All right, so the next paper is Selective Neurotomy for Spasticity, Single-Center Experience. Dr. Eli? Hello. My name is Elias. I'm a PGY-4 resident at the University of Utah Hospital. I'll be talking about Selective Neurotomy for Spasticity, a Single-Center Study. I have no disclosures. Spasticity is a leading cause of impaired mobility in patients with cerebral palsy, stroke, multiple sclerosis, traumatic brain injury, spinal cord injury, as well as anoxic injury. Spastic disorders can be disabling, and this treatment can be challenging. Severe spasticity in the upper and lower extremity can mask residual motor function, can make passive movement difficult, can generate pain, can hinder comfort in daily activity, and cause a non-aesthetic appearance. Treatment options include medical management with oral medication, as listed, and the goal of these oral medications are to treat the primary symptoms of spasticity, which are spasms, clonus, as well as resistance. Physical therapy is geared towards range-of-motion exercises and splinting, which can be painful and result in noncompliance. Patients who fail conservative management undergo chemo-denervation, tendon lengthening or muscle transfer, and or peripheral neurectomy. The old surgical standard was to perform muscle lengthening or tendon transfer, and this paper suggests that 14 out of 25 patients who underwent this procedure resulted in late deformity. Overall, tendon surgery by itself does not work, and you have to treat the underlying pathology. And the underlying pathology lies within the afferent pathway. By partially denervating a nerve, you are reducing the afferent information. This is a sample surgical neurectomy for the sural nerve. The sural nerve is isolated. It's dissected out. Using an electrical stimulator, you find the efferent or the motor pathway, and using an operative microscope, you surgically resect 50% to 80% of the nerve. You can bipolar the ends to prevent regrowth and suture that. After partial denervation, the remaining efferent fibers sprout collaterals and reinnervate those denervated muscle fibers, resulting in this group-type appearance. In terms of the extent of resection, this is debatable among surgeons, but most surgeons agree on resecting or partially denervating 50% to 80% of a nerve fiber. And maximal growth occurs at eight months. The study we performed is a retrospective study that included all patients with upper and lower extremity spasticity who failed medical management and sought surgical treatment by our senior author, Dr. Mark Mahan. And the timeframe for this is 2014 to 2018. Variables collected include age, gender, etiology of spasticity, category of spasticity, as well as preoperative and postoperative Ashford scores, complication, and patient satisfaction. The category spasticity was split among upper and lower extremity. In the upper extremity, we focused on elbow flexion spasticity, elbow extension spasticity, shoulder adduction spasticity, wrist flexion, finger flexion spasticity, and pronation spasticity. In the lower extremity, we focused on plantar flexion spasticity, foot inversion spasticity, adductor spasticity, and hamstring spasticity. Our primary outcome was comparing our preoperative modified Ashford score to our postoperative modified Ashford score, which is collected by an independent physical therapist. And our secondary outcome include range of motion, patient or caregiver satisfaction, as well as reported increased use or ease of use. This is the modified Ashford scale. It ranges from 0 to 4, 0 being no increase in muscle tone, and 4 on the other spectrum, meaning affected part is rigid in flexion or extension. We identified 25 patients, 17 of them were male, 8 were female, and the most common cause for spasticity is ischemic stroke, followed by TBI, cerebral palsy, and hemorrhagic stroke. Dr. Mahan performed a total of 54 selective anorectomies on these patients. The most common procedure performed was for elbow flexion, followed by wrist flexion and finger flexion spasticities. This is, however, research in progress, and we've been able to collect postoperative follow-up on 13 of these patients with a total of 25 procedures performed. Average follow-up is 11 months. Additionally, during his selective anorectomy on seven of these patients, he performed tenotomy. On seven patients, he performed tendon lengthening, and other seven patients had tendon transfers. One patient had revision surgery. Looking at the sample plantar flexion in a total of five patients comparing preoperative and postoperative modified Ashford score on the graph on the left, you can see that four of these patients had significant reduction in their postoperative modified Ashford score. One of them did not, and their passive motion was preserved throughout, and in terms of the angle of catch, it's mildly improved. Looking at eight patients who had anorectomy for elbow flexion spasticity, three of them had very good results, another three had modest results, and one of them did not have any improvement. However, their passive motion was preserved, and their angle of catch was increased. All in all, in total of 25 procedures, comparing preoperative modified Ashford scores to their postoperative modified Ashford scores, there's a significant statistical reduction in their postoperative modified Ashford score. This means that there is a significant decrease in their spasticity. In terms of looking at their angle of catch, there is an increase in their angle of catch. However, it has not reached statistical significance yet. We also wanted to look at patient satisfaction surveys. Anecdotally, they have been very satisfied with the surgery. However, we're in the process of quantifying this by administering PRISM surveys as well as post-surgery satisfaction scores. These aren't available yet, but we'll have the rest of the data collected. Going forward, the challenge is, one, collecting the rest of the data, and then secondly is distinguishing between dystonia versus spasticity, figuring out how much the extent of resection, and then also trying to figure out which patients would benefit from an additional tendon transfer with a selective neurectomy. In conclusion, this is the first North American study, first North American series of denervation procedure for spasticity. This is a very reasonable option for patients with severe spasticity who fail medical management. Listed are the benefits of selective neurectomy. Thank you.

selective neurotomy

spasticity treatment

cerebral palsy

stroke

multiple sclerosis