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CLINICAL ARTICLE
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 21-27

Results of selective motor fasciculotomy in spastic upper limbs due to cerebral palsy (a review of 30 children and adults)


Department of Neurosurgery, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Andhra Pradesh, India

Date of Web Publication21-Apr-2015

Correspondence Address:
Aniruddh Kumar Purohit
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad - 500 082, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-4264.153559

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  Abstract 

Objectives: To assess the outcome of selective motor fasciculotomy in relieving upper limb harmful resistant spasticity and thereby to improve motor functions in persons with cerebral palsy.
Materials and Methods: Thirty people having cerebral palsy (16 males and 14 females) age ranging from 5-35 (mean age = 12.66) years with upper limb resistant spasticity were studied. The participants having spastic hemiplegia (N = 11), triplegia (N = 9) and quadriplegia (N = 10) were assessed using Modified Ashworth Scale (MAS), Selective Voluntary Control Grade (SVC), WeeFIM Scale and hand function evaluation. Selective motor fasciculotomy (SMF) was performed on musculocutaneous nerve (N = 15), median nerve (N = 35) and ulnar nerves (N = 3) for elbow flexors, pronators and radial wrist flexors and ulnar wrist flexors spasticity respectively. Pre and post op therapeutic exercises were performed.
Results: Statistical analysis using Wilcoxon Signed Ranks test showed significant reduction in spasticity and improvement in selective voluntary control, hand functions (grasp to hold a rod) and WeeFIM self care domain. There was no recurrence in spasticity and no complications following surgery.
Conclusions: The SMF of musculocutaneous, median and ulnar nerves significantly reduces spasticity in the affected muscle groups and thereby improves the self care (motor) functions in selected people with cerebral palsy who have harmful resistant spasticity without any organic shortening of the muscles. The procedure is safe and the spasticity does not recur.

Keywords: Cerebral palsy, fasciculotomy, neurotomy, upper limb spasticity


How to cite this article:
Reddy S, Puligopu AK, Purohit AK. Results of selective motor fasciculotomy in spastic upper limbs due to cerebral palsy (a review of 30 children and adults). Indian J Cereb Palsy 2015;1:21-7

How to cite this URL:
Reddy S, Puligopu AK, Purohit AK. Results of selective motor fasciculotomy in spastic upper limbs due to cerebral palsy (a review of 30 children and adults). Indian J Cereb Palsy [serial online] 2015 [cited 2017 Apr 23];1:21-7. Available from: http://www.ijcpjournal.org/text.asp?2015/1/1/21/153559


  Introduction Top


Spasticity and dystonia involving upper limb in non-progressive neurological disorders are challenging to treat, as these impairments not only produce pain and are cosmetically unacceptable but also functionally restrict activities of daily living and vocational skills. Permanent relief using treatment modalities like therapeutic exercises, botulinum toxin etc., is unlikely. [1],[2],[3],[4],[5] Surgical procedure like selective motor fasciculotomy (SMF, also known as selective neurotomy) may have benefit in managing these resistant cases, [6],[7],[8],[9],[10],[11],[12],[13],[14] in which the nerve fascicles carrying excessive impulses are ablated there by permanent relief in harmful spasticity is obtained without losing control and balance.


  Materials and Methods Top


This is a prospective study of randomly selected 30 subjects who underwent (SMF) for the treatment of spasticity in upper limbs due to cerebral palsy from January 2008 to January 2013.

Exclusion criteria

  • Poor motor control in upper limbs
  • Moderate to severe contractures in upper limbs
  • Severe mental sub-normality.
Preoperative evaluation

Subjects with upper limb spasticity were evaluated using Modified Ashworth's Scale (MAS) and Selective Voluntary Control (SVC) Grading. The upper limb motor functions were evaluated using WeeFIM Scale and hand function assessment, which assesses opposition, pinch and grasp. [15],[16],[17],[18] Outcome of hand function assessment was classified into good, fair and poor, where good means near normal function, fair was impaired function but still the function was possible and poor when the subject could not attempt the function.

