RESUMO
The evolution of neurosurgical approaches to spasticity spans centuries, marked by key milestones and innovative practitioners. Probable ancient descriptions of spasmodic conditions were first classified as spasticity in the 19th century through the interventions of Dr. William John Little on patients with cerebral palsy. The late 19th century witnessed pioneering efforts by surgeons such as Dr. Charles Loomis Dana, who explored neurotomies, and Dr. Charles Sherrington, who proposed dorsal rhizotomy to address spasticity. Dorsal rhizotomy rose to prominence under the expertise of Dr. Otfrid Foerster but saw a decline in the 1920s due to emerging alternative procedures and associated complications. The mid-20th century saw a shift toward myelotomy but the revival of dorsal rhizotomy under Dr. Claude Gros' selective approach and Dr. Marc Sindou's dorsal root entry zone (DREZ) lesioning. In the late 1970s, Dr. Victor Fasano introduced functional dorsal rhizotomy, incorporating electrophysiological evaluations. Dr. Warwick Peacock and Dr. Leila Arens further modified selective dorsal rhizotomy, focusing on approaches at the cauda equina level. Later, baclofen delivered intrathecally via an implanted programmable pump emerged as a promising alternative around the late 1980s, pioneered by Richard Penn and Jeffrey Kroin and then led by A. Leland Albright. Moreover, intraventricular baclofen has also been tried in this matter. The evolution of these neurosurgical interventions highlights the dynamic nature of medical progress, with each era building upon and refining the work of significant individuals, ultimately contributing to successful outcomes in the management of spasticity.
Assuntos
Espasticidade Muscular , Rizotomia , Rizotomia/história , Rizotomia/métodos , Espasticidade Muscular/cirurgia , Humanos , História do Século XX , História do Século XIX , História do Século XXI , Procedimentos Neurocirúrgicos/história , Procedimentos Neurocirúrgicos/métodos , Baclofeno/uso terapêutico , Baclofeno/história , Paralisia Cerebral/cirurgia , Paralisia Cerebral/história , História do Século XVIIIRESUMO
PURPOSE: The dentate nucleus (DN) is the largest, most lateral, and phylogenetically most recent of the deep cerebellar nuclei. Its pivotal role encompasses the planning, initiation, and modification of voluntary movement but also spans non-motor functions like executive functioning, visuospatial processing, and linguistic abilities. This review aims to offer a comprehensive description of the DN, detailing its embryology, anatomy, physiology, and clinical relevance, alongside an analysis of dentatotomy. METHODS AND RESULTS: We delve into the history, embryology, anatomy, vascular supply, imaging characteristics, and clinical significance of the DN. Furthermore, we thoroughly review the dentatotomy, emphasizing its role in treating spasticity. CONCLUSIONS: Understanding the intricacies of the anatomy, physiology, vasculature, and projections of the DN has taken on increased importance in current neurosurgical practice. Advances in technology have unveiled previously unknown functions of the deep cerebellar nuclei, predominantly related to non-motor domains. Such discoveries are revitalizing older techniques, like dentatotomy, and applying them to newer, more localized targets.
Assuntos
Núcleos Cerebelares , Humanos , Núcleos Cerebelares/cirurgia , Núcleos Cerebelares/anatomia & histologia , Procedimentos Neurocirúrgicos/métodos , Espasticidade Muscular/cirurgiaRESUMO
Spasticity is a prevalent symptom of upper motor neuron syndrome, becoming debilitating when hindering voluntary movement and motor function and causing contractures and pain. Functional neurosurgery plays a crucial role in treating severe spasticity. Despite extensive literature on SDR for lower limb spasticity, there is a scarcity of papers regarding the procedure in the cervical region to alleviate upper limb spasticity. This case report details a cervical dorsal rhizotomy (CDR) performed for upper limb spasticity, resulting in significant improvement in spasticity with sustained outcomes and low complication rates. Neuroablative procedures like CDR become an option to treat spasticity.
