Management of spastic hand by selective peripheral neurotomies

Available online 20 August 2011

Peer review under responsibility of Alexandria University Faculty of Medicine

Figures & data

Table 1 Modified Ashworth scale.

Grade	Patient's status
0	No increase in muscle tone
1	Slight increase in tone with a catch and release or minimal resistance at end of range of motion
1+	Slight increase in tone but with minimal resistance through range of motion following catch
2	More marked increase in tone but limb easily moved
3	Considerable increase in tone, passive movement is difficult
4	Affected part is rigid

All patients had spasticity either G3 or G4 preoperatively.

Table 2 Functional outcome of 10 patients who underwent SPN using Oswestry scale.⁶

Oswestry scale of spasticity grading (Functional outcome)	No of case Preop.	No of case Postop.
G0 = Solely spastic: No willed movement. Tonic reflexes or spinal reflexes present	2
G1 = Very severe spasticity: Movement very poor, being a total spastic synergy and in one pattern only, i.e. either only total extension if the limb is passively flexed or only total flexion from an extended position	5
G2 = Sever spasticity: Movement poor, being a marked total spastic synergy but in both flexion and extension patterns, i.e. the patient can reflex the extended limb and extend the flexed limb, with or without some isolated proximal control	3	2
G3 = Moderate spasticity: Movement fair, spastic synergy, but some isolated control in a small range of movement at a distal joint (ankle or wrist)		6
G4 = Mild spasticity: Movement good with isolated distal control possible in a good range although spastic synergy is still apparent on reinforcement by resistance to the movement, or by effort exerted in another part of the body		2
G5 = No spasticity: Movement normal. No spastic synergy
Total	10	10

Preop. = Preoperative

Postop. = Postoperative

Figure 1 Schematic representation of median nerve neurotomy.³ (a) S-shaped skin incision on the right forearm. (b) Dissection of the median nerve in two stages. First stage of the dissection (upper figure), the PT is retracted upward and laterally and the FCR medially. Branches from the median nerve (MN), before it passes under the fibrous arch of the FDS, are dissected: to the PT(1) and two nerve trunks to the FCR, PL and FDS(2), (3). Second stage of the dissection (lower figure), the fibrous arch of the FDS is sectioned to allow a more distal dissection of the median nerve. The FDS is retracted medially and branches from the median nerve are identified: (1) to the FPL; (2) to the FDP; (3) the interosseous nerve and its proper branches to these muscles.

Figure 2 Abnormal spastic hand posture (flexion of wrist and fingers). Before (A) and after (B) surgery.

Figure 3 Abnormal spastic hand posture (thumb in hand deformity). Before (A) and after (B) surgery.

Table 3 Summary data and outcome of 10 patients who underwent SPN of median and ulnar nerves.

No.	Age	Sex	Etiology	Abnormal posture of wrist and fingers	Operative program of SPN (Amount of denervation + spastic muscle)	complications	Outcome using Ashworth scale
							Preop.	Postop. + follow up period (months)
1	18	M	Cervical cord injury	Spasticity of wrist and fingers with radial deviation+ pronation	75% of motor fibers to PT, FCR, FDS, FDP+ 50% of fibers to FCU		G 3	G1+ good result 22 m
2	50	M	Cerebral stoke	Spasticity of wrist and fingers with radial deviation+ pronation	80% of motor fibers to PT, FCR, FDS, FDP+ 50% of fibers to FCU	Wound infection	G 4	G1 excellent result 42 m
3	15	F	Cerebral palsy	Spasticity of wrist and fingers with ulnar deviation	75% of motor fibers to PT, FDS, FDP, FCU+ 50% of fibers to FPL, FCR		G3	G1+ good result 23 m
4	31	M	Head injury	Spasticity of wrist and fingers with radial deviation+ pronation	75% of motor fibers to PT, FCR, FDS, FDP+ 50% of fibers to FCU		G 3	G1 excellent result 18 m
5	41	F	Cerebral stoke	Spasticity of wrist, fingers and thumb + pronation	75% of motor fibers to PT, FCR, FDS, FDP,FPL+ 50% of fibers to FCU	Recurrence of spasticity	G 3	G 3 poor result 15 m
6	45	F	Cerebral stoke	Spasticity of wrist and fingers with radial deviation	80% of motor fibers to FCR, FDS, FDP+ 65% of fibers to FCU		G 4	G1 excellent result 21 m
7	58	F	Cerebral stoke	Spasticity of wrist and fingers with radial deviation+ pronation	75% of motor fibers to PT, FCR, FDS, FDP+ 50% of fibers to FCU		G 3	G 2 fair result 12 m
8	49	M	Cerebral stoke	Spasticity of wrist, fingers and thumb with adduction- flexion	75% of motor fibers to, FCR, FDS, FDP, FPL, AP + 50% of fibers to FCU		G 3	G1+ good result 22 m
9	18	M	Cerebral palsy	Spasticity of wrist and fingers with ulnar deviation	80% of motor fibers to FDS, FDP, FCU+ 65% of fibers to FPL, FCR		G 4	G0 excellent result 18 m
10	34	F	Cervical cord injury	Spasticity of wrist, fingers and thumb with flexion+ pronation	75% of motor fibers to PT, FCR, FDS, FDP, FPL+ 50% of fibers to FCU	Transient paresis of wrist flexors	G 3	G1+ good result 17 m

Preop . = preoperative Postop. = postoperative PT = pronators teres FCR = flexor carpi radialis FDS = flexor digitorum superficialis FCU = flexor carpi ulnaris.