Different surgical modalities for spastic conditions

1. Start with the Great name of ALLAH, the most Merciful and the most beneficent.

2. SURGERY FOR SPASTICITY
Dr Zeeshan Nasir

3. INTRODUCTION
 Defined as Velocity dependent resistance to passive
movements of joints and its associated musculature
 Hyper-excitability of Stretch reflex
 May serve as compensatory response for loss of
motor power

4. TWO COMPONENT OF STIFFNESS
 Dynamic: shortening of muscles caused by
spasticity, manifested as hyper-reflexia, clonus and
velocity dependent resistance to passive joint
movements
 Fixed: Shortening of muscles, manifested as
contracture, less velocity dependent and persists
under local blockade or anaesthesia

5. CLINICAL EVALUATION
 Modified Ashworth Scale

6. INDICATION OF TREATMENT
• Functional Disability
• Impaired locomotion
• Contractures
• Deformities
• Neurosurgical intervention; Not controlled by
physical therapy and medication.

7. SURGICAL OPTIONS

8. GUIDELINES

9. SPASTICITY APPROACH IN CHILDREN
 Observe child clinically
to understand the child
function
 Measure the range of
motion or contracture
 Quantify the spasticity
using scale
 Grade the child on
Gross motor function
with time

10. GOAL OF SURGERY
 To reduce excessive tone; to prevent other muscles
from being damages
 To re-equilibrate the balance between paretic
agonist and spastic antagonist
 With poor residual function; aim to halt orthopaedic
deformities and improve comfort

11. TIBIAL NEUROTOMY EXAMPLE

12. INTRA-THECAL BACLOFEN

13. INTRODUCTION
 Acts on dorsal grey
matter of spinal cord
 Lipophilic GABA
agonist; only affect B
type
 Partial permeates BBB
 Act on presynaptic and
post-synaptic areas

14. KINETICS AND DISTRIBUTION
 Half life of bolus
baclofen in CSF is 90
mints in bolus infusion
 In steady, slow rate
infusion, the steady
balance occur at about
12 to 18 hours later.

16. EFFICACY AND SIDE EFFECT
 A bolus of 50 to 100 microgram intra-thecal reduces
abnormal muscle tone 2 or more points on
ashworth scale.
 Side effects: drowsiness, mental confusion, light-
headedness and ataxia
 Bolus infusion are associated with hypotension,
nausea and respiratory depression.
 Large dose 1 to 10 mg can results in coma
 Moderate overdose can be treated with
physostigmine (0.5 to 2mg).
 Tapering of dose should be done.

17. BOTULINUM TOXIN

18. BOTULINUM TOXIN
 Focal
 Complementary effect
 Delayed neurosurgical
intervention
 Not always helpful,
may need neurotomies
 Effective primary
treatment
 Definitive option
 Repeated every 6-12
months
 Immun-o-resistence
can develop
 Stimulate selective
neurotomy
Lower limbs Upper limb

19. SELECTIVE PERIPHERAL
NEUROTOMIES

20. INTRODUCTION
 More selective by using intra-operative electrical
stimulation and micro- surgery
 Involves sectioning of one or more motor branches
 Work by interruption of segmental reflex arc in both
afferent & efferent limb
 Must not include sensory nerve fibers; can cause
neuropathic pain
 Sectioning of approximately 50 to 80% branches

22. PREOPERATIVE MOTOR BLOCK
 Local blockade with long lasting anaesthetic (2 to 3
hours with bupivacaine)
 To evaluate the strength of antagonist muscle
 To rule out associated conditions like articular limitation,
musculotendinous contracture and articular ankylosis
 Botulinum toxin injections as a prolonged test
 Strategy to appreciate the benefits of neurotomy

23. ANAESTHESIA
 The efficacy of procedure can be evaluate by
stretch reflex (clonus) intra-operatively.
 General anaesthesia without long lasting
Curarization to identify nerve fascicles
 Muscles relaxant must be avoided
 Nitrogen mono-oxide and propofol is
contraindicated

24. ELECTRO-PHYSIOLOGIC MAPPING
 For anatomical identification of motor fascicles
 Stimulation is performed at 2 Hz with low
intensity
 Bipolar or tripolar stimulation
 Response by observing clinical observable
movements
 If possible, use EMG recordings

25. SECTIONING
 50 to 80 % sectioning, depending the degree of
spasticity
 Resection over 5mm approx
 Proximal stamp coagulation
 Then stimulation is performed again in proximal and
distal stamp
 If stimulation is still intense, the section is performed
further
 Aim is to dec motor innervation to avoid recurrence of
spasticity

26. OBTURATOR NEUROTOMY
 Diplegic children with cerebral palsy
 Paraplegic patients to facilitate perineal washing and
self catheterization.

27. HAMSTRING NEUROTOMY
 To counter flexion deformity of knee.

28. TIBIAL NEUROTOMY
 Equinovarus spastic foot with or without dystonic claw toe.

29. FEMORAL NEUROTOMY
 To treat the excessive spasticity of quadriceps muscles

30. MUSCULOCUTANOUS NEUROTOMY
 Spasticity of elbow with flexion mediated by bicep brachi and brachialis muscle.

31. MEDIAN NEUROTOMY
 Spasticity of
forearm, wrist,
fingers, Swan
neck deformity
and adduction
flexion of
thumb.

32. ULNAR NEUROTOMY
 Spasticity of wrist with flexion and ulnar deviation,
thumb flexion and adduction, swan neck deformity

33. COMPLICATION
 Sensory disturbance; paresthesias, dysesthesias,
complex regional pain syndrome and
deafferentation pain
 Decreased muscle strength especially prehension
or talus deformity
 Recurrence of spasticity

34. DORSAL RHIZOTOMIES, DREZOTOMY

35. TYPES OF SPASTIC SURGERY AT SPINE
 Dorsal Rhizotomies
 Ventral Rhizotomies
 Longitudinal myelotomy
 Intrathecal chemical Rhizotomy
 Percutaneous radio-frequency Rhizotomy
 Selective posterior Rhizotomy
 Partial dorsal rhizotomy
 Functional dorsal rhizotomy
 Microsurgical DREZotomy (MDT)

36. DORSAL RHIZOTOMY

37. KEYHOLE INTER-LAMINAR DORSAL RHIZOTOMY

39. DREZOTOMY

40. JAZAKALLAH, ALLAH HAFIZ