Assuntos
Paralisia Cerebral , Rizotomia , Humanos , Rizotomia/efeitos adversos , Resultado do Tratamento , Espasticidade Muscular/etiologia , Espasticidade Muscular/cirurgia , Procedimentos Neurocirúrgicos/efeitos adversos , Extremidade Superior/cirurgia , Paralisia Cerebral/cirurgiaRESUMO
PURPOSE: As progressive hip dislocation causes pain in children with spastic cerebral palsy (CP) and spasticity needs surgical correction, we aimed to describe clinical and radiographic outcomes in CP patients with painful hip deformity treated with the Castle salvage procedure. METHODS: We included all patients operated in the same hospital between 1989 and 2017 with painful spastic hips and femoral head deformity making joint reconstruction unfeasible. We collected clinical and functional data from medical records and evaluated radiographies to classify cases for femoral head shape and migration, type of deformity, spinal deformity, and heterotopic ossification. We investigated quality of life one year after surgery. RESULTS: We analyzed 41 patients (70 hips) with complete medical records. All had severe function compromise GMFCS V (Gross Motor Function Classification System) and heterotopic ossifications, all but one had scoliosis, and most had undergone other surgeries before Castle procedure. Patients were followed up for 77.1 months (mean) after surgery. The mean initial migration index was 73%. Seven patients had complications, being three patients minor (two femur and one tibial fracture) and four majors (patients requiring surgical revision). Quality of life was considered improved by most of the carers (35 children; 85.3%) as level 4/5 according to CPCHILD instrument. No child was able to stand or walk, but moving in and out of bed, of vehicles, and to a chair, remaining seated, or visiting public places was "very easy." CONCLUSION: We considered most patients (37 patients-90%, 66 hips-94%) as having satisfactory outcomes because they had no or minor complications, absence of pain, free mobility of the lower limbs and were able to sit in a wheelchair.
Assuntos
Paralisia Cerebral , Luxação do Quadril , Espasticidade Muscular , Qualidade de Vida , Humanos , Paralisia Cerebral/complicações , Paralisia Cerebral/cirurgia , Masculino , Feminino , Criança , Estudos Transversais , Luxação do Quadril/cirurgia , Adolescente , Resultado do Tratamento , Espasticidade Muscular/cirurgia , Espasticidade Muscular/etiologia , Pré-Escolar , Moldes CirúrgicosRESUMO
PURPOSE: It is known that cerebral palsy (CP) children's caregivers suffer from burden, depression, and stress, impairing their quality of life (QoL). The more severe the CP, the more burden the caregiver has. Psychosocial support, education, therapies, and financial support are inversely related to the level of stress of the caregiver. Most parents of CP patients submitted to selective dorsal rhizotomy (SDR) report improvement not just on spasticity, but also in the functional role of the children, what can impact on caregiver's QoL. Our objective was to evaluate the burden of CP children's caregivers with and without previous SDR. METHODS: Spastic CP children caregivers were divided into two groups: those who take care of children without previous SDR (control group) and those that children were previously submitted to SDR (surgical group). The burden index was compared between groups using Burden Interview Questionnaire (BIQ). For statistical analysis, we used SPSS. RESULTS: The control group had enrolled 31 participants and the surgical group 36. The mean GMFCS level on the control and surgical groups was 3.94 ± 1.26 and 3.74 ± 1.12 (p = 0.61), respectively. The surgical group caregivers presented less burden related to the feeling that they should be doing more to their child (p = 0.003) and if they could do a better job in caring (p = 0.032), compared to controls. The total BIQ index was not significantly different between groups (surgical 32.14 ± 12.34 vs. control 36.77 ± 12.77; p = 0.87). Low economic status had a weak correlation to a higher BIQ index (R2 = 0.24). After age-matching, there was a significative higher BIQ index in the control group (p = 0.008). CONCLUSION: Caregivers of spastic CP children who were previously submitted to SDR presented less burden related to feeling of the amount of given care than those without previous surgery. The impression that they could do a better job with their kids was higher in the control group. The severity of CP and low economic status were related to more burden in both groups. After pairing groups by age, the control group had a significative higher BIQ index compared to the SDR group. CLINICAL TRIAL REGISTRATION: Trial registration number: CAAE 73407317.6.0000.0068 (Ethical and Research Committee of University of Sao Paulo, Sao Paulo, Brazil, approved on 08/06/2021). All the subjects were freely given an informed consent to participate in the study that was obtained from all participants. Non-consented ones were excluded from the study.
