Management of spastic hand by selective peripheral neurotomies

Selective peripheral neurotomies [SPN] are proposed when spasticity is focalized on muscles that are under the control of a single or few peripheral nerves. This study was done to evaluate the functional results of SPN of median and ulnar nerves in 10 patients who had spastic hyperflexion of the wrist and fingers. All patients preoperatively had spasticity either G3 or G4 as measured by modified Ashworth scale. All cases underwent surgery in the form of variable combination of SPN of median and ulnar nerves depending on the pattern and distribution of spasticity. Depending on the degree of preoperative spasticity, 50-80% of the isolated motor branches of fascicles were resected under the operating microscope. Mean postoperative follow up examination period was 21 months. There was no operative mortality. One patient had wound infection. Transient paresis of flexors of the wrist and fingers because of excessive nerves sectioning occurred in one patient that responded well to physiotherapy. Postoperatively, all the patients had immediate improvement of their spasticity grade. After initial improvement, recurrence of spasticity occurred in one patient 6 months postoperatively and that might be due to insufficient amount of nerve sectioning. Abnormal hand posture that was present in all cases improved in 9 patients [90%] postoperatively, while pain that was present in 50% of cases improved in all these cases postoperatively as measured by visual analogue scale. Assessment of outcome after surgery was done by comparing modified Ashworth scale preoperatively and postoperatively. At the last follow up examination period, excellent results were obtained in 40% of patients, good results in 40% of patients, fair results in 10% of patients, and poor results in 10% of cases. In well-selected patients, SPN can yield good effects on refractory spasticity of the hand and its consequences