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Utilization of intraoperative electromyography for selecting targeted fascicles and determining the degree of fascicular resection in selective tibial neurotomy for ankle spasticity

  • Clinical Article - Functional
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Abstract

Background

Selective tibial neurotomy (STN) is an effective neurosurgical intervention for treating ankle spasticity. The authors use intraoperative electromyography (EMG) for selecting targeted fascicles and determining the degree of fascicular resection in STN. This study reports surgical techniques and outcomes of the operation.

Methods

Participants who underwent STN with utilization of intraoperative EMG were recruited. Modified Ashworth Scale (MAS), passive range of motion (PROM) of the ankle in plantar flexion and dorsiflexion, Massachusetts General Hospital Functional Ambulatory Classification (MGHFAC) and ability to attain full plantigrade stance were assessed pre- and postoperatively.

Results

Twenty-one STNs were performed in 15 patients. The mean pre- and postoperative MAS and PROM were 2.8 and 0.4 (p < 0.001), 39.5o and 66.0o (p < 0.001), respectively. The mean level of MGHFAC was improved from 3.3 preoperatively to 4.9 postoperatively (p < 0.01). Six non-ambulators had significant amelioration in MGHFAC level. Postoperatively, 19 of 21 lower limbs achieved full plantigrade, and 6 patients could perform selective voluntary motor control of the ankle.

Conclusion

STN is an effective procedure for spastic ankle in well-selected cases. Intraoperative EMG helps in selection of targeted fascicles, increases objectivity in neurotomy and prevents excessive denervation.

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Conflicts of interest

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Authors and Affiliations

  1. Division of Neurosurgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok Road, Siriraj, Bangkok, Bangkok Noi, 10700, Thailand

    Bunpot Sitthinamsuwan, Luckchai Phonwijit & Sarun Nunta-aree

  2. Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

    Teerada Ploypetch & Witsanu Kumthornthip

  3. The Group of Multidisciplinary Spastic Hypertonia Management in Children with Cerebral Palsy, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

    Bunpot Sitthinamsuwan, Luckchai Phonwijit, Teerada Ploypetch & Witsanu Kumthornthip

  4. Department of Surgery, Uttaradit Hospital, Uttaradit, Thailand

    Kannachod Chanvanitkulchai

Authors
  1. Bunpot Sitthinamsuwan
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  2. Kannachod Chanvanitkulchai
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  3. Luckchai Phonwijit
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  4. Teerada Ploypetch
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  5. Witsanu Kumthornthip
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  6. Sarun Nunta-aree
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Corresponding author

Correspondence to Bunpot Sitthinamsuwan.

Additional information

Comment

Botulinum toxin injection is presently the most commonly used procedure to treat focal spasticity. Nonetheless, many different strategies have been adopted throughout the history of neurosurgery, including section, lesions, drug infusion and stimulation of the entire neuraxis.

The first successful treatment was the section of the obturator nerve by Lorenz in 1897. These types of peripheral nerve operations continue to be useful and have been made more effective by employing intraoperative EMG monitoring. In their well-written and concise article, the authors clearly illustrate their surgical procedure and results. The article also demonstrates the efficacy of this procedure and its utility in specific situations. In fact, non-destructive neuromodulation procedures, in particular pump implantation for intrathecal baclofen administration, have the important characteristics of being adjustable and reversible, but are in general indicated for adult patients with diffuse cerebral of spinal spasticity. Selective peripheral neurotomies remain effective treatment options indicated for focalized spasticity in the limbs, in particular when harmful spasticity affects one or a few muscular groups and after treatment with botulinum toxin injections has been tried and revealed insufficient.

Alfredo Conti

Messina, Italy

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Sitthinamsuwan, B., Chanvanitkulchai, K., Phonwijit, L. et al. Utilization of intraoperative electromyography for selecting targeted fascicles and determining the degree of fascicular resection in selective tibial neurotomy for ankle spasticity. Acta Neurochir 155, 1143–1149 (2013). https://doi.org/10.1007/s00701-013-1686-0

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  • DOI: https://doi.org/10.1007/s00701-013-1686-0

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