Highly Selective Partial Neurectomy for Lower-Extremity Spasticity: 2-Dimensional Operative Video

Spasticity is a common debilitating condition after central nervous system injury. The principal therapies—sedating antispasticity medications and focal therapies (eg, botulinum toxin)—may not provide sufficient reduction in tone, have intolerable side effects, and lose efficacy over time. Selective neurectomy is a surgical option for durable reduction in tone.1-6 Although commonly performed internationally, neurectomies are used less often within the USA. We present the surgical case of a 23-yr-old woman with cerebral palsy and severe spastic diplegia. Medications, injections, and tendon surgeries had failed to relieve her spastic lower extremities. She presented with crouch gait, adductor scissoring, and bilateral equinovarus. She had previously benefitted significantly from bilateral hamstring and obturator neurectomies, with improvement in mobility. She desired tibial neurectomies for her bilateral equinovarus, which impacted her gait substantially. To reduce unwanted plantarflexion and internal rotation tone, selective neurectomies of the motor nerves to the medial and lateral gastrocnemius, soleus, and posterior tibialis muscles were performed. The surgical video details a technique for longitudinally opening the epineurium, separating small nerves into their individual fascicles, and subdividing submillimeter fascicles by approximately 50% to 60% of the fascicle cross-sectional area. She reported significant improvement in gait, her modified Ashworth score dropped from 3 to 0, and her motor power remained unchanged, which is equivalent or better than most published results.2,7 Neurectomies are a highly effective procedure for focal extremity spasticity. Additional clinical series or trials would help establish the appropriate indications and durability and quantify the risks and benefits. The patient consented to treatment and publication.

A Study of Tibial Nerve in the Popliteal Fossa Along With Its Variations in Its Branching Pattern

Background: A detailed Knowledge of these variations in motor branching patterns will help the surgeons when certain procedures are done for calf reduction and also when selective neurectomy is required. It is also required by the anesthetists to give neurolytic blocks. Subjects and Methods: 40 formalin-fixed lower limbs of adult human cadavers were selected. The origin of the tibial nerve, variations in a branching pattern, number of muscular branches given was studied by dissection. The Level of origin of these nerves was taken to the apex of the head of the fibula (AHF). Results: In 70 % of specimens the origin of the Tibial Nerve was < 12 cm and in 30 % it was between 12-24 cm above the level of AHF. In 10% of cases, the sural nerve originated from the nerve to the medial head of gastrocnemius (MHG). In 82.5% of specimens, the MHG received one branch from the tibial nerve and in 17.5% it received two branches. The lateral head of Gastrocnemius (LHG) received one branch from the tibial nerve. In 10%, there was a common branch for the LHG and the soleus muscle. 90% of specimens had one branch and 10% had two branches that supplied the soleus muscle. A single branch supplied the plantaris muscle. The popliteus muscle also received a single branch. Conclusion : The results in the study provide information that is required by the anatomists, surgeons, radiologists and anesthetists.