Effects of Diagnostic Tibial Nerve Block and Selective Tibial Nerve Neurotomy on Spasticity and Spastic co-contractions: A Retrospective Observational Study.

OBJECTIVE: To assess the effects of diagnostic nerve block and selective tibial neurotomy on spasticity and co-contractions in patients with spastic equinovarus foot. METHODS: Among 317 patients who underwent a tibial neurotomy between 1997 and 2019, 46 patients who met the inclusion criteria were retrospectively screened. Clinical assessment was made before and after diagnostic nerve block and within 6 months after neurotomy. A total of 24 patients underwent a second assessment beyond 6 months after surgery. Muscle strength, spasticity, angle of catch (XV3), passive (XV1) and active (XVA) ankle range of motion were measured. The spasticity angle X (XV1-XV3) and paresis angle Z (XV1-XVA) were calculated with the knee in flexed and extended positions. RESULTS: Tibialis anterior and triceps surae strength remained unchanged, while both Ashworth and Tardieu scores were highly reduced after nerve block and neurotomy at all measurement times. XV3 and XVA increased significantly after block and neurotomy. XV1 increased slightly after neurotomy. Consequently, spasticity angle X and paresis angle Z decreased after nerve block and neurotomy. CONCLUSION: Tibial nerve block and neurotomy improve active ankle dorsiflexion, probably by reducing spastic co-contractions. The results also confirmed a long-lasting decrease in spasticity after neurotomy and the predictive value of nerve blocks.

Case Study of Intrathecal Baclofen Pump Motor Shutdown Secondary to the Effect of the Magnetic Field Created by a Personal Digital Tablet and Magnetic Cover.

ABSTRACT: We present the case of a posttraumatic C6 AIS A tetraplegic patient with spasticity treated with an intrathecal baclofen pump, who noticed a transient increase in his spasticity each time he used a digital tablet (Ipad) protected by a magnetic shell placed on his abdomen. Telemetry confirmed transient motor shutdown responsible for withdrawal symptoms each time the tablet was used. Symptoms resolved after the removal of the protective shell. Effects of magnetic fields like magnetic resonance imaging are known to stall the pump rotor, which recover at the end of magnetic resonance imaging. Other sources of magnetic fields like laptops or new smartphones with magnet charging technology may also interfere with implanted devices. We therefore recommend patients to avoid close contact of magnetic devices with the intrathecal baclofen pump. More robust studies are warranted to assess the effect of the new magnetic technologies on the function of intrathecal pumps.

International Recommendations to Manage Poststroke Equinovarus Foot Deformity Validated by a Panel of Experts Using Delphi.

OBJECTIVE: To establish international recommendations for the management of spastic equinovarus foot deformity. DESIGN: Delphi method. SETTING: International study. PARTICIPANTS: A total of 24 international experts (N=24) in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopedic surgeons, neurosurgeons, plastic surgeons). INTERVENTIONS: Experts answered 3 rounds of questions related to important aspects of diagnosis, assessment, and treatment of spastic equinovarus foot deformity. MAIN OUTCOME MEASURES: A consensus was established when at least 80% of experts agreed on a statement RESULTS: A total of 52 items reached consensus. Experts recommend assessing effect of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity, and evaluate the activity of antagonist muscles. Motor nerve blocks, 2-dimensional video analysis, and radiologic examinations are often required to complement a clinical examination. The treatment of equinovarus foot depends on the correctability of the deformity and the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between physicians and the patient, which will define personalized attainable goals before surgery. CONCLUSION: The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and nonspecialists to diagnoses and assess the deformity and direct patients to a network of experts to optimize patient functional recovery and improve their autonomy.

Intraspinal Iliac Venous Stent Migration with Lumbar Nerve Root Compression.