Once subjects develop resistance to nonablative therapies, they were taken up for surgery. The goals of surgery and further treatment including the need to continue therapeutic exercises were discussed in detail with the parents. All subjects were also explained regarding the possibility of requirement of second-stage surgery which may include more ablation of the same nerve or the ablation of another nerve of the affected muscle group in cases who have residual spasticity.

All subjects planned for surgery were admitted and routine blood investigations were performed. Subjects were kept fasting 6 hours prior to surgery. On the day of surgery thorough bath was given and the limbs were wrapped with povidone iodine soaked gauge bandages.

Surgery

On day of surgery all subjects had an intravenous line placed in non- operative limb prior to shifting into operation theatre and antibiotics were given. The subject was positioned supine with arms abducted by 45° and placed over sidearm rest. Induction was carried out by single low dose of vecuronium. Reassessment of the contractures was performed and angles of contractures noted. Operative limb was cleaned with povidone iodine scrub and solution, and the body was draped keeping operative limb fully exposed so that the movements of the limb could be observed during electrostimulation of the nerve. Intradermal infiltration of lignocaine mixed with adrenalin (1 in 200,000) was used to raise a peau-de-orange patch along the line of incision. Care was taken to avoid injecting the drug into the deeper planes so as to prevent infiltration of the underlying nerve, as this may otherwise lead to erroneous findings during the stimulation of the nerve.

Musculocutaneous nerve

The skin was incised at a point 2 ± 1 cm distal to the tendinous lateral-most end of the anterior axiliary fold and carried up to 6 ± 4 cm distally. The skin, subcutaneous tissue, superficial and deep fascia were incised along the line of incision and glistening aponeurosis of the biceps brachii was exposed. It was incised longitudinally and the muscle was split along the long axis of its fibers (muscle splitting approach) with the help of artery forceps and right-angled Langen Bach retractors. The index finger was also used to split the muscle and palpate the nerve that feels like a cord. The nerve was found underneath the biceps brachii and over the brachialis. The nerve was further dissected along its long axis with the help of small size cottonoids. The epineurium was incised along the long axis of the nerve. The branches were dissected till their entry into the muscles [Figure 1].
Figure 1: Nerve with its branches and fascicles entering into muscles

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Median nerve

A horizontal skin crease incision was given in the cubital fossa. Skin, subcutaneous tissue, superficial and deep fascia were incised along the line of incision and bicipital aponeurosis was exposed. It was incised transversely toward the medial aspect up to the pronator teres muscle leaving the main tendon intact. The nerve was found between the two heads of pronator teres. It was further dissected along its long axis with the help of peanut size cottonoids. The epineurium was incised along the long axis of the nerve. A proximal branch exiting from the main trunk proximal to the transverse elbow line, running medially and entering into the muscle, was split into its component fascicles and a distal branch running along the ventral aspect of the main trunk, which could be easily lifted away from the main trunk, was found disappearing at the distal end of the wound under the muscles of the forearm, and was also dissected into its component fascicles.

The wrist flexor branch (s) exiting medially from the main trunk, distal to the transverse elbow crease, was also dissected into its component fascicles.

Ulnar nerve

The skin was incised longitudinally, one-fourth above and three- fourth below the transverse elbow line, in the groove between the medial epicondyle and olecranon process. The subcutaneous tissue, superficial and deep fascia were incised along the line of the incision. The ulnar nerve was dissected in between the two heads of flexor carpi ulnaris. The epineurium was incised along the long axis of the nerve. The dissection was performed from the trunk of the nerve along its branches till its ramification as fascicles into the muscle. The branch at the site of its entry into the muscle was found as the ideal site for dissection, as the natural process of separation into fascicles was observed clearly at this site.

