. The effect of GABA agonists on recovery of consciousness is not yet established, but review of such case studies becomes a clue to solve problems in PVS, and there may be hidden serendipity.

Lidocaine hyperselective motor blocks of the triceps surae nerves: role of the soleus versus gastrocnemius on triceps spasticity and predictive value of the soleus motor block on the result of selective tibial neurotomy

OBJECTIVES

This prospective study was designed to evaluate the clinical and gait parameter changes induced by two types of hyperselective motor blocks of the triceps surae nerves (superior soleus and gastrocnemius nerves) and their ability to predict the results of selective tibial neurotomy.

DESIGN

Seven adult patients (four males and three females, mean age of 41 yrs old) with spastic foot were included in this study. Clinical (equinus foot score, ankle range of motion, spasticity, pain, and comfort wearing shoes), and gait analysis (kinematic and electromyographic parameters) assessment were performed before and after each motor block (superior soleus nerve and gastrocnemius nerve) and 1 mo after selective tibial neurotomy.

RESULTS

The superior soleus nerve block was effective on clinical parameters (triceps surae stretch reflex scores decreased from 2.57 to 0.9, and mean walking time decreased from 44 to 32.1 secs) and on kinematics parameters (the total duration of the gait cycle was decreased because of a reduction of the R3 and swing phases). The same results are observed after soleus neurotomy.

CONCLUSION

This work confirms the practical value of selective superior soleus nerve motor block and that this block provides a useful prediction of the effect of selective soleus neurotomy. It constitutes an additional argument in favor of the predominant role of the soleus in spastic foot.

Selective peripheral neurotomy (SPN) for spasticity in childhood

OVERVIEW

Excess spasticity leads to disability that is marked by impaired locomotion, handicapping deformities and, if not controlled, discomfort and pain. Selective peripheral neurotomy in the child is indicated for severe focal spasticity, when botulinum toxin injections cannot delay surgery any longer.

MATERIALS AND METHODS

Preoperative motor blocks mimicking the outcome of the surgical procedure are essential to establish the objectives of neurotomy. In the lower limb, obturator neurotomy is indicated for spasticity in the adductor muscles, hamstring neurotomy for the knee flexion and tibial neurotomy for the spastic foot. Anterior tibial neurotomy is indicated for the extensor hallucis spasticity and femoral neurotomy for spasticity in the quadriceps. In the upper limb, neurotomy of the pectoralis major and teres major nerves is indicated for spasticity of the internal rotators of the shoulder. Neurotomy of the musculocutaneous nerve is indicated for spasticity of the flexors of the elbow, and neurotomy of median and ulnar nerves are indicated for spasticity of the pronators and flexors of the wrist and fingers.

CONCLUSION

Selective peripheral neurotomy is a valuable neurosurgical procedure in well-trained surgical hands for severe focalised spasticity.

Morbidity associated with high gastrocnemius recession: retrospective review of 126 cases

To evaluate morbidity associated with surgical lengthening of the gastrocnemius, medical records were reviewed retrospectively for 126 patients (mean age, 49.7 years; range, 8-78 years) who had undergone open gastrocnemius recession. Ten patients had isolated recession; 116 had gastrocnemius recession with an additional foot or ankle procedure on the ipsilateral limb. During a mean follow-up period of 19 months (range, 6-50 months), all patients were examined for any postoperative complications associated with the recession. Complications were defined as the presence of postoperative infection, wound dehiscence, nerve problems, decreased muscle strength, scar problems, or calcaneus gait (overlengthening). Uncomplicated outcome was defined as absence of all these complications and return to regular activity, both occurring during a follow-up of at least 6 months. Postsurgical complications developed in 9 (6%) of the 126 patients: 6 (4%) had scar problems, 2 (1.33%) had wound dehiscence, 2 (1.33%) had infection, 3 (2%) had nerve problems, and 1 (0.67%) developed complex regional pain syndrome. No patient complained of either a limp or gait disturbance. Neither persistent decrease in muscle strength nor calcaneus gait was seen. These data suggest that the open gastrocnemius recession procedure has low associated morbidity.

Long-term functional results of selective peripheral neurotomy for the treatment of spastic upper limb: prospective study in 31 patients

Object

To manage refractory upper-limb spasticity, selective peripheral neurotomy (SPN) is proposed when the spastic muscles to be treated are under the control of a single or a few peripheral nerves. The aim of this study was to assess prospectively the long-term effects of SPN.