BACKGROUND: Venous stenting is a common treatment for chronic peripheral venous disease. The most frequent complications caused by this technique are stent misplacement and intracardiac or intravascular stent migration. In this publication, we will describe the first case of an intraspinal stent misplacement leading to lumbar nerve root compression. CASE DESCRIPTION: Our patient was a 20-year-old woman with a bilateral pulmonary embolism caused by a right common iliac vein thrombosis and a severe compression of the left common iliac vein by the right common iliac artery (May-Thurner or Cockett syndrome). She underwent an endovascular stenting of the left iliac vein. A few days later, she reported some pain in the right L5 radicular and showed signs of hypoesthesia of the left leg and of paresis of the left extensor hallucis longus muscle. A lumbar computed tomography scan showed a stent misplacement into the spinal canal through the left L5 foramen with nerve root compression. She underwent a surgical removal of the stent through a unilateral L5-S1 laminarthrectomy. The postoperative follow-up showed a complete clinical recovery and a control lumbar computed tomography scan confirmed the L5 nerve root decompression. CONCLUSIONS: The intraspinal misplacement of a venous stent is a rare complication that may cause nerve root injury. It requires a prompt treatment. Surgically removing the stent by a posterior approach seems to be a simple and safe therapeutic option.

Serotonin Syndrome Mimicking Intrathecal Baclofen Withdrawal in a Patient with Hereditary Spastic Paraparesis.

CONTEXT: Serotonin syndrome is a drug-induced condition related to an increased level of serotonin in the brain, which may induce neuromuscular, autonomic and mental symptoms. CASE REPORT: A 40-year-old woman with hereditary spastic paraparesis (Strumpell-Lorrain disease) with an implanted intrathecal baclofen pump for severe spasticity. Two days after starting a medication known to inhibit serotonin re-uptake (paroxetine), she developed a sudden increase in lower limb spasticity with continuous spasms, fever, tachycardia and hypertension. Intrathecal baclofen withdrawal was excluded, confirming serotonin syndrome. CONCLUSION: Medications that inhibit serotonin reuptake may induce serotonin syndrome, resulting in increased spasticity in patients with spinal cord lesions, and should be prescribed with caution.

Chromothripsis in an Early Recurrent Chordoid Meningioma.

BACKGROUND: Chromothripsis is characterized by a multitude of chromosomal rearrangements during a unique cataclysmic event in a cell life. Disintegration of one or several chromosomes is followed by a chaotic rearrangement of generated fragments. It might play a role in oncogenesis and tumor progression. It is observed in 2%-3% of cancers and is rarely reported in benign tumors. We report a case of massive chromothripsis in a fast growing chordoid meningioma. CASE DESCRIPTION: A 55-year-old woman was admitted for a meningeal mass developing in the right parietal parasagittal area. She underwent subtotal resection of the tumor. Histologic analysis revealed a chordoid meningioma (World Health Organization grade II). Six months later, magnetic resonance imaging showed a large bilateral tumor recurrence. After a second surgery, the patient received radiotherapy. Thereafter, the clinical course was uneventful. Comparative genomic hybridization showed only a monosomy X in the primary tumor. In the recurrent meningioma, this anomaly was associated with a massive chromothripsis including more than 370 chromosomal abnormalities affecting chromosomes 1-22. CONCLUSIONS: Chromothripsis is rarely described in benign tumors and especially in meningiomas. In the presented case, the high number of chromosomal rearrangements and the onset of this phenomenon at a later stage of tumor progression are very unusual. The role of surgical stress on the emergence of chromothripsis and its relation with tumor aggressiveness are discussed.

Botulinum toxin type A or selective neurotomy for treating focal spastic muscle overactivity?