Assuntos
Paralisia Cerebral , Rizotomia , Criança , Humanos , Cuidadores , Paralisia Cerebral/cirurgia , Qualidade de Vida , Resultado do Tratamento , Espasticidade Muscular/cirurgia , BrasilRESUMO
OBJECTIVE: To analyze and compare the efficacy of two selective dorsal rhizotomy (SDR) techniques with intraoperative neurophysiological monitoring, using instrumented three-dimensional gait analysis. INTRODUCTION: SDR is a common, irreversible surgical treatment increasingly used to address gait disturbances in children with chronic non-progressive encephalopathy by reducing spasticity. Various techniques have been used, which mainly differ in the percentage of rootlets selected for sectioning. A greater proportion of rootlets sectioned leads to a more effective reduction of spasticity; however, there is a potential risk of unwanted neurological effects resulting from excessive deafferentation. While there is evidence of the short- and long-term benefits and complications of SDR, no studies have compared the effectiveness of each technique regarding gait function and preservation of the force-generating capacity of the muscles. MATERIALS AND METHODS: Instrumented three-dimensional gait analysis was used to evaluate two groups of patients with spastic cerebral palsy treated by the same neurosurgeon in different time periods, initially using a classic technique (cutting 50% of the nerve rootlets) and subsequently a conservative technique (cutting no more than 33% the nerve rootlets). RESULTS: In addition to an increase in knee joint range of motion (ROM), in children who underwent SDR with the conservative technique, a statistically significant increase (p = 0.04) in the net joint power developed by the ankle was observed. Patients who underwent SDR with the conservative technique developed a maximum net ankle joint power of 1.37 ± 0.61 (unit: W/BW), whereas those who were operated with the classic technique developed a maximum net ankle joint power of 0.98 ± 0.18 (unit: W/BW). The conservative group not only showed greater improvement in net ankle joint power but also demonstrated more significant enhancements in minimum knee flexion during the stance phase and knee extension at initial contact. CONCLUSION: Our results show that both techniques led to a reduction in spasticity with a positive impact on the gait pattern. In addition, patients treated with the conservative technique were able to develop greater net ankle joint power, leading to a better scenario for rehabilitation and subsequent gait.
Assuntos
Paralisia Cerebral , Rizotomia , Criança , Humanos , Rizotomia/métodos , Resultado do Tratamento , Raízes Nervosas Espinhais/cirurgia , Marcha/fisiologia , Amplitude de Movimento Articular/fisiologia , Paralisia Cerebral/complicações , Espasticidade Muscular/cirurgiaRESUMO
PURPOSE: This study aims to determine the utility of selective partial neurectomy of the musculocutaneous nerve (MCN) in pediatric patients with bilateral spastic elbow. METHODS: A prospective, cross-sectional, case series study was performed in nine pediatric patients (four females and five males) with bilateral spastic elbow, all with a 11.4-year-old average age, where 18 selective partial neurectomies of the MCN were carried out. They were evaluated with goniometry of both spastic elbows at resting position and active amplitude, and staging spasticity employing the Modified Ashworth Scale (MAS) in the preoperative and postoperative period. The results are reported 1 year after surgery. RESULTS: The etiology of the spasticity was secondary to cerebral palsy in eight patients (88.8%) and in one patient (11.11%) secondary to traumatic brain injury. A clinical improvement was observed in goniometry comparing the preoperative and postoperative resting position, a mean preoperative of 44.38 degrees (SD ± 7.61) versus 98.05 degrees (SD ± 24.44), respectively, and preoperative active amplitude a mean of 86.55 degrees (SD ± 15.97) versus the mean postoperative of 47.33 (SD ± 17.86). A relevant decrease on the MAS after surgical intervention was observed, resulting from an average preoperative state according to MAS of 3.78 (SD ± 0.42) to a postoperative state according to MAS of 1.44 (SD ± 0.51), these changes being statistically significant (p ≤ 0.001). No postoperative complications were observed. CONCLUSIONS: Selective partial neurectomy of the MCN has shown good results in patients with bilateral spastic elbow in whom antispastic drugs and physical therapy have failed, and has prove permanent effects.
Assuntos
Cotovelo , Nervo Musculocutâneo , Masculino , Feminino , Humanos , Criança , Cotovelo/cirurgia , Nervo Musculocutâneo/cirurgia , Espasticidade Muscular/etiologia , Espasticidade Muscular/cirurgia , Estudos Prospectivos , Estudos Transversais , Denervação/efeitos adversosRESUMO
PURPOSE: Spasticity is the result of a variety of lesions to the central nervous system and one of the most common causes of disability worldwide. Selective peripheral neurectomy (SPN) is a surgical procedure that permanently decreases focal spasticity. The authors' objective is to provide recommendations, in terms of probabilities, for locating terminal motor entry points to muscles of the thigh, as alternatives for proximal incision sites to SPN. METHODS: The femoral, obturator, and sciatic nerves, and its corresponding motor rami, were systematically dissected on cadaveric specimens, and terminal motor entry points to each muscle of the thigh were located and carefully measured, relative to the length of the thigh. Measurement distributions were obtained and normal transformations were used when necessary. RESULTS: In 23 adult cadaveric specimens, 779 motor rami were dissected. Entry points' locations are presented as a percentage of the length of the thigh in means and standard deviations, which roughly corresponds to 64 and 95% probability of finding a motor entry point. CONCLUSION: Alternative incisions directly over the motor entry points, for the muscles of the thigh, may be helpful when considering SPN as treatment for focal spasticity. A prior degree of certainty of the location of the nerve to be severed may simplify surgical approach.