Methods

Thirty-one patients with disabling upper-limb spasticity were selected by a multidisciplinary team using clinical, analytical, and functional scales as well as nerve block tests for assessment. Sixty-four SPNs were performed at the level of the musculocutaneous (15 SPNs), the median (25 SPNs), and the ulnar (24 SPNs) nerves. Results of a long term follow up (mean 4.5 years) showed statistically significant improvement on 1) analytical assessment (p < 0.01): resting position, active amplitude, and motor strength; 2) Ashworth Scale scoring (p < 0.01); 3) hand function assessment (p < 0.01); and 4) rating of daily activities. Four patients with severe painful spasticity experienced complete pain relief after surgery. On the basis of a Visual Analog Scale ranging from 0 to 100, the mean degree of patient satisfaction was 61.5. Complications occurred in five patients (15%): two postoperative hematomas, one (temporary) hypesthesia, and one transient paresia of the wrist and finger flexors.

Conclusions

Selective peripheral neurotomy leads to long-term satisfactory improvement in function and/or comfort with a low morbidity rate in appropriately selected patients suffering from severe harmful spasticity of the upper limb that has been refractory to conservative therapy. Patients must be selected after complete assessment by a multidisciplinary team.

Selective tibial neurotomy in the treatment of spastic equinovarus foot: a 2-year follow-up of three cases

OBJECTIVE

To objectively assess the decrease in spasticity and the improvement in gait after tibial nerve neurotomy performed to treat spastic equinovarus foot.

DESIGN

Before-after trial with a 2-yr follow-up. Three hemiplegic patients with spastic equinovarus foot were treated with a selective peripheral neurotomy of the tibial motor nerve branches (soleus, lateral and medial gastrocnemius and tibialis posterior nerves). Evaluation included clinical assessment of spasticity (Ashworth scale), maximal Hoffmann reflex (H(max))/compound muscle action potential (M(max)) ratio measurement, gait analysis, and muscle stiffness evaluation performed before and 2 mos, 1 yr, and 2 yrs after the neurotomy.

RESULTS

Spasticity, muscle stiffness, and H(max)/M(max) ratio decreased after neurotomy. The kinematic (ankle dorsal flexion and knee recurvatum) and kinetic variables (maximum ankle muscle moment and external work) of the gait were permanently improved after neurotomy. Interestingly, kinetic variables seemed to gradually improve with time after the neurotomy.

CONCLUSION

Tibial neurotomy is an effective and durable treatment for spastic equinovarus foot.

Spastic equinus foot: multicenter study of the long-term results of tibial neurotomy

OBJECTIVE

Tibial neurotomy is a surgical technique widely used for the treatment of spastic equinus foot, but it has rarely been evaluated. The primary objective of this prospective study was to provide an objective quantification of the long-term results of tibial neurotomy.

METHODS

This multicenter prospective study was conducted from 1999 to 2003. Fifty-five patients with spastic equinus foot were treated in five neurosurgical centers. Preoperative and postoperative clinical evaluation comprised description of the foot deformity, study of stretch reflexes, evaluation of the repercussions of the deformity, and gait analysis. Selective neurotomy was performed in all patients.

RESULTS

No postoperative complications were observed. The mean postoperative follow-up was 10 months. Tibial neurotomy improved the appearance of the foot (equinus and varus deformities, claw toes); the equinus score decreased from 1.54 to 0.273 after the operation. Stretch reflex scores were decreased significantly and for a long term after surgery; the mean triceps surae stretch reflex score decreased from 2.46 to 0.47. The angle of passive dorsiflexion of the ankle increased significantly (from -0.56 degrees to +6.85 degrees). Gait analysis demonstrated a statistically significant increase in the speed of the patient's gait after surgical treatment; the time taken by the patient to walk 10 m at a normal speed in shoes decreased from a mean of 55 seconds to 35.16 seconds. Postoperatively, 92.7% of preoperative objectives had been achieved.

CONCLUSION

Tibial neurotomy ensures long-term functional improvement of patients with spastic equinus foot. It provides a lasting response for these patients compared with other, more transient treatments.