OBJECTIVE: To discuss the effectiveness, indications, limitations and side effects of botulinum toxin type A and selective neurotomy for treating focal spastic muscle overactivity to help clinicians choose the most appropriate treatment. METHODS: Expert opinion based on scientific evidence and personal experience. RESULTS: Botulinum toxin type A can decrease muscle tone in different types of spastic muscle overactivity, which allows for treating a large variety of spastic patterns with several etiologies. The toxin effect is sometimes insufficient to improve functional outcome and is transient, thereby requiring repeated injections. Selective neurotomy is a permanent surgical treatment of the reflex component of the spastic muscle overactivity (spasticity) that is effective for spastic equinovarus foot. The neurotomy provides a greater and more constant reduction in spasticity. However, the long-lasting effect on the non-reflex muscle overactivity, especially dystonia, is doubted. The effectiveness, clinical indications, advantages, side effects and limitations of both techniques are discussed. CONCLUSION: Botulinum toxin type A has the highest level of evidence and the largest range of indications. However, the botulinum toxin effect is reversible and seems less effective, which supports a permanent surgical treatment such as selective neurotomy, especially for the spastic foot. Further research is needed to compare the effect of botulinum toxin type A and selective neurotomy for the different types of spastic muscle overactivity and clinical patterns.

Effect of the neuro-orthopedic surgery for spastic equinovarus foot after stroke: a prospective longitudinal study based on a goal-centered approach.

BACKGROUND: Neuro-orthopedic surgery is recognized as an effective treatment to improve walking capacity in case of spastic equinovarus foot. However, the effect of surgery on the 3 domains of the International Classification of Functioning, Disability and Health (ICF) has never been studied. AIM: The aim of this study was to assess the efficacy of the neuro-orthopedic surgery for spastic equinovarus foot after stroke based on a goal-centered approach and on the 3 domains of the International Classification of Functioning, Disability and Health (ICF). DESIGN: Prospective, single blind, case-series, intervention study (before-after trial) with a 1-year follow-up. SETTING: University Hospital of Mont-Godinne. POPULATION: Eighteen hemiplegic patients with spastic equinovarus foot. METHODS: A selective tibial neurotomy and/or an Achille tendon lengthening, and/or a tibialis anterior tendon transfer were performed to correct a disabling SEF. The primary outcome measure was the goal attainment scale. The secondary outcome measures included body function and structure (spasticity, strength, range of motion, pain, gait speed, ankle kinematics), activities (walking aids, functional ambulation category, functional walking category, ABILOCO) and social participation and quality of life (Satispart-Stroke, SF-36) assessment before and 2 months and 1 year after surgery. RESULTS: An increase in the goal attainment scale score, in the body function and activity/participation domains of the ICF, a decrease in triceps spasticity and pain, an increase in ankle range of motion and gait speed, an improvement in equinus and a reduction in walking aids were observed. CONCLUSIONS: This study confirms the efficacy of the neuro-orthopedic surgical treatment of spastic equinovarus foot after stroke to improve walking capacities and to achieve personal goals in the body function and activity/participation domains of the ICF. CLINICAL REHABILITATION IMPACT: In case of post-stroke spastic foot, a personalized neuro-orthopedic surgical program including neurotomy, tendon lengthening and/or transfer improves patient-centered goals in the different domains of the ICF.

Assessment and treatment of spastic equinovarus foot after stroke: Guidance from the Mont-Godinne interdisciplinary group.

OBJECTIVE: To present interdisciplinary practical guidance for the assessment and treatment of spastic equinovarus foot after stroke. RESULTS: Clinical examination and diagnostic nerve block with anaesthetics determine the relative role of the factors leading to spastic equinovarus foot after stroke: calf spasticity, triceps surae - Achilles tendon complex shortening and dorsiflexor muscles weakness and/or imbalance. Diagnostic nerve block is a mandatory step in determining the cause(s) of, and the most appropriate treatment(s) for, spastic equinovarus foot. Based on interdisciplinary discussion, and according to a patient-oriented goal approach, a medical and/or surgical treatment plan is proposed in association with a rehabilitation programme. Spasticity is treated with botulinum toxin or phenol-alcohol chemodenervation and neurotomy, shortening is treated by stretching and muscle-tendon lengthening, and weakness is treated by ankle-foot orthosis, functional electrical stimulation and tendon transfer. These treatments are frequently combined. CONCLUSION: Based on 20 years of interdisciplinary expertise of management of the spastic foot, guidance was established to clarify a complex problem in order to help clinicians treat spastic equinovarus foot. This work should be the first step in a more global international consensus.

