Abstract
We studied the microselective neurotomy (MSN) and its advantages to alleviate disabling spasticity. The best indication for MSN is focal spasticity. We performed 298 MSN, 87 nerves on the upper limb, 211 nerves on the lower limb) in 68 patients. The initial causes were: stroke, cranial trauma, postoperative complications and multiple sclerosis. MSN procedures were performed on the median nerve (n = 40) for wrist and finger flexion; musculo-cutaneus nerve (n = 38) for elbow flexion; ulnaris nerve (n = 9) for cubital deviation of the hand; gastrocnemius nerve (n = 98) and soleus nerve (n = 49) for equinus foot, tibial posterior nerve (n = 45) for varus foot, and fascicles (or bundles) of the flexor digitorum for “claw” toes (n = 19). The main preoperative test to identify the responsible nerve was a neuromuscular block with local anesthesia (lidocaine or bupivacaine) injected into the site of the nerve connecting the spastic muscle. During surgery, the identified nerve was exposed and its epineurium opened. Nerve bundles were teased apart into individual rootlets and a number of rootlets cut were previously planned, according to the spasticity. Follow-up was performed for up to 10 years, with a mean period of 29 months. Results demonstrated a reduction of limb spasticity of 2 to 3 points: modified Ashworth scale (MAS). Pain and clonus were also diminished in the affected limb. In some cases, voluntary movement was once again possible. MSN is a useful alternative in those cases of focal spasticity where physiotherapy and nerve block with botulinum toxin or phenol no longer produce satisfactory results.
Highlights
In a vast majority of plegic or paretic patients, spasticity worsens their ability to gain improvement from rehabilitation and physiotherapy and it is the cause of painful and abnormal postures
We studied the microselective neurotomy (MSN) and its advantages to alleviate disabling spasticity
Spasticity can be treated by several means: conservative approaches, such as pharmacotherapy, neuromuscular blocks with phenol or botulinum toxin [1] [2]; and invasive procedures, such as intrathecal infusion of baclofen/baclofen pump, dorsal selective radicellotomy, dorsal root entry zone (DREZ)-otomy, and microselective neurotomy (MSN) of the motor peripheral nerves which directly connect to the muscles whose spasticity needs to be alleviated
Summary
In a vast majority of plegic or paretic patients, spasticity worsens their ability to gain improvement from rehabilitation and physiotherapy and it is the cause of painful and abnormal postures. Introduced by Stoffel, cited by Decq [3], the MSN technique was later improved by Gross [4] and popularized by Sindou [5] [6] [7] and reproduced by many others [8] [9] [10] [11]. The objective of this technique is to reduce motor innervation to spastic muscles by sectioning motor fascicles within the nerve, sparing sensory fascicles, all identified in open microsurgery. If these complications are already present, MSN should be complemented with an orthopedic correction [17] [18]
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