Assuntos
Músculo Esquelético , Coxa da Perna , Humanos , Adulto , Coxa da Perna/cirurgia , Músculo Esquelético/cirurgia , Músculo Esquelético/inervação , Denervação/métodos , Espasticidade Muscular/cirurgia , CadáverRESUMO
Spasticity is amotor disorder that leads to a resistance to passive jointmovement. Cerebral palsy is the most important cause of spasticity and can be caused by several factors, including multiple gestations, alcoholism, infections, hemorrhages, drowning, and traumatic brain injuries, among others. There aremany scales that help tomeasure andmonitor the degree of impairment of these patients. The initial treatment should focus on the causal factor, such as tumors, inflammation, degenerative diseases, hydrocephalus, etc. Subsequently, the treatment of spastic musculature includes oral or intrathecal myorelaxants, spinal cord electrostimulation, neurotomies, Lissauer tract lesion, dentatotomy and selective dorsal rhizotomy. The latter is a safetechnique, possibleto beperformed inmost centers with neurosurgical support, and it is effective in the treatment of severe spasticity. In this article, the authors describe the surgical technique and conduct a review the literature.
Assuntos
Doença dos Neurônios Motores/cirurgia , Rizotomia/reabilitação , Espasticidade Muscular/cirurgia , Espasticidade Muscular/etiologia , Paralisia Cerebral/complicações , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Rizotomia/métodos , Laminoplastia/métodos , Relaxantes Musculares Centrais/uso terapêuticoRESUMO
BACKGROUND: Surgical interventions for spasticity aim to improve motor function and pain in cases that are refractory to medical treatment. Ablation of the cerebellar dentate nucleus (dentatotomy) may be a useful alternative. CASE REPORT: A 55-year-old male patient with spasticity, secondary to a traumatic cervical spinal cord injury with quadriparesis, had bilateral lumbar DREZotomy with an improvement that lasted for 6 years. Ten years after the DREZotomy, a progressive increased spasticity manifested as spastic diplegia (Ashworth 4) and spontaneous muscle painful spasms (Penn 4), as well as spasticity in the upper extremities, predominantly on the right side (Ashworth 3). A right radio frequency dentatotomy was performed with intraoperative electrophysiological monitoring. Spasticity scales were applied at the following times: preoperative and at 1 and 8 months after surgery. During the first month, the patient presented a clear decrease in spasticity ipsilateral to the side of lesioning (Ashworth 1) and of painful spasms in the lower extremities (Penn 1). After 8 months, spasticity ipsilateral to the injury decreased even more to Ashworth (0), but a progressive increase in muscle spasms of lower extremities was observed (Penn 2). CONCLUSION: Stereotactic dentatotomy may be an effective surgical alternative for management of spasticity associated with painful spasms in selected patients.
Assuntos
Espasticidade Muscular , Dor , Núcleos Cerebelares/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Espasticidade Muscular/cirurgiaRESUMO
INTRODUÇÃO: A espasticidade pode ser considerada como uma das mais impactantes alterações secundárias à paralisia cerebral. Nos últimos anos, a Rizotomia Dorsal Seletiva (RDS) tem sido destacada como um procedimento cirúrgico eficaz para o tratamento da espasticidade dos membros inferiores de crianças com paralisia cerebral. OBJETIVOS: Verificar por meio de uma revisão sistemática da literatura os efeitos em médio e longo prazo, da RDS sobre a função motora grossa e a marcha em crianças e adolescentes com paralisia cerebral. Além de averiguar se existe um consenso na literatura sobre os critérios de indicação da RDS. MÉTODOS: Uma pesquisa foi realizada na rede internacional nos bancos de dados de acordo com os seguintes critérios de inclusão: (1) desenho: estudos envolvendo o acompanhamento pós-operatório longitudinal; (2) população: crianças e adolescentes com paralisia cerebral espástica; (3) intervenção: RDS; (4) grupo controle com intervenção diferente ou sem intervenção; (5) desfecho: melhora da função motora, melhora da espasticidade e desempenho da marcha. RESULTADOS: Foi encontrado um total de seis artigos que preencheram os critérios de inclusão e foram utilizados nesta revisão. Nos estudos analisados, foram observadas melhoras significativas na variável cinemática da marcha com diminuição da espasticidade no grupo RDS. CONCLUSÃO: A RDS diminui a espasticidade com efeitos positivos sobre a função motora grossa e a marcha de crianças e adolescentes com paralisia cerebral, porém estudos adicionais são necessários para esclarecer a eficácia da RDS aplicada em grupos musculares de membros inferiores.