Intramedullary spinal cord metastasis of cholangiocarcinoma: a case report.

BACKGROUND: Cholangiocarcinomas are rare tumors, and metastasis to the intramedullary spinal cord is also rare. To the best of our knowledge, this is the first case of simultaneous cholangiocarcinoma and intramedullary spinal cord metastasis to be described in the medical literature. CASE PRESENTATION: A 62-year-old Caucasian male with a cholangiocarcinoma presented pain around his left shoulder without any other symptoms. The results by magnetic resonance imaging and F18 fluorodeoxyglucose positron emission tomography/computer tomography revealed an intramedullary metastasis at the C4 level, with spinal cord compression, and numerous secondary parenchymal brain metastases. CONCLUSION: This patient was treated successfully with a combination of radiotherapy, corticosteroids, and chemotherapy. He experienced complete relief of the symptoms and showed improvements upon subsequent radiological evaluations.

Comparison between tibial nerve block with anaesthetics and neurotomy in hemiplegic adults with spastic equinovarus foot.

OBJECTIVE: The aim of the study was to compare the effect of diagnostic motor nerve block with anaesthetics and of selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic adults. METHODS: In this prospective observational study, 30 hemiplegic adults with spastic equinovarus foot benefited from a diagnostic nerve block with anaesthetics followed by a selective tibial neurotomy performed at the level of the same motor nerve branches of the tibial nerve. Spasticity (Ashworth scale), muscle strength (Medical Research Council scale), passive ankle dorsiflexion (ROM), gait parameters (10 meters walking test) and gait kinematics (video assessment) were assessed before and after the nerve block and two months and two years after selective tibial neurotomy. RESULTS: The decrease in spasticity and the improvement in gait kinematics were similar after the diagnostic nerve block and two months and two years after neurotomy. The diagnostic nerve block did not revealed the slight increase in gait speed and in tibialis anterior muscle strength that was observed two years after neurotomy. CONCLUSION: This study suggests that diagnostic nerve block with anaesthetics and selective neurotomy equally reduce spasticity and improve gait in case of spastic equinovarus foot in hemiplegic adults. Diagnostic nerve block can be used as a valuable screening tool before neurotomy.

Evaluation of the quality of information on the Internet available to patients undergoing cervical spine surgery.

OBJECTIVE: To evaluate the quality of information available on the Internet to patients with a cervical pathology undergoing elective cervical spine surgery. METHODS: Six key words ("cervical discectomy," "cervical foraminotomy," "cervical fusion," "cervical disc replacement," "cervical arthroplasty," "cervical artificial disc") were entered into two different search engines (Google, Yahoo!). For each key word, the first 50 websites were evaluated for accessibility, comprehensibility, and website quality using the DISCERN tool, transparency and honesty criteria, and an accuracy and exhaustivity scale. RESULTS: Of 5,098,500 evaluable websites, 600 were visited; 97 (16%) of these websites were evaluated for quality and comprehensiveness. Overall, 3% of sites obtained an excellent global quality score, 7% obtained a good score, 25% obtained an above average score, 15% obtained an average score, 37% obtained a poor score, and 13% obtained a very poor score. High-quality websites were affiliated with a professional society (P = 0.021), had bibliographical references (P = 0.030), and had a recent update within 6 months (r = 0.277, P < 0.001). No correlation between global quality score and other variables was observed. CONCLUSIONS: This study shows that the search for medical information on the Internet is time-consuming and often disappointing. The Internet is a potentially misleading source of information. Surgeons and professional societies must use the Internet as an ally in providing optimal information to patients.

A randomized controlled trial of selective neurotomy versus botulinum toxin for spastic equinovarus foot after stroke.

