Hyper-selective neurectomy for knee flexion spasticity: anatomic bases and surgical technique.

PURPOSE: Spasticity may result from damage to neurons of the corticospinal tracts and loss of inhibitory supraspinal influences following head trauma. Traditionally, peripheral nerve surgeries for spasticity in lower limbs were limited to selective neurectomies. Here we used hyper-selective neurectomy (HSN) to release hamstring spasticity at the muscle spindle level. METHODS: This study describes anatomic bases and surgical technique of HSN and its results in treating spastic knee flexion in a 23-year-old male who developed severe spasticity following severe brain injury. The spasticity was prominent in the left knee. The surgical technique including resection of over one centimeter of three-quarters of the overstimulated nerve rami at the entry point of the nerve into the muscle is shown in the video 1. RESULTS: After the surgery Visual Analog Scale and Modified Ashworth Score reduced from 7 to 3 and 4 to 1, respectively. Popliteal angle improved from 118° to 73° at the second months after the surgery. CONCLUSION: Hyper-selective neurectomy is a safe and reliable therapeutic option for the treatment of permanent trauma induced spasticity in the lower limb.

Iatrogenic Cervical Nerve Root Injury After Spine Surgery: How Nerve Surgeons Can Assist Spine Surgeons.

BACKGROUND: Iatrogenic cervical nerve root injury may occur during cervical spine surgeries, which leads to upper limb palsy. The question of how a permanent iatrogenic upper limb palsy would be managed remains unclear. Recent developments of nerve transfer have led to a considerable interest in its applications. This study outlines a new reconstructive approach forupper limb palsy following cervical spine surgery using nerve transfer. METHODS: In an attempt to reconstruct iatrogenic upper limb palsy, we performed nerve transfer in 4 patients with permanently lost functions. Medical Research Council Scale for Muscle Strength was used to assess muscle strength. Electromyography was performed to assess the reinnervation of the target muscles. RESULTS: All patients underwent surgery between 7 and 12 months after primary injury. Spinal accessory nerve to suprascapular nerve transfer with or without transferring the long head of triceps branch of the radial nerve to anterior branch of the axillary nerve was used to reconstruct shoulder abduction in 2 patients. Double fascicular nerve transfer (a fascicle of the ulnar nerve to biceps branch and a fascicle of the median nerve to brachialis branch of the musculocutaneous nerve) was used to reconstruct elbow flexion in 3 patients. One patient had lost both his elbow flexion and shoulder abduction. After a mean of 10 months of follow-up, all patients improved to a muscle strength of M4 without donor deficit. CONCLUSION: In our view, these results represent an excellent initial step toward the treatment of iatrogenic nerve root injury after spine surgery.

Reanimation of triceps muscle using ulnar nerve fascicle transfer to the nerve to long head of the triceps muscle.

BACKGROUND: Triceps muscle serves an important role in extension of the elbow. Its action is required for reaching out objects without using the trunk. Elbow extension is an important function for natural stabilization of the elbow. The aim of this study was to evaluate restoration of elbow extension in adults suffering triceps muscle palsy with various causes, by using transfer of a fascicle of ulnar nerve to the long head of triceps branch of the radial nerve. MATERIALS AND METHODS: In the present case series, 7 patients with partial brachial plexus injury or posterior cord injury, where triceps muscle was involved, were subjected to motor fascicle of ulnar nerve transfer to the nerve to long head of triceps for restoration of elbow extension. Follow-ups, including EMG-NCV (electromyography-nerve conduction velocity) 6 and 12 months after surgery and elbow extension muscle strength using MRC grading, were carried out. RESULTS: Six patients (85.71%) achieved a functional muscle strength of M4 for their elbow extension. In all of the patients, re-innervation was discovered using EMG-NCV. CONCLUSION: This surgical technique (ulnar nerve fascicle transfer to long head of the triceps) for improving elbow extension is promising in patients with brachial plexus injury.