Physiological effects of selective tibial neurotomy on lower limb spasticity (original) (raw)
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American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 2006
To objectively assess the decrease in spasticity and the improvement in gait after tibial nerve neurotomy performed to treat spastic equinovarus foot. 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. 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 grad...
Journal of Rehabilitation Medicine, 2011
Objective: Spastic equinovarus foot is a major cause of disability for neurorehabilitation patients, impairing their daily activities, social participation and general quality of life. Selective tibial nerve neurotomy is a neurosurgical treatment for focal spasticity, whose acceptance as treatment for spastic equinovarus foot remains controversial. we performed a systematic review of the literature to assess the efficacy of tibial nerve neurotomy as a treatment for adult patients presenting with spastic equinovarus foot. Methods: we queried PubMed, Science Direct, trip Database and PeDro databases with the following keywords: "equinus deformity" OR "muscle spasticity" AND "neurotomy." Results: we selected a total of 11 non-randomized and uncontrolled studies, suggesting that neurotomy could be an efficient treatment to reduce impairments in spastic equinovarus foot patients. Discussion: Our conclusions are based primarily on case series studies. the effects of tibial nerve neurotomy had not been compared with a reference treatment through a randomized controlled trial, which would be necessary to increase the level of scientific evidence. Moreover, further studies using quantitative, validated and objective assessment tools are required to evaluate the efficacy of tibial nerve neuro tomy accurately based on the International Classification of Functioning, Disability and Health from the world Health Organization.
Anatomical bases of tibial neurotomy for treatment of spastic foot
Surgical and Radiologic Anatomy, 2008
Spastic pes equines, possibly associated with varus posture or spastic claw of the toes, can require neurosurgical treatment. In these cases, a selective fascicular neurotomy can be proposed, which consists of a partial section of some motor collateral branches of the tibial nerve. In order to avoid sensory and trophic complications after surgery due to an excessive manipulation of the nerve, accurate anatomical data must be collected. Therefore, biometric, histological and ultrastructural studies were carried out. A total of 50 dorsal compartments of the leg were dissected. The distance between the emergence of each muscular branch of the tibial nerve and anatomical landmarks were measured. Complementary histological study was processed on three specimens with slices stained by Masson's trichromatic method. Eventually, electronic microscopy observation was processed on two other specimens. In 16 cases (32%), we found a common muscular branch for all the muscles of the dorsal leg compartment, which emerged from the nerve trunk near the tendinous arch of the soleus (67 § 29 mm from the femorotibial articular line). In the other cases, muscular branches of the nerve emerged from its ventral lateral aspect, with variable origins (inferior nerve for the soleus: 82 § 31 mm from the femorotibial articular line, nerve for Xexor digitorum longus: 116 § 41 mm, nerve for tibialis posterior: 106 § 51 mm, with a second nerve in 9/50 cases, nerve for Xexor hallucis longus: 129 § 48 mm, with a second nerve in 6 cases). Histological and ultrastructural analysis conWrmed the presence of the motor nervous Wbers in the ventral lateral part of the nerve trunk. These new anatomical Wndings allow a more precise dissection during operative procedure, in order to avoid sensory or trophic complications.
Alexandria Journal of Medicine
Background: ''Selective peripheral neurotomies" (SPNs) are indicated for the treatment of refractory focal and multifocal spasticity of lower limbs in adults. Objective: To evaluate the surgical results of selective peripheral neurotomies in 20 adult patients who had refractory focal & multifocal spasticity of the lower limbs, follow up period of one year. Patients and Methods: Prospective study included 20 adult patients who had refractory spasticity of the lower limbs. Preoperative evaluation for muscle tone using Modified Ashworth Score (MAS), muscle power using Medical Research Council Scale (MRCS), functional assessment using Oswestry Functional Scale (OFS) and Range Of Motion (ROM) using manual goniometry were done for all patients. All cases underwent surgery in the form of SPN of tibial, obturator, sciatic and/or femoral nerves. Follow up of the patients was done at 10th day, 3, 6 months and one year postoperatively. Results: The mean age of patients was 31.35 ± 12.42 years. There were statistically significant improvement of muscle tone, muscle power, functional assessment and range of motion between preoperative and one year postoperative values. Improvement of the muscle tone was from a preoperative Mean ± SD of 3.60 ± 0.68 on MAS to a postoperative 2.30 ± 0.86 at one year, improvement of muscle power on MRCS was from preoperative Mean ± SD 3.75 ± 1.08 to postoperative 4.08 ± 0.69 at one year, There was a functional improvement from a preoperative Mean ± SD of 3.0 ± 0.73 on OFS to 3.60 ± 0.60 at one year postoperatively. Also, there was a significant improvement between preoperative ROM Mean ± SD 61.25 ± 15.29 and one year postoperatively 72.25 ± 12.19. Conclusions: Selective peripheral neurotomies could effectively improve muscle tone, muscle power, functional performance & range of motion in patients with refractory focal and multifocal spasticity in the lower limbs.
