Neurosurgery for Spasticity: A Practical Guide for Treating Children and Adults

✍ Scribed by Marc Sindou, Manon Duraffourg, George Georgoulis

• Publisher: Springer
• Year: 2022
• Tongue: English
• Leaves: 358
• Edition: 2nd ed. 2022
• Category: Library

✦ Synopsis

The book, in its second edition, is devoted to the neurosurgical management of spasticity and focal dystonia. Starting with a chapter on the anatomical and physiological bases of spasticity and a short history of its neurosurgical treatment, it describes the neurosurgical methods currently available. As management differs between adults and children, the book is also structured accordingly, including evaluation, decision-making, Intrathecal Baclofen therapy (ITB), Botulinum toxin therapy and Surgery. The large spectrum of scales for assessing hypertonia, spasticity, dystonia, contracture and joint/bone deformities, as well as the scoring systems for quantifying functional abilities are critically reviewed. Beyond ITB, the neurosurgical options covered include the microsurgical procedures focusing on the peripheral nerves, dorsal roots, Dorsal Root Entry Zone and spinal cord, and their intra-operative monitoring.

In this second edition, the orthopedic surgical interventions available will take a large place, either as alternative solutions , or even better as important complements after spasticity be solved by the neurosurgical treatments.

Based on surgical experience collected with more than a thousand and eight-hundred patients, the book gathers the most important aspects of our present understanding, presented using a practical, educational approach. It stresses the importance of a multidisciplinary approach, including neurologists, pediatricians and rehabilitation specialists. Close collaborations with other surgical disciplines like orthopedic surgery and neuro-urology are outlined.

