Evaluation of selective peripheral neurotomies in the treatment of refractory lower limb spasticity in adults

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.

[Methods and results of neurosurgical treatment of cerebral palsy]

Treatment of spastic syndrome and muscular dystonia in patients with cerebral palsy is a complex clinical problem. Effectiveness of conservative treatment is not high enough. Modern neurosurgical techniques for spastic syndrome and dystonia are divided into destructive interventions and surgical neuromodulation. Their effectiveness is different and depends on the form of disease, severity of motor disorders and age of patients.

OBJECTIVE

To evaluate the effectiveness of various methods of neurosurgical treatment of spasticity and muscular dystonia in patients with cerebral palsy.

MATERIAL AND METHODS

We To evaluate the effectiveness of various methods of neurosurgical treatment of spasticity and muscular dystonia in patients with cerebral palsy.analyzed literature data in the PubMed database using the keywords «cerebral palsy», «spasticity», «dystonia», «selective dorsal rhizotomy», «selective neurotomy», «intrathecal baclofen therapy», «spinal cord stimulation», «deep brain stimulation».

RESULTS

Effectiveness of neurosurgery was higher for spastic forms of cerebral palsy compared to secondary muscular dystonia. Destructive procedures were the most effective among neurosurgical operations for spastic forms. Effectiveness of chronic intrathecal baclofen therapy decreases in follow-up due to secondary drug resistance. Destructive stereotaxic interventions and deep brain stimulation are used for secondary muscular dystonia. Effectiveness of these procedures is low.

CONCLUSION

Neurosurgical methods can partially reduce severity of motor disorders and expand the possibilities of rehabilitation in patients with cerebral palsy.

Selective peripheral neurotomy (SPN) as a treatment strategy for spasticity

Spasticity can be caused by central nervous system dysfunction, such as cerebral palsy and stroke. The accepted pathogenesis of spasticity is that the muscles are in the state of uninhibited stretch reflex without enough control of central nervous system. So far, there is no ideal way about how to repair central nervous system. However, the uninhibited stretch reflex can be reduced, targeting the posterior root of the spinal cord and peripheral nerves innervating the limbs, which are called selective posterior rhizotomy (SPR) and selective peripheral neurotomy (SPN), respectively. SPN is indicated for focal or multifocal spasticity, which is well accepted due to its low invasiveness and ease of use. How does the operation work? What do we do before and during this operation? Is there any risk to the patients? Our review summarizes the mechanism, indications, preoperative assessments, techniques, and complications of SPN. We hope that the spastic patients, such as pediatric cerebral palsy patients and older stroke patients, will benefit from this surgery.