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

Current techniques for the treatment of spasticity and their effectiveness

This review highlights the role of existing spasticity treatment methods in reducing muscle tone and improving function. The surgical methods today mainly include selective dorsal rhizotomy, selective neurotomy, intrathecal baclofen treatment (ITB), etc. These techniques (except ITB) can lower patients' muscular tone in the long term and improve function to some extent. The young procedures, contralateral C7 nerve transfer and T1 neurotomy, are still under research. ITB and nonsurgical treatment methods, botulinum toxin A (BoNT-A) and extracorporeal shockwave therapy (ESWT), can reduce muscle tone in the short term, but the long-term efficacy is unsatisfactory. In addition, the effects of improving function are relatively controversial. The economic cost of these treatment methods is also heavy for patients. In addition, some studies have reported that some kinds of electrical/magnetic stimulation can improve the patients' function. They can potentially be used as an adjunctive treatment for spasticity. According to current studies and our own experience, surgery methods (except ITB) are still recommended for patients, whose spasticity has a major detrimental influence on their everyday lives, taking into account patient benefits and cost-effectiveness. There are also some problems in the current research on spasticity treatment, such as incomplete guidelines and a relative lack of high-quality studies, which is what the doctors need to strive for. Further exploration is needed to find the treatment methods that can reduce muscle tone while improving patients' function to better benefit patients.

Clinical Recovery of Spastic Finger Flexion Using Hyperselective Neurectomy: A Case Series

PURPOSE

Hyperselective neurectomy (HSN) is an advanced peripheral nerve ablation procedure that can relieve spasticity and enhance the quality of life in patients with spasticity following upper motor neuron injuries. The main advantage of HSN is that it can treat spasticity as well as preserve hand function. Thus, HSN may be the procedure of choice in patients with spastic functional hands. In this study, we present the surgical technique and results of HSN of the flexor digitorum superficialis (FDS) in the setting of spastic finger flexion.

METHODS

HSN of the FDS was performed on 18 patients with functional hands. We employed the Peraut and House categorizations to evaluate pain reduction and improvement of hand function, respectively.

RESULTS

The patients exhibited marked improvement in finger spasticity following HSN. Finger function was preserved, and all patients demonstrated improved hand function, as evidenced by an increase in the House Score from 0 to 2 before surgery to a range of 4 to 8 after the intervention. All patients experienced relief from pain.

CONCLUSIONS

HSN of the FDS branch is a technique that should be considered to reduce finger flexor spasticity and preserve finger flexion function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Motion analysis for the evaluation of dynamic spasticity during walking: A systematic scoping review

BACKGROUND

Three-dimensional (3D) gait analysis has the potential to assess dynamic spasticity (DS). However, little is known about which parameters can be utilized for assessment.

OBJECTIVE

To evaluate the application of 3D gait analysis in assessing DS during walking and to identify the most relevant parameters for clinical practice.

METHODS

A systematic scoping review was conducted by a multidisciplinary team of researchers and clinicians. A literature search of the PubMed, Web of Science and Cochrane Library databases was conducted using the following inclusion criteria: (i) clinical trial study; (ii) focused on the relationship between spasticity and gait analysis indicators during walking. The risk of bias was assessed using the Mixed Methods Appraisal Tool. Data were analyzed using content analysis and quantification techniques.

RESULTS

Four key parameters in 3D gait analysis-spatiotemporal parameters, kinematics, kinetics, and myoelectric signals-are utilized to evaluate alterations in DS during walking. Among the spatiotemporal parameters, the most frequently used metrics are speed, stride length, and cadence. In kinematics, the ankle and knee joint angles are the most commonly measured indicators. For kinetics, the ankle joint moment and plantar pressure are the primary focus. For myoelectric signals, the most utilized metrics include the patterns and duration of muscle co-contraction.

CONCLUSIONS

3D gait analysis is feasible for precisely evaluating DS during walking. However, to obtain a comprehensive evaluation, it is essential to integrate multiple metrics. High-quality research is urgently needed to provide more precise assessment protocols by analyzing changes in gait parameters before and after spasticity interventions.

Efficacy of selective neurotomy for focal lower limb spasticity: a systematic review

OBJECTIVE

Selective neurotomy has been suggested as a permanent treatment for focal spasticity. A systematic literature review was performed to investigate the efficacy of selective neurotomy regarding focal lower limb spasticity.

METHODS

A systematic search in PubMed, Medline, Cochrane, and Embase databases was carried out. Studies were included if they reported on the following outcomes: muscle tone, muscle strength, pain, ankle range of motion and/or walking speed, after selective lower limb neurotomy in any type of upper motor neuron syndrome.

RESULTS

A total of 25 non-randomized and/or uncontrolled studies and 1 randomized controlled study were selected. The included studies reported improvements in terms of leg muscle tone, pain, passive range of ankle motion, and walking speed.

CONCLUSION

The results suggest that selective neurotomy is effective for reducing lower limb spasticity, without any negative effects on walking speed. However, this conclusion is primarily based on uncontrolled case series, whereas conclusions on clinical efficacy should preferably be based on comparison with a reference treatment through (randomized) controlled trials. Future studies should also include quantitative, validated functional assessment tools to further establish the efficacy of selective neurotomy as long-lasting treatment for patients with focal lower limb spasticity.

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.

Functional outcomes following surgery for spastic hip adductor muscles in ambulatory and non-ambulatory adults

OBJECTIVE

To evaluate functional outcomes of surgery of spastic hip adductor muscles (obturator neurotomy with or without adductor longus tenotomy) in ambulatory and non-ambulatory patients, using preoperatively defined personalized goals.

DESIGN

Retrospective observational descriptive study.

PATIENTS

Twenty-three patients with adductor spasticity who underwent obturator neurotomy between May 2016 and May 2021 at the Clinique des Cèdres, Cornebarrieu, France, were included.

METHODS

Postoperative functional results were evaluated in accordance with the Goal Attainment Scaling method. Patients were considered "responders" if their score was ≥ 0. Secondary outcomes included spasticity, strength, hip range of motion and change in ambulatory capacity. When data were available, a comparison of pre- and postoperative 3-dimensional instrumented gait analysis was also performed.

RESULTS

Among the 23 patients only 3 were non-walkers. Seventeen/22 patients achieved their main goal and 14/23 patients achieved all their goals. Results were broadly similar for both walking goals (inter-knee contact, inter-feet contact, fluidity, walking perimeter, toe drag) and non-walking goals (intimacy, transfer, pain, posture, dressing).

CONCLUSION

Surgery of spastic hip adductor muscles results in functional improvement in ambulation, hygiene, dressing and posture and can be offered to patients with troublesome adductor overactivity. The use of a motor nerve block is recommended to define relevant goals before the surgery.