INTRODUCTION: Spasticity can be considered one of the most striking alterations secondary to cerebral palsy. In recent years, Selective Dorsal Rhizotomy (SDR) has been highlighted as an effective surgical procedure for the treatment of lower limb spasticity in children with cerebral palsy. OBJECTIVES: To verify through a systematic review of the literature the medium and long-term effects of SDR on gross motor function and gait in children and adolescents with cerebral palsy. Secondarily, to verify if there is a consensus in the literature on the criteria to indicate SDR. METHODS: A search was performed in the international network databases according to the following inclusion criteria: (1) design: studies involving longitudinal postoperative follow-up; (2) population: children and adolescents with spastic cerebral palsy; (3) intervention: SDR; (4) control group with different intervention or without intervention; (5) outcome: improvement of motor function, improvement of spasticity and gait performance. RESULTS: A total of six articles were found that met the inclusion criteria and were used in this review. In the studies analyzed, significant improvements were observed in the kinematic gait variable with decreased spasticity in the SDR group. CONCLUSION: SDR decreases spasticity with positive effects on gross motor function and gait of children and adolescents with cerebral palsy, but additional studies are needed to elucidate the efficacy of RDS applied to lower limb muscle groups.
Assuntos
Humanos , Criança , Adolescente , Paralisia Cerebral/cirurgia , Paralisia Cerebral/diagnóstico , Paralisia Cerebral/reabilitação , Rizotomia/métodos , Procedimentos Neurocirúrgicos , Espasticidade Muscular/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Análise da MarchaRESUMO
BACKGROUND: Spastic thumb deformity in cerebral palsy significantly impedes hand function. Flexion-adduction forces across the first ray is the result from imbalance between intrinsic and extrinsic muscles. Multiples surgeries have been devised for the treatment of this condition such as contracture release and by tendon transfers for balancing the muscles forces. We report the results of a less demanding surgical technique, intended to avoid hyperextension of the metacarpophalangeal joint previously described in other series. METHODS: Five patients with cerebral palsy who underwent a surgical correction for their thumb-in-palm deformity between January 2013 and August 2014 were included. All patients were assessed postoperatively with a minimum follow up of six months. Three criteria were chosen to evaluate functional ability: capacity to perform pinch, volitional muscle control and usefulness of the hand in daily life activities. RESULTS: Patients who had surgery for spastic thumb deformity were reviewed. The thumb was maintained out of the palm in all patients. Three patients were able to perform correct pinch, achieved volitional muscle control and a more functional hand. One patient had limitation to achieve one of the evaluated daily life activities and one patient lacked active thumb movement for pinch, motor control and achieved no daily life activities. No postoperative complications were recorded. CONCLUSIONS: We present a less challenging technique that should be taken into account for the treatment of thumb-in-palm deformity. Appearance and functional improvement can be achieved with this surgical procedure avoiding disadvantages of secondary deformities.