Selective Posterior Rhizotomy for Painful Spasticity in the Lower Limbs of Hemiplegic Patients After Stroke: Report of Two Cases

OBJECTIVE AND IMPORTANCE

Selective posterior rhizotomy (SPR) has been performed mainly in children with cerebral palsy. Seldom has the use of SPR been reported for reduction of spasticity after stroke. We describe two elderly patients with hemiplegia who underwent unilateral SPR for pain caused by spasticity after stroke.

CLINICAL PRESENTATION

The first patient was a 68-year-old woman who experienced spasticity and pain in her right leg during the chronic stage of a left cerebral infarction. The second patient was an 89-year-old man who had intolerable spastic pain in his left hemiplegic leg 3 months after a right cerebral infarction.

INTERVENTION

Both patients underwent unilateral SPR on the spastic side to reduce the pain. After surgery, the patients' pain resolved. In the first patient, the ability to perform activities of daily living also improved.

CONCLUSION

Antispastic medications are often sufficient for treatment of post-stroke spasticity. In selected cases, however, SPR can be beneficial for improving painful spasticity.

Alcohol neurolysis of tibial nerve motor branches to the gastrocnemius muscle to treat ankle spasticity in patients with hemiplegic stroke

OBJECTIVE

To evaluate the effectiveness of alcohol neurolysis of tibial nerve motor branches to the gastrocnemius muscle for the treatment of ankle plantarflexor spasticity in patients with hemiplegic stroke.

DESIGN

Case series.

SETTING

Inpatient and outpatient clinics in the rehabilitation department of a university hospital.

PARTICIPANTS

Twenty-two patients with hemiplegic stroke (mean age, 48y).

INTERVENTIONS

Motor branch block (MBB) of the tibial nerve to the gastrocnemius muscle with 50% ethyl alcohol in cases of spastic ankle.

MAIN OUTCOME MEASURES

The severity of spasticity was assessed using the Modified Ashworth Scale (MAS) score of ankle plantarflexor, clonus score of the ankle, and the passive range of motion (PROM) of ankle dorsiflexion.

RESULTS

The MAS score was reduced in 17 (77%) of 22 patients during the 6-month follow-up, and spasticity reappeared at the level of the pre-MBB state in 5 patients (23%). The mean values of all parameters were significantly improved. The changes of mean values from the pre-MBB to the 6-month post-MBB stage were as follows: MAS score, 3.3+/-0.7 versus 1.7+/-1.1; clonus score, 1.6+/-0.7 versus 0.4+/-0.8; and PROM, 17.1 degrees +/-13.0 degrees versus 28.6 degrees +/-4.7 degrees. No serious complications were observed during the 6-month follow-up period.

CONCLUSIONS

MBB of the tibial nerve to the gastrocnemius muscle is an effective and safe procedure for relieving localized spasticity of the ankle plantarflexors.

Selective blocks of the motor nerve branches to the soleus and tibialis posterior muscles in the management of the spastic equinovarus foot11No commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a financial benefit on the author(s) or on any organization with which the author(s) is/are associated

OBJECTIVE

To identify the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor nerve blocks in the management of the spastic equinovarus foot.

DESIGN

Descriptive study by computed tomography (CT) scan of 12 hemiplegic legs.

SETTING

Spasticity group at a university hospital.

PARTICIPANTS

Twelve patients with hemiplegia (6 men, 6 women) with spastic equinovarus foot.

INTERVENTION

Three-dimensional location of the motor nerve branches to the soleus and tibialis posterior muscles with CT scan, followed by selective motor branch blocks with anesthetics.

MAIN OUTCOME MEASURES

Vertical, horizontal, and deep coordinates determined by CT scan in relation to anatomic surface landmarks (upper extremity of the fibula and vertical metallic element). Soleus and tibialis posterior spasticity (Ashworth Scale), soleus H-wave maximum (Hmax)/M-wave maximum (Mmax) ratio, and sensory testing before and after the blocks.

RESULTS

The mean coordinates +/- standard deviation for the soleus motor branch were 10+/-5 mm (vertical), 17+/-9 mm (horizontal), and 30+/-4 mm (deep); for the tibialis posterior motor branch they were 45+/-6mm (vertical), 17+/-8mm (horizontal), and 47+/-4 mm (deep). Spasticity and Hmax/Mmax ratio decreased after the blocks, confirming their efficiency. No subjects experienced additional sensory deficit.

CONCLUSION

Our study determined the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor branch blocks and neurolytic procedures. These coordinates allow us to perform selective motor blocks without CT scan.