Annals of Physical and Rehabilitation Medicine, 2015
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. ß
Journal of Rehabilitation Medicine, 2008
Objective: to quantitatively evaluate the effect of motor nerve branch block and neurotomy of the soleus nerve on triceps surae spasticity, reviewing 2 cases. Methods: Beside clinical assessment, we carried out a quantitative measurement of the stiffness of the ankle flexor muscles. the path length of the phase diagram between elastic and viscous stiffness quantifies the reflex response to movement and reflects the importance of the spasticity. The assessments were carried out before and 30 min after motor nerve branch block of the upper soleus nerve and more than 7 months after neurotomy. Results: Both patients presented with pronounced ankle plantar flexor spasticity: their path lengths were more than 6 times greater than normal values at baseline (#1: 354 N m rad -1 ; #2: 409 N m rad -1 ). Motor nerve branch block and neurotomy allowed a near-normalization of elastic and viscous stiffness of ankle plantar flexor muscles in the 2 patients. their path length was almost similarly improved by motor nerve branch block (#1: 127 N m rad -1 ; #2: 231 N m rad -1 ) and neurotomy (#1: 60 N m rad -1 ; #2: 162 N m rad -1 ). Conclusion: these case reports highlight the fundamental role of the soleus muscle in triceps surae spasticity in our patients, the predictivity of motor nerve branch block in the preoperative assessment, and the effectiveness of soleus neurotomy in spastic equinus foot.
Acta Neurochirurgica, 2013
Background Selective tibial neurotomy (STN) is an effective neurosurgical intervention for treating ankle spasticity. The authors use intraoperative electromyography (EMG) for selecting targeted fascicles and determining the degree of fascicular resection in STN. This study reports surgical techniques and outcomes of the operation. Methods Participants who underwent STN with utilization of intraoperative EMG were recruited. Modified Ashworth Scale (MAS), passive range of motion (PROM) of the ankle in plantar flexion and dorsiflexion, Massachusetts General Hospital Functional Ambulatory Classification (MGHFAC) and ability to attain full plantigrade stance were assessed pre-and postoperatively. Results Twenty-one STNs were performed in 15 patients. The mean pre-and postoperative MAS and PROM were 2.8 and 0.4 (p<0.001), 39.5 o and 66.0 o (p<0.001), respectively.
Journal of Rehabilitation Research and Development, 2016
The aim of this study was to analyze the displacements of center of pressure (COP) using an in-shoe recording system (F-Scan) before and after motor nerve block and neurotomy of the tibial nerve in spastic equinovarus foot. Thirty-nine patients (age 45 +/-15 yr) underwent a motor nerve block; 16 (age 38 +/-15.2 yr) had tibial neurotomy, combined with tendinous surgery (n = 9). The displacement of the COP (anteroposterior [AP], lateral deviation [LD], posterior margin [PM]) was compared between paretic and nonparetic limbs before and after block and surgery. At baseline, the nonparetic limb had a higher AP (17.3 vs 12.3 cm, p < 0.001) and LD (4.0 vs 3.3 cm, p = 0.001) and a smaller PM (2.9 vs 4.7 cm, p = 0.001). For the paretic limb, a significant increase of AP was observed after block (13.5 vs 12.3 cm, p = 0.02) and after surgery (13.7 vs 12.3 cm, p = 0.03). A significant decrease of PM was observed after surgery (4.5 vs 3.3 cm, p < 0.001) with no more difference between two limbs (2.8 vs 3.3 cm, p = 0.44). This study shows that the F-Scan system can be used to quantify impairments and be useful to evaluate the effects of treatment for spastic foot. It suggests that changes in AP displacement following block may predict the effects of neurotomy.
How I do it: selective tibial neurotomy
Acta Neurochirurgica, 2020
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.