Assuntos
Paralisia Cerebral/complicações , Deformidades Adquiridas da Mão/cirurgia , Procedimentos Ortopédicos/métodos , Tenotomia/métodos , Polegar/anormalidades , Polegar/cirurgia , Adolescente , Criança , Feminino , Seguimentos , Deformidades Adquiridas da Mão/etiologia , Humanos , Masculino , Espasticidade Muscular/cirurgia , Estudos ProspectivosRESUMO
Introduction: selective dorsal rhizotomy (SDR) is a neurosurgical, non-reversible intervention to treat disabling spasticity in children with cerebral palsy (CP), improving their motor function and general performance. Objective: to assess functional outcomes of SDR in CP patients at Institutos teletón Chile, 6 and 12 months post-surgery. Patients and Method: Clinical records of all patients that underwent a SDR procedure between November 2010 and November 2013 were reviewed. Eighteen cases (spastic diplegia; age 7.5 +/- 2.9 years) were found, and their relevant pre-, peri- and post operative data after 6 and 12 months, were analyzed, as: clinical history, physical examination, evidence of preventricular leukomalacia (PVL), aspects related to surgery, and functional outcomes, including Gross Motor Function Measurement (GMFM)-66 and -88, Pediatric Evaluation Disability Inventory (PEDI) and gait lab (GL) using Gait Deviation Index (GDI). Results: Fifty percent of the subjects were classified as GMFCS II-III and the other 50 percent as GMFCS IV. A clinical important reduction in lower limb spasticity, particularly in triceps surae and hip flexors was observed in all patients, as well as improved muscular strength in many of them. GMFM-66 and GMFM-88 scores improved (p < 0.01). A trend towards improvement, without significant differences was observed in PEDI scores (GMFCS IV patients), and a significant improvement in GDI in ambulant patients (p < 0.015). Conclusions: SDR is a valid option to achieve long-lasting control of spasticity, 12 months after surgery, in children with spastic cerebral palsy, improving also functional capacity.
Introducción: la rizotomía dorsal selectiva (RDS) es una intervención neuro-quirúrgica irreversible para tratarla espasticidad discapacitante en niños con parálisis cerebral (PC). Su finalidad es mejorar la función motora y funcionalidad global de los pacientes. Objetivo: Evaluar los resultados funcionales de la RDS en los pacientes de Institutos teletón Chile con PC a los 6 y 12 meses postoperatorio. Pacientes y Método: Se revisan las fichas clínicas de los pacientes operados de RDS entre noviembre de 2010 y noviembre de 2013. Se encuentran 18 casos (diplejia espástica; edad 7,5 +/- 2,9 años), cuyos datos clínicos relevantes pre, peri y postoperatorios a 6 y 12 meses, fueron analizados: historia y examen físico; presencia de leucomalacia periventricular (LMPV); aspectos quirúrgicos y resultados funcionales de: Gross Motor Function Measurement (GMFM)-66 y 88, Pediatric Evaluation Disability Inventory (PEDI) y en laboratorio de marcha (LM), el Gait Deviation Index (GDI). Resultados: 50 por ciento correspondieron a pacientes GMFCS II-III y 50 por ciento a GMFCS IV. Se obtuvo importante reducción clínica de espasticidad de extremidades inferiores, especialmente plantiflexores de tobillo y flexores de cadera en todos los pacientes y en muchos un aumento de la fuerza muscular. Hubo mejoría en función motora gruesa evaluado con GMFM-66 (p < 0,001) y GMFM-88 (p < 0,001). tendencia a mejoría, sin diferencias significativas en PEDI (pacientes GMFCS IV) y mejoría significativa de GDI en pacientes ambulantes (p < 0,015). Conclusiones: La RDS es una opción válida para el control duradero de la espasticidad, a 12 meses, en niños con parálisis cerebral espástica, proporcionando además mejorías funcionales.
Assuntos
Masculino , Feminino , Humanos , Adolescente , Pré-Escolar , Criança , Adulto Jovem , Paralisia Cerebral/cirurgia , Espasticidade Muscular/cirurgia , Rizotomia/métodos , Paralisia Cerebral/reabilitação , Avaliação da Deficiência , Espasticidade Muscular/reabilitação , Resultado do TratamentoRESUMO
PURPOSE: The median nerve is responsible for the motor innervation of most of the muscles usually involved in upper limb spasticity. Selective neurectomy is one of the treatments utilized to reduce spasticity. The purpose of this study was to describe the variations of the motor branches of the median nerve in the forearm and draw recommendations for an appropriate planning of selective neurectomy. MATERIALS AND METHODS: The median nerve was dissected in the forearm of 20 fresh cadaver upper limbs. Measurements included number, origin, division, and entry point of each motor branch into the muscles. RESULTS: One branch for the pronator teres was the most common pattern. In 9/20 cases, it arose as a common trunk with other branches. A single trunk innervated the flexor carpi radialis with a common origin with other branches in 17/20 cases. Two, three or four branches innervated the flexor digitorum superficialis, the first one frequently through a common trunk with other branches. They were very difficult to identify unless insertions of pronator teres and flexor digitorum superficialis were detached. The flexor digitorum profundus received one to five branches and flexor pollicis longus one to two branches from the anterior interosseous nerve. CONCLUSIONS: There is no regular pattern of the motor branches of the median nerve in the forearm. Our findings differ in many points from the classical literature. Because of the frequency of common trunks for different muscles, we recommend the use of peroperative electrical stimulation. Selective neurotomy of flexor digitorum superficialis is technically difficult, because the entry point of some of their terminal branches occurs just below the arch and deep to the muscle belly.