Each fascicle was stimulated using bipolar current starting from 0.1 mA, gradually increasing by 0.1 mA, up to 2 mA. Fascicles, which showed intense contraction with a lower threshold and correlating clinically with severity of spasticity and voluntary control, were considered for ablation. About one-third (1/3) to three-fourth (3/4) of the fascicles of the dissected branches were ablated. The proximal stump was clipped using a silver clip. All the dissected neural tissue, prior to coagulation, was dipped in saline to avoid heat dissipation and then the sectioned proximal stumps were coagulated using bipolar coagulation to make the stump brown colored. If the stump is under-coagulated (white) it may regenerate and if the stump is over coagulated (black) then it may get auto amputated and may re-grow. Clipping of the stump was performed to identify the dissected branches in cases of re- exploration and may also probably help in decreasing the incidence of the re growth. The limb was immobilized using slab across the joint. The slab was applied for a period of 2 weeks and gradual active exercises were begun later. [19]


  Results Top


Out of total 34 randomly selected subjects from January 2008 to January 2013, subjects who were operated, four of the patients did not complete six months of follow-up. The results of 30 subjects who completed follow-up were analyzed and are as follows.

Age and gender distribution

Out of total 30 subjects who had undergone surgery, 26 were under and four were above the age of 18 years [age ranging from 5-35, mean age = 12.66 years, [Figure 2]. The male to female ratio was 1.2:1.
Figure 2: Age distribution

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Subjects

Thirteen (43%) subjects underwent musculocutaneous nerve SMF for elbow flexor spasticity, N = 15 (2 subjects had undergone bilaterally). 30 (100%) subjects underwent SMF of the median nerve for pronator spasticity, N = 35 (five subjects had undergone bilaterally). Twenty-nine (96%) subjects underwent SMF of the median nerve for wrist flexor spasticity, N = 34 (five subjects had undergone bilaterally); three (10%) subjects in the same group also underwent SMF of the ulnar nerve, N = 3.

The outcomes of spasticity on various targeted muscles, selective voluntary control and functions have been shown in the [Table 1], [Figure 3] [Figure 4] [Figure 5] [Figure 6] [Figure 7] [Figure 8].
Figure 3: Change in pre and post operative elbow flexor's spasticity

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Figure 4: Change in pre and post operative elbow flexor's selective voluntary control

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Figure 5: Change in pre and post operative pronator's spasticity

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Figure 6: Change in pre and post operative pronator's selective voluntary control

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Figure 7: Change in pre and post operative wrist flexor's spasticity

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Figure 8: Change in pre and post operative wrist flexor's selective voluntary control

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Table 1: Outcome of spasticity on various muscle groups with mean pre and post operative values, mean change and P values

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Results of SMF on functional evaluation

WeeFIM Scale was impaired in 16 children. The mean pre-op and post-op WeeFIM scores were 105.7 and 110.5 respectively. The mean increase in score was 4.85 (P = 0.001). Self-care domain of WeeFIM scale was also analyzed to meet with the objectives of the study. The mean pre-op and post-op scores of this domain were 32.15 and 35.45 respectively. The mean increase in score was 3.3 (P = 0.0009).

The functions of the intrinsic muscles of the hand (opposition, pinch and grasp) were evaluated. There was improvement in opposition and pinch functions in second and third fingers. However, it did not reach statistical significance. The P value for the ability to grasp a 2"rod was significant (0.0012). The ability to grasp a rod lower than 2" diameter was not significant (P = 0.072 for 1 inch rod and P = 0.32 for half inch rod).

Complications and recurrence

None of the subjects had any complication and there was no recurrence of spasticity till the present follow-up period.


  Discussion Top


In general the recommended treatment of spasticity is to try intially with non-ablative measures like therapeutic exercises, use of splints and orthotics, usage of medications, nerve blocks and muscle injections to produce helpful muscle tone. However, the surgical measures like soft tissue release and motor fasciculotomies (neurotomies) are necessary only when the spasticity does not respond to these modalities. [3],[4],[5] All subjects in the study were planned for surgery when they showed no further reduction in harmful spasticity to non-ablative measures.

