- Email: [email protected]
Surgical management of spasticity
Surgical Management of Spasticity MANUEL DUJOVNY, M.D. RANJIT K. LAHA, M.D. HOWARD YONAS, M.D. SPASTICITY ASSOCIATED WITH FLEXOR SPASM of the lower extremities may cause considerable annoyance to the patient and may pose a serious problem of nursing care. It also interferes significantly with rehabilitative goals in an already handicapped patient. Various forms of drug therapy have generally been ineffectual or have only shown limited benefit in some patients. ~, '~ Over the years, a wide variety of surgical treatments have been used to control spasticity and flexor spasm of the lower extremities, with variable results. Peripheral neurectomy, myotomy and tenotomy have not been uniformly successful2 Although surgical posterior and anterior rhizotomies and cordectomy have relieved spasticity, they have resulted in sensory deficit and/or muscle atrophy.l,~-,~, 1, The effects of posterior rhizotomy have been short-lasting and unfavorable, since the sensory deficit is increased. The anterior rhizotomy advocated by Munro, -~1although successful in relieving spasticity, leads to muscle atrophy and precludes any future hope of motor function recovery. Similarly, selective cordectomy has resulted in permanent destruction of spinal cord functions, with abolition of bladder, bowel and erection reflexes. 24 The results of chemical rhizotomies have been inconsistent and unpredictable", ''~ (Fig 28). The use of radiofrequency energy for producing lesions of neural structures was first proposed by Kirschner in 1942. '.~ Although initially successful, the technique was abandoned until the late 1950s, when the technology for t e m p e r a t u r e control of the lesion was developed. Numerous authors have since demonstrated the clinical usefulness and safety of radiofrequency lesions in the t r e a t m e n t of trigeminal neuralgia. 2-~,"~ The ability to create a central lesion under local anesthesia was a clear improvement over the previous open surgical procedures. Also, the radiofrequency lesion has been shown to create a differential lesion with a preferential injury to C and delta A nerve fibers. '~, ,.,3 In 1972, U e m a t s u 24 introduced the use of this technique for performing a rhizotomy. He reported on 13 patients with chronic back and e x t r e m i t y pain disorders and 3 with severe spasticity, who were favorably treated with percutaneous radiofrequency rhizotomies. Under fluoroscopic control, the thermoprobe (85C for 120 seconds) was positioned against the exiting nerve via an oblique approach at the intervertebral foramen (Fig 29). Proximity to the nerve root was then verified by obtaining an appropriate 249
A
fL~1~ t
/
/
,f
!
/
!
J
!
'
,/
cs\
1,, ~
l
!
I 1
i
/
,t E
Fig 28.-Diagrammatic representation of miscellaneous flaps. A, transverse flap, across the back for sacral ulcer. Usually safe to rotate in one stage. B, anteriorly based thigh flap, for trOchanteric ulcer. C,bipedicle flap for trochanteric ulcer, rarely used. D, "saddle flap"; this flap lies over the pressure area with patient in sitting position. E, turn-over flexor digitorum brevis muscle flap for heel ulcer. Split-thickness skin graft to cover muscle.
radicular response with low-voltage repetitive stimulation. In 1977, Kennemore ~4 reported on a series of 25 patients with lower extremity spasticity who were treated with radiofrequency rhizotomies. The good clinical results obtained were believed to be due to reduced C fiber input to the intrinsic activity of the injured spinal cord. Although a number of cases required repeated procedures, the ~initial results have encouraged us to use this technique. To date, we have treated 15 patients, with a follow-up period of up to 1 year. All patients were initially given baclofen, but no significant relief of spasticity was obtained. Immediately following the radiofrequency rhizotomy, however, the spasticity was favorably altered in all 15 cases. Although some degree of spasticity returned after about 8 weeks, all patients responded to baclofen, often in moderate dosages, when no benefit had been noted preoperatively. A repeat procedure can be performed to bring about ease and relief of the spasticity. 250
Spasticity Flexor Spasm
,EL,EF ,( . . . . i Dorsal Lo,,giludlnal
J
f .
~'"7--'-~1 v
Yes
"
"
'
JMvolo~o-~y
__|Percutaneous
J
|
sue GEeYI-----~l,o~o,oquo.,yl IRhi'Ot°', y _ I
RELIEF
Fig 29.-Schematic representation of sequential options for the treatment of spasticity.