Assuntos
Variação Anatômica , Denervação/métodos , Antebraço/inervação , Nervo Mediano/anatomia & histologia , Espasticidade Muscular/cirurgia , Músculo Esquelético/inervação , Idoso , Idoso de 80 Anos ou mais , Cadáver , Dissecação , Feminino , Humanos , Masculino , Nervo Mediano/cirurgia , Pessoa de Meia-Idade , Guias de Prática Clínica como AssuntoRESUMO
Spasticity represents a common and very often incapacitating neurologic condition, for which a limited number of treatment options are available. Stereotactic ablation of the dentate cerebellar nuclei (dentatotomy) was widely used in the past with variable results. In the present study, we reviewed 12 consecutive cases operated on at the Midland Centre for Neurosurgery and Neurology at Birmingham University (Smetwick, UK) in the 1980s. The following clinical aspects were analyzed: severity of spasticity, occurrence of abnormal movements (dystonia/athetosis), language fluency, gait, and overall clinical condition. Follow-up ranged from 0.5 to 94 (mean: 31.6) months. Immediate improvement was noted in 10 patients, and five of them had sustained this improvement at the time of the last assessment. A more pronounced improvement was observed for gait, relative to speech and abnormal movements. No significant morbidity related to the procedure was observed. We conclude that dentatotomy is a safe procedure that should still be considered in specific cases. Here, we review the cases reported in the literature, and present a mechanistic hypothesis about how dentatotomy influences motor tonus, in light of the current knowledge about cerebellar physiology. We believe that this issue is critical for the development of alternative surgical approaches targeting the cerebellum, such as chronic electric stimulation.
Assuntos
Núcleos Cerebelares/cirurgia , Distonia/cirurgia , Espasticidade Muscular/cirurgia , Procedimentos Neurocirúrgicos/métodos , Adolescente , Adulto , Criança , Distonia/etiologia , Distonia/fisiopatologia , Feminino , Seguimentos , Lateralidade Funcional , Humanos , Masculino , Espasticidade Muscular/complicações , Espasticidade Muscular/fisiopatologia , Paraparesia Espástica/cirurgia , Paresia/cirurgia , Técnicas Estereotáxicas , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Treatment of spastic planovalgus feet is challenging, especially in patients with severe and rigid deformities. The available techniques do provide some correction but not at the site of the deformity and sometimes the correction is lost over time. We describe a new surgical approach at the site of the deformity. TECHNIQUE: Indications for the surgery included adolescents or young adults with severe and rigid planovalgus deformities of the feet resulting from cerebral palsy. Through a medial approach, arthrodesis of the talonavicular, navicular-medial cuneiform, and medial cuneiform first metatarsal joints was internally fixed using a single-molded plate over the plantar surface of the foot, recreating the longitudinal arch. METHODS: We retrospectively reviewed 21 patients (35 feet) with spastic cerebral palsy in whom the new technique was indicated for severe and rigid deformity, gait dysfunction, and pain (mean age, 190 months; range, 96-345 months). The mean age of the patients was 16 years (range, 8-29 years). We analyzed the patients clinically and radiographically. The minimum followup was 2.5 years (mean, 58 months; range, 2.5-7.5 years). RESULTS: At last followup, 34 of the 35 feet (97%) had radiographic improvement of the deformity with no difficulties wearing shoes; one patient had persistent pain despite bone union. Union was achieved initially in eight patients (17 feet) and in another eight (10 feet) after revision surgery, of 27 of the 35 feet. The radiographic calcaneal inclination angle improved an average of 13°. The lateral talocalcaneal angle decreased from a mean of 43° to 26° after surgery. Four patients (five feet) had revision surgery for pseudoarthrosis, and another four patients (five feet) had revision surgery for other problems. CONCLUSIONS: Based on our preliminary observations, we believe stabilization of the medial column is a reasonable option for treating selected patients with severe and rigid planovalgus feet by providing a stable and pain-free foot, recreating the anatomy, and allowing the use of braces or regular shoes. Further studies with longer followup periods will be required to confirm these initial results and to verify if these findings persist over time. LEVEL OF EVIDENCE: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.
