Fascicular motor neurotomy associated to single event multilevel surgery in cerebral palsy. A long-term review with gait analysis

Abstract

The aim of this study is assessment of functional benefits after multilevel surgery associated with selective partial neurotomies, focusing on rectus femoris (RF), semitendinosus and semimembranosus muscles (medial hamstring MH) and the function of hip and knee joints. This is a series of patients who had multilevel surgery associated with selective neurotomy on RF, MH between 2009 and 2016. Clinical data were knee range of motion and Modified Ashworth Scale for RF and MH, energy expenditure index and Gross Motor Function Measure. Gait analysis data were speed, cadence, step length, time of stance phase, articular range of motion and articular moment on hip and knee flexion. Gait deviation index (GDI) and gait profile score (GPS) were calculated. All data were collected before surgery, and at last gait analysis follow-up available for each patient. Thirty-four patients were included. The average time assessment after surgery was 33.35 months ± 13.8. There is significant improvement of GDI and GPS, respectively from 74.2 ± 11.6 to 79.7 ± 8.2 ( P = 0.010) and from 11.54 ± 4.1 to 9.5 ± 2.5 ( P = 0.005). Knee flexion decreased at body weight acceptance phase: 30.8 ± 9.9° to 24.7 ± 6.6° ( P = 0.006). Maximum joint moments were closer toward normality at knee on 55% of gait cycle: 0.2118 ± 0.25 Nm/kg to 0.1119 ± 0.14 Nm/kg ( P = 0.003), at hip on 10% of gait cycle: 0.1261 ± 0.39 Nm/kg to 0.4419 ± 0.32 Nm/kg ( P = 0.004) and for knee flexion at 95% of gait cycle: 0.1340 ± 0.45 Nm/kg to 0.1883 ± 0.068 Nm/kg ( P = 0.005). GMFM (E item) increased from 75.39 ± 30.3% to 78.84 ± 27.8% ( P = 0.009). There is clinical and functional benefits. GDI and GPS were improved after procedure combining single event multilevel surgery with neurotomy. Moreover, kinematics of gait cycle is improved particularly at the beginning of gait cycle.