✦ Table of Contents

Preface
Acknowledgments
Contents
1: Introduction
References
Part I: General Information
2: History of Neurosurgical Treatment for Spasticity
2.1 Introduction
2.2 Pioneering Works
2.3 Surgery on the Peripheral Nerves
2.4 Surgery on Spinal Roots
2.5 Surgery on the Spinal Cord
2.6 Surgery in the Dorsal Root Entry Zone
2.7 Stereotactic Lesioning Techniques at the Encephalic Level
2.8 Neurostimulation Methods
2.9 Intrathecal Infusion of Baclofen
2.10 Conclusion
References
3: Anatomical Bases of Tone and Spasticity
3.1 Introduction
3.2 The Spinal Reflexes Involved in the Genesis of Spasticity
3.3 The Organization of the Spinal Cord
3.3.1 The Alpha Motoneurons
3.3.2 The Primary Afferents
3.3.3 The System of Spinal Interneurons
3.3.4 The Ascending Pathways
3.4 The Supraspinal Descending Pathways
3.4.1 The Corticospinal System
3.4.2 The Descending Lateral Brainstem System
3.4.3 The Descending Medial Brainstem System
3.5 Importance of the Reticular Formation
3.5.1 The Reticular Formation Afferents
3.5.2 The Specific Efferent Reticular Formation Pathways
3.6 Conclusions
References
Part II: Adults
4: Assessment of Spasticity in Adults
4.1 Introduction
4.2 Characterization of some Important Clinical Patterns in So-Called Spastic Patients
4.3 Clinical Patterns of Abnormal Postures in Spasticity
4.3.1 Lower Limb
4.3.1.1 Hip Flexion
4.3.1.2 Adducted Thighs
4.3.1.3 Extended Knee
4.3.1.4 Flexed Knee
4.3.1.5 Equinovarus Foot
4.3.1.6 Claw Toes
4.3.1.7 Striatal Toe
4.3.2 Upper Limb
4.3.2.1 Adducted and Internally Rotated Shoulder
4.3.2.2 Flexed Elbow
4.3.2.3 Pronated Forearm
4.3.2.4 Flexed Wrist
4.3.2.5 Clenched Fist
4.3.2.6 Thumb in Palm
4.3.2.7 Swan Neck
4.4 Clinical Diagnosis and Evaluation of the Spasticity
4.4.1 Clinical Characterization of Spasticity
4.4.2 Range of Motion
4.4.3 Retractions and Contractures
4.4.4 Electrophysiological Assessment
4.4.4.1 H-Reflex
4.4.4.2 Ib Inhibition (Conditioned Reflex)
4.4.4.3 Hmax/Mmax Ratio
4.4.4.4 H-Wave Excitability Curve
4.4.4.5 Conclusion on Electrophysiological Assessment
4.5 Assessment of Functional Disability Attributed to Spasticity
4.6 Gait Analysis
4.7 Assessment Under Tests
4.8 Conclusion
References
5: Decision-Making for Adults with Disabling Spasticity
5.1 Introduction
5.2 Intrathecal Baclofen Therapy
5.3 Lesioning Procedures
5.3.1 Peripheral Neurotomies
5.3.2 Dorsal Rhizotomies
5.3.3 Longitudinal Myelotomy
5.3.4 Surgery in the Dorsal Root Entry Zone (DREZ)
5.4 Conclusion
References
6: Intrathecal Baclofen Therapy
6.1 Introduction
6.2 Physiologic and Pharmacokinetic Effects of Baclofen
6.3 Implanted Programmable Pump
6.4 Surgical Indications and Patient Selection
6.4.1 Spasticity of Spinal Origin
6.4.2 Spasticity of Brain Origin
6.4.3 Spasticity and/or Dystonia Due to Cerebral Palsy
6.4.4 Alternative Methods for Patients with Brain Lesion or Cerebral Palsy Harboring Focalized and Severe Spasticity and/or Dystonia
6.5 Patient Selection and Screening
6.6 Timing for Implantation
6.7 Interaction of Ventricular Shunt and Baclofen Pump
6.8 Primoimplantation Surgical Technique
6.8.1 Installation
6.8.2 Catheter Placement
6.8.3 Tunneling and Pump Implantation
6.8.4 Intra-Operative Imaging
6.8.5 Postoperative Instructions
6.9 Dosing After Implantation
6.10 Surgical Technique for Insertion of Intrathecal Catheter Connected to a Reservoir for Testing
6.11 Surgical Technique for Pump Replacement
6.12 Long-Term Management
6.12.1 Dosing Adaptation
6.12.2 Imaging
6.13 Filling Procedure
6.14 Early and Long-Term Complications of ITB
6.14.1 Side Effects and Complications of Baclofen
6.14.2 General and Devices-Related Complications
6.14.2.1 Infections
6.14.2.2 Device-Related Complications
6.14.3 Troubleshooting Management
6.15 Outcomes
6.15.1 Effect on Spasticity and Dystonia
6.15.2 Effect on Spasms
6.15.3 Effects on Pain
6.15.4 Effects on Orthopedic Deformities
6.15.5 Effect on Urinary Function
6.15.6 Effects on Paroxysmal Sympathetic Activity/Dysautonomia
6.15.7 Effects on Respiratory Function
6.16 Intraventricular Baclofen
6.17 Cost-Effectiveness
6.18 Conclusion
References
7: Botulinum Toxin Injections for Spasticity
7.1 Introduction
7.2 Clinical Pharmacology
7.3 Site and Dose Determination
7.4 Procedure
7.5 Onset, Duration of Therapeutic Effects, Side Effects
7.6 Conclusions
References
8: Peripheral Neurotomy
8.1 Introduction
8.2 Mechanisms of the Hypotonia
8.3 Surgical Principles
8.3.1 Preoperative Nerve Blocks
8.3.2 Anesthesia
8.3.3 Electrophysiologic Mapping
8.3.4 Sectioning
8.4 Surgical Techniques
8.4.1 Surgery on the Lower Limb
8.4.1.1 Obturator Neurotomy for the Hip
8.4.1.2 Hamstring Neurotomy for the Knee
8.4.1.3 Tibial Neurotomy for the Foot