Assuntos
Artrodese/métodos , Paralisia Cerebral/cirurgia , Pé Chato/cirurgia , Deformidades Adquiridas do Pé/cirurgia , Adolescente , Adulto , Paralisia Cerebral/complicações , Paralisia Cerebral/fisiopatologia , Criança , Feminino , Pé Chato/etiologia , Pé Chato/fisiopatologia , Deformidades Adquiridas do Pé/etiologia , Deformidades Adquiridas do Pé/fisiopatologia , Humanos , Masculino , Espasticidade Muscular/complicações , Espasticidade Muscular/fisiopatologia , Espasticidade Muscular/cirurgia , Paralisia/etiologia , Paralisia/fisiopatologia , Paralisia/cirurgia , Complicações Pós-Operatórias , Reoperação , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Apesar de o tratamento da espasticidade em pacientes com paralisia cerebral fundamentar-se, essencialmente, na cinesioterapia e medicamentos administrados como infiltrações ou por via oral, ocorrem situações nas quais tais intervenções não surtem os efeitos desejados, seja em virtude da gravidade da espasticidade ou da contra-indicação e efeitos adversos ao uso da toxina botulínica. Também podem ocorrer distorções do aparelho locomotor resultantes do constante estímulo deformante da espasticidade e da alteração biomecânica que ela impõe ao posicionamento de membros durante a marcha, ortostatismo ou outras posições de repouso. Nestas últimas situações, estão indicados procedimentos cirúrgicos que visam a melhoria da condição biomecânica, adequação do posicionamento e maior eficiência da movimentação em geral. Este artigo de revisão tem por objetivo apresentar as formas alternativas de administração de drogas para o controle da espasticidade, como a bomba de baclofeno, cujo implante exige procedimento cirúrgico, outras indicações e intervenções cirúrgicas para o controle da espasticidade e de suas conseqüências como deformidades e alteração de função além de procedimentos fisioterápicos e uso de órteses sempre com o objetivo de redução dos quadros espásticos.
Although the espasticidade treatment in patients with cerebral palsy is based essentially on cinesioterapia and drugs administrated as chemical blockades infiltration or orally, there are situations where such aid does not have the desired effect, either because of the seriousness of the espasticidade or contra-indications and adverse effects of the botulinum toxin. We can also see human musculoskeletal apparatus deformities resulting from constant deforming stimulus of espasticidade and amendment biomechanics that it imposes on the member positioning during the gait, ortostatismo or other rest positions. In this situation, are indicated surgical procedures which aim at improving the condition of positioning biomechanics, adequacy and efficiency of movement in general. This review article has the aim to provide alternative forms of drug administration for the control of espasticidade, as baclofen bump that requires a chirurgical procedure and others indications and surgeries for the control of espasticidade and its consequences as deformities. We will discuss also the indications for physiotherapy procedures and ortheses indications with the indication to reduce spasticity.
Assuntos
Humanos , Criança , Adulto , Terapias Complementares , Espasticidade Muscular/cirurgia , Espasticidade Muscular/etiologia , Espasticidade Muscular/reabilitação , Paralisia Cerebral/fisiopatologia , Toxinas Botulínicas Tipo A , Procedimentos Ortopédicos , Paralisia Cerebral/complicaçõesRESUMO
Spastic diplegia is present in three-fourths of children with cerebral palsy, interfering with gait and frequently accompanied by severe pain. The authors report the case of a 28-year-old woman with history of perinatal hypoxia, who presented with cerebral palsy and severe spastic diplegia (Ashworth Scale Score 4, Tardieu Scale Score 5) and was confined to a wheelchair. She complained of pain in the left hip and knee with mixed neuropathic and somatic components. She consistently rated pain intensity as 10 of 10 on a visual analog scale, and her symptoms were resistant to multiple treatments. The patient underwent selective bilateral adductor myotomies and the implantation of an infusion pump for intrathecal lidocaine application. Postoperative control of pain and spasticity was dramatic (scores of 0 on the Ashworth, Tardieu, and visual analog scales) and persisted throughout a follow-up period of 36 months. This is the first report in the literature of combined selective neurotomies for the treatment of spasticity and chronic lidocaine subarachnoid infusion to treat associated pain. This therapy could represent an alternative to treat spasticity associated with neuropathic and somatic pain.