Peripheral neurotomies belong to micro-surgical procedures for retractable spasticity. They are indicated for severe focal spasticity for upper and lower limb. Among the methods for controlling spasticity, peripheral neurotomies are indicated for focal spasticity giving a permanent effect. Our surgical experience is dealing with peripheral neurotomies in the lower limb, mainly at the tibial nerve, and in the upper limb at the musculocutaneous, medial, and ulnar nerve. An anesthetic block with a long-lasting anesthetic used as a preliminary test may help predict the outcome by mimicking the effect of a planned neurotomy. The anesthetic nerve block could be performed easily under ultrasound guidance. As an example for tibial nerve, the patient is installed in prone position. After stimulation on popliteal fossa, the nerve is detected by muscle contractions at 3 mA, and if there is still reaction at 0.8 mA, we proceed to the perineural injection of the local anesthetic. For lower limb, after tibial neurotomy, you can see the improvement of equinovirus spastic the improvement of standing by reducing the severe varus, and a better motion by reducing the claw-toe's deformity. This is the view of right tibial nerve in popliteal region, where we can observe the main trunk with the medial and lateral gastrocnemius branches, the soleus nerve and the distal part of the tibial nerve. Peripheral nerve electrical stimulation helps to identify fascicles by muscular responses. With blue we can see the medial and lateral gastrocnemius branches, and with green the soleus branch. The intraoperative electrical stimulation of soleus branch gives clinically a strong plantar flexion. Here is the intraoperative electrical stimulation of lateral gastrocnemius branch and the stimulation of medial gastrocnemius branch. Of note, the parameters of stimulation are 2 Hz of frequency and 1 mA of intensity. The distal part of trunk is dissected where the branch for posterior tibialis gives strong internal rotation of foot. And the main distal part of trunk gives flexion of toes. Interpartial suction is performed over approximately 3-5 mm stamps are coagulated to prevent regrowth. Compared to distal stimulation, proximal gives a weak response. After partial sectioning of posterior tibialis branch, we can observe the reduction of internal foot rotation. Here is the distal part of the tibial nerve just superior to the soleus archaid after opening the epineurium. And here is motor fascicle stimulation and dissection. The selected motor fascicles are sectioned up to 3 mm. Stimulation shows reduction of toes flexion and at the end the epineurium is saturated. Post-operatively, the spastic dystonic equinovirus foot is well corrected. And eventually, the dorsiflexion of foot is corrected too. Peripheral neurotomy in upper limb aims to better cosmetic performance and functional prehension. For musculocutaneous neurotomy, skin incision is made along the superior remedial aspect of the biceps brachii. Dissection of the nerve is made of the musculocutaneous nerve between the biceps brachii muscle laterally and the coracobrachialis muscle medially. The trunk is identified and then the branches to brachialis and to biceps brachii are recognized by stimulation provoking elbow flexion. For medial nerve, skin incision is made at the medial aspect of the biceps brachii tendon at the level of the elbow, locitudinal along the bicipital crest. The medial nerve is searched medially to the brachial artery under the lasertus fibrosus. The pronator teres is retracted upward and laterally and the flexor carpi radialis medially. So after sectioning of the fibrosus arc of the flexor digitoro superficialis, the medial nerve with its branches to the pronator teres, palmaris longus, flexor digitoro profundus and flexor digitoro superficialis are dissected. Stimulation of the pronator teres branch provokes pronation. Respectively, palmaris longus wrist flexion, flexor digitoro profundus flexion of digital interphalangeal joint, flexor digitoro superficialis flexion of metacarpal and proximal interphalangeal joints, and finally, flexor digitalis pollicis thumb flexion. For ulnar nerve at the level of the elbow, the skin incision is made at the level of the olecranon epitrochlear groove. After opening of the epineurium, adductor pollicis stimulation provokes thumb adduction and flexor carpi ulnaris wrist flexion with ulnar deviation. Here is an example of combined triple neurotomy for spastic dystonic upper limb in a hemiplegic teenager. Postoperatively, there is improvement in capability for prehension and decrease in spasticity dystonic flexion during grip.

peripheral neurotomies

focal spasticity

upper limb

lower limb

surgical techniques