In this series (N = 30) all subjects had spasticity due to cerebral palsy. Most of the subjects were under 18 years of age. Many of them have come late (later than 4-6 years age) because of late referrals and various socio-economical, educational and geographic constraints. All subjects in this series had normal intelligence or minimal mental sub normality.

Spasticity outcomes

Elbow flexor spasticity

The reduction in elbow flexor spasticity following SMF of the musculocutaneous nerve (N = 15) was significant in all the subjects (N = 13) with six achieving normotonia. All subjects had improvement in selective voluntary control and cosmetic appearance. There were associated benefits of surgery on shoulder joint movements and adjacent joints. There was relief in elbow flexion dynamic (on activity) spasticity (N = 5), which manifested during activities like walking.

Garland et al., performed complete musculocutaneous neurectomy in adult subjects with stroke by which they produced complete denervation of biceps and brachialis. They showed improvements in spasticity, cosmetic appearance, and personal hygiene. [13] In recent studies, preoperative planning and perioperative electrostimulation helped to quantify the fascicular ablation rather than complete neurectomy to achieve better results. The senior author of the present series had reported 36% of residual spasticity following musculocutaneous nerve SMF with limited (50% or less) fascicular ablation. [14] In the present series we report greater reduction in spasticity (mean postoperative MAS = 0.73), which was comparable with Marrawi et al. (mean postoperative MAS = 0.8) following more fascicular ablation. [7],[8]

Pronator spasticity

The reduction in pronator spasticity following SMF of the median nerve (n = 35) was significant in all the subjects (N = 30), however, not to the extent of elbow flexor spasticity reduction. The mean postoperative spasticity on MAS was 1.36, which was higher when compared to that of Marrawi et al. (Ashworth's Scale was 0.6). [7],[8] Even then there was improvement in selective voluntary control and self-care domain on WeeFIM Scale in the present series.

Wrist flexor spasticity

The reduction in wrist flexor spasticity following SMF of the median (N = 34) and ulnar nerves (N = 3) was significant in all the subjects. The mean postoperative spasticity on MAS was 0.74 (whereas on Ashworth's Scale 0.48 in Marrawi et al., series). [7],[8] This has resulted in improvement in selective voluntary control and self-care domain of Wee FIM Scale, that is, eating, dressing, grooming, toileting, and bathing.

Functional outcome

Hand functions

Distal effects of surgery on the pronators and wrist flexors were seen in the form of improved hand functions like opposition, pinch and grasp. Grasping to large objects improved more than other functions. Improvements were noted more often in the index and the middle finger (median nerve) than the ring and the little finger (ulnar nerve). This could be explained because we have performed median nerve SMF more often than both median and ulnar nerves together.

Functional activities

The self-care activities improved following surgery in all subjects. Thirty-three percent of subjects showed improvement from dependence to complete independence in performing self- care activities.

Cosmetic outcome

All subjects improved cosmetically following the reduction in spasticity. They were having better look of the limb while performing self-care activities, walking and during leisure time.

The operative scars of musculocutaneous nerve SMF were cosmetically acceptable as they were hidden under the arm sleeves.

In the present series the SMF of the median nerve was performed by a horizontal skin crease incision unlike the linear incision parallel to long axis of the limb carried across the joint as described in other series. There was hardly any visible scar in most of the subjects of the present series.

Follow-up

There was no recurrence during the mean follow-up period of 10 months (ranging from 6-24 months) despite ablating the fascicles close to the muscle.

Complications

The incisions and the tissue (including neural) handling techniques described earlier prevented development of any scar contractures and wound complications.


  Acknowledgements Top


We thank Naveen Kumar Balne and colleagues, Department of Physiotherapy, for their pre and postoperative evaluation and training of subjects.

We also thank Dr. Dilip Kulkarni, Dr. Padmaja Durga and their colleagues of the Department of Anesthesia for challenging non- curare muscle relaxant free anesthesia. We are grateful to our study group children and adults along with their families for giving us this opportunity and providing their consent to participate in this research.

 
  References Top

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[PUBMED]  Medknow Journal  


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