The Role of Selective Peripheral Neurectomy in the Treatment of Upper Limb Spasticity.

Abstract

Management of upper limb spasticity remains challenging. Selective peripheral neurectomy (SPN) is a relatively recent intervention for cases refractory to medical therapy. The aim of this study was to conduct a systematic review looking at the efficacy and outcomes of SPN, in order to clarify the patient selection criteria and surgical technique. A search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, Open Grey and CINAHL was conducted. Inclusion criteria included studies comparing pre- and post-operative outcomes for SPN, neurectomy, fasciculotomy and upper limb spasticity. Only case series were reported with no randomised controlled trials found. 7 studies met the inclusion criteria with a total of 174 patients. A meta-analysis was not possible due to the degree of baseline heterogeneity. All studies had no control arm for comparison of outcomes, with a high risk of bias due to poor internal and external validity, as well as design and performance bias. Surgical techniques differ vastly between studies, with percentage of fascicles ablated between 30-80% and length of neurectomy between 5-10 mm. Some advocated removing end branches while others performed fascicular SPN proximally. 13 patients underwent orthopaedic or neurosurgical procedures, which are both confounding factors. All studies reported an improvement in spasticity although functional outcomes were reported with non-standardized measures. Recurrence rates were reported to be 0-16.1% (mean 3.72%). From this systematic review, SPN appeared to be a useful technique in selected cases, but overall no firm conclusions can be drawn regarding the best surgical technique, or the extent of functional improvement.