BACKGROUND: Selective neurotomy is a permanent treatment of focal spasticity, and its effectiveness in treating spastic equinovarus of the foot (SEF) was previously suggested by a few nonrandomized and uncontrolled case-series studies. OBJECTIVES: This study is the first assessor-blinded, randomized, controlled trial evaluating the effects of this treatment. METHODS: Sixteen chronic stroke patients presenting with SEF were randomized into 2 groups: 8 patients underwent a tibial neurotomy and the remaining 8 received botulinum toxin (BTX) injections. The soleus was treated in all patients, and the tibialis posterior and flexor hallucis longus were treated in about half of patients. The primary outcome was the quantitative measurement of ankle stiffness (L-path), an objective measurement directly related to spasticity. Participants were assessed by a blind assessor before their intervention and at 2 and 6 months after treatment. Evaluations were based on the 3 domains of the International Classification of Functioning, Disability and Health (ICF). RESULTS: Compared with BTX, tibial neurotomy induced a higher reduction in ankle stiffness. Both treatments induced a comparable improvement of ankle kinematics during gait, whereas neither induced muscle weakening. Activity, participation, and quality of life were not significantly modified in either group. CONCLUSIONS: This study demonstrates that the tibial nerve neurotomy is an effective treatment of SEF, reducing the impairments observed in chronic stroke patients. Future studies should be conducted to confirm the long-term efficacy based on the ICF domains.

Effects of selective tibial nerve neurotomy as a treatment for adults presenting with spastic equinovarus foot: a systematic review.

OBJECTIVE: Spastic equinovarus foot is a major cause of disability for neurorehabilitation patients, impairing their daily activities, social participation and general quality of life. Selective tibial nerve neurotomy is a neurosurgical treatment for focal spasticity, whose acceptance as treatment for spastic equinovarus foot remains controversial. We performed a systematic review of the literature to assess the efficacy of tibial nerve neurotomy as a treatment for adult patients presenting with spastic equinovarus foot. METHODS: We queried PubMed, Science Direct, Trip Database and PEDro databases with the following keywords: "equinus deformity" OR "muscle spasticity" AND "neurotomy." RESULTS: We selected a total of 11 non-randomized and uncontrolled studies, suggesting that neurotomy could be an efficient treatment to reduce impairments in spastic equinovarus foot patients. DISCUSSION: Our conclusions are based primarily on case series studies. The effects of tibial nerve neurotomy had not been compared with a reference treatment through a randomized controlled trial, which would be necessary to increase the level of scientific evidence. Moreover, further studies using quantitative, validated and objective assessment tools are required to evaluate the efficacy of tibial nerve neurotomy accurately based on the International Classification of Functioning, Disability and Health from the World Health Organization.

Selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic patients: a 2-year longitudinal follow-up of 30 cases.

OBJECTIVE: To assess the long-term efficacy of selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic patients. DESIGN: Intervention study (before-after trial) with an observational design and 2-year follow-up. SETTING: Spasticity group in a university hospital. PARTICIPANTS: Hemiplegic patients (N=30) with spastic equinovarus foot. INTERVENTION: A selective neurotomy was performed at the level of the motor nerve branches of the tibial nerve. MAIN OUTCOME MEASURES: Spasticity (Ashworth scale), muscle strength (Medical Research Council scale), passive ankle dorsiflexion, gait parameters (6 min walking test), and gait kinematics (video assessment) were assessed before and at 2 months, 1 year, and 2 years after selective tibial neurotomy. RESULTS: Compared with preoperative values, there was a statistically significant decrease in triceps surae spasticity, an increase in gait speed, and a reduction in equinus and varus in swing and stance phases at 2 months postoperatively. This improvement persisted at 1 and 2 years after selective tibial neurotomy. Selective tibial neurotomy does not induce permanent triceps muscle weakness or triceps surae-Achilles' tendon complex shortening. CONCLUSION: This study confirms the long-lasting beneficial effect of selective tibial neurotomy on spasticity, gait speed, and equinovarus deformity in the treatment of spastic equinovarus foot in hemiplegic patients.