8.4.1.4 Anterior Tibial Neurotomy for the Extensor Hallucis
8.4.1.5 Femoral Neurotomy for the Quadriceps
8.4.2 Surgery on the Upper Limb
8.4.2.1 Pectoralis Major and Teres Major Neurotomy for the Shoulder
8.4.2.2 Musculocutaneous Neurotomy for the Elbow
8.4.2.3 Median Neurotomy for the Wrist and Fingers
8.4.2.4 Ulnar Neurotomy for the Wrist and Fingers
8.5 Outcomes
8.5.1 In Adults
8.5.1.1 Lower Limb
8.5.1.2 Upper Limb
8.5.2 In Children
8.6 Hypotheses for Failure
8.7 Complications and Their Avoidance
8.7.1 Local Complications
8.7.2 Neurological Complications
8.8 Conclusions
References
9: Surgery in the Dorsal Root Entry Zone
9.1 Introduction
9.2 Indications
9.3 Surgical Technique
9.3.1 Operative Procedure at Cervical Level
9.3.2 Operative Procedure at Lumbosacral Level
9.4 Outcome, Side Effects, and Complications
9.5 Conclusions
References
Part III: Children
10: Spasticity and Hypertonia in Cerebral Palsy: Mechanisms and Surgical Implications
10.1 Introduction
10.2 Characterization of the Main Clinical Patterns with Hypertonia
10.3 Mechanisms of Hypertonia in CP
10.4 Contractures and Deformities
10.5 Surgical Implications
References
11: Assessment of Spasticity in Pediatric Patients
11.1 Background
11.2 Physical Examination
11.3 Assessment of Range of Motion
11.4 Quantification of Spasticity
11.5 Quantification of Dystonia
11.6 Evaluation of Functional Abilities
11.6.1 The Gross Motor Function Classification System (GMFCS)
11.6.2 The New York University Classification System
11.6.3 The Gross Motor Function Measure (GMFM) Score
11.6.4 The Gillette Functional Assessment Questionnaire (FAQ)
11.6.5 The Pediatric Outcome Data Collection Instrument (PODCI)
11.7 Dynamic Gait Analysis
11.8 Video Recordings
11.9 The Goal Attainment Scale
11.10 Conclusion
References
12: Decision-Making for Neurosurgical Treatment in Children with Disabling Spasticity
12.1 Introduction
12.2 Mechanisms of the Handicap
12.3 Clinical Examination and Therapeutic Planning
12.4 Decision-Making for Spastic Diplegia in CP Children
12.5 Decision-Making in Quadriplegic Children
12.6 Management of Focal Spasticity in Lower Limb
12.7 Management of Focal Spasticity in Upper Limb
12.8 The Particular Case of Hemiplegia
12.9 Children with Cerebral Palsy Presenting with Mixed Spasticity and Dystonia
12.10 Conclusion
References
13: Dorsal Rhizotomy for Children with Cerebral Palsy
13.1 Introduction
13.2 Various Approaches
13.2.1 Whole Cauda Equina Exposure Through Laminectomy–Laminotomy L1–S1
13.2.2 The Limited Exposures at the Thoraco–Lumbar Junction
13.2.3 The Keyhole Interlaminar Dorsal Rhizotomy (KIDr) Procedure
13.3 Protocols for Anesthesia and Early Postoperative Cares
13.3.1 Protocol for Anesthesia
13.3.2 Early Postoperative Care
13.4 Intraoperative Neuromonitoring (ION) (Fig. 13.6)
13.4.1 The Anatomical Mapping
13.4.2 The Physiological Testing
13.4.3 The Combined Anatomical and Physiological Intraoperative Assessment
13.5 Quantification of Dorsal Root Sectioning
13.5.1 Most Admitted Cutting
13.5.2 Policy Established on Empirical Bases
13.5.3 Importance of Intraoperative Neurophysiological Exploration
13.5.4 Proportion of Root Cutting Still Controversial
13.6 Complications: Their Prevention (Table 13.3)
13.7 Outcome
13.8 Indications
13.8.1 Steps of Selection
13.8.2 Objectives of the Dorsal Rhizotomy
13.8.3 Time for the Surgery
13.9 Conclusion
References
Part IV: Other Disciplines
14: Neuro-orthopedic Surgery for the Correction of Spastic Disorders
14.1 Introduction
14.2 Neuro-orthopedic Procedures
14.2.1 Soft Tissue Procedures
14.2.2 Bony Procedures
14.3 Spasticity in Lower Limb
14.4 Spasticity in Upper Limb
14.5 Main Indications
14.5.1 Hemiplegic Adults
14.5.2 Paraplegic or Tetraplegic Adults
14.5.3 Patients with Cerebral Palsy
14.6 Conclusion
References
15: Management of Neurogenic Overactive Bladder
15.1 Introduction
15.2 Anatomical Bases and Mechanisms
15.3 Clinical Presentation
15.4 Urodynamic Exploration
15.5 Treatment
15.5.1 Urologic Surgery
15.5.2 Neurological Surgery
15.6 Conclusion
References
Part V: Addendum
16: Brief on Decision-Making for Neurosurgery of Spasticity in Adults and Children
16.1 Introduction
16.2 Who to Operate? The Candidates
16.3 Why to Operate? The Objectives and Limits
16.4 When to Operate? Before Irreversibility of Contractures and Deformities
16.5 How to Operate? Tailored Operations
16.6 Where to Operate? Necessity of a Specialized Multidisciplinary Team
17: Scales and Forms to Be Used in Practice
17.1 Introduction
17.2 Pre- and Post-operative Assessment in Adults and Children
17.3 Muscles Involved and the Corresponding Nerves or Roots to Be Targeted
17.4 Surgical Planning
Index