Our experience has shown t h a t the creation of percutaneous radiofrequency lesions of t h e lower t h o r a c o l u m b a r and upper sacral roots is a safe and effective technique to alter lower extremity spasticity. It has been useful where total relief of spasticity is required, such as in the closure of decubitus ulcers, where 2 or 3 weeks are needed for healing of the operative wound, In cases of failure, a Bischof myelotomy is recommended as an a l t e r n a t i v e procedure. In 1951, Bischof~ described t h e technique of longitudinal myelotomy in t h e t r e a t m e n t of'lower e x t r e m i t y spasticity. Since Bischofs description of a more physiologic approach for the relief of spasticity with preservation of residual function, several a u t h o r s have applied the techniques with encouraging results2.1~, 17, 25 The operation involves separation of the anterior from t h e posterior h a l f of t h e spinal cord at t h e T11 - $1 s e g m e n t s in t h e central grey, t h e r e b y i n t e r r u p t i n g the poly- and monosynaptic reflex arcs as well as t h e collaterals of Kolliker. 3' 7 We have followed the dorsal midline approach for its suggested advantages, especially the possible sparing of the connections between the p y r a m i d a l t r a c t and the anterior horn cells. P r e s e r v a t i o n of the motor p a t h w a y s m a y allow motor function recovery after myelotom:~, as noted by Laitinen and Singounas. 2~ Persistence or recurrence of spasticity after t h e first myelotomy were noted in 4 of our 24 patients. The m y e l o t o m y was subseq u e n t l y repeated with satisfactory results in 2 of 3 of these cases. The poor clinical results in t h e r e m a i n i n g 2 cases were a t t r i b u t e d to the presence of fixed contractures of t h e hip and knee joints. Ivan and Wylie I~ have suggested t h a t a resection of t h e joints in such cases m a y offer better results. Several authors have noted preservation of residual sensory function p o s t o p e r a t i v e l y , if such was the s t a t u s before operationY ° An increased sensory i m p a i r m e n t following operation has also been observed. In most cases, sensations w e r e recovered 251
Fig 30.-Thermoprobe placed in the intervertebral forarnen.
spontaneously. '7 In our cases with p a r t i a l sensory loss, some preservation of sensation in the lower l i m b s was noted postoperatively. Several authors h a v e noted preservation, i m p r o v e m e n t or worsening of b l a d d e r function after myelotomy. '7' '-'~ No signific a n t b l a d d e r function i m p r o v e m e n t was noted in a n y of our pat i e n t s after myelotomy. A deterioration of bladder function was noted in the i m m e d i a t e postoperative period i n 3 of our p a t i e n t s who wore Condom catheters. It has been suggested tha t u n i l a t e r a l downward extension of the myelotomy from t h e $ 1 - 5 se gme nts m a y be done for spastic bladder. A l t h o u g h o u r longest follow-up h a s been: only slightly longer t h a n 4 years, we believe t h a t dorsal l o n g i t u d i n a l mye lotomy is a n effective m e a s u r e in controlling severe lower e x t r e m i t y spasticity w h e n previous p h y s i o t h e r a p y or p e r c u t a n e o u s rhizotomy h a v e failed. In the presence of severe j o i n t contractures, the previous t r e a t m e n t s m a y not be successful in i m p r o v i n g the p a t i e n t ' s condition. REFERENCES 1. Benedetti, A., Carbonin, C., and Colombo, F.: Extended posterior cervical rhizotomy for severe spastic syndromes 'with dyskinesias, Appl. Neurophysiol. 40:41, 1977178. 2. Bischof, W.: Die longitudinale Myelotomie, Zentrabl. Neurochir. 2:79, 195. 3. Bischof, W.: Zur dorsalen longitudinalen Myelot0mie, Zentrabl. Neurochir. 28:123, 1967. 4. Cusick, J. F,, Larson, S. J., and Sances, J. A.: The effect of T-myelotomyon spasticity. Surg, Neurol. 6:289, 1976. 5. Davidoff,R. A.: Pharmacology of spasticity, Neurology 28:46, 1978. 252
6. Davis, R.: Spasticity following spinal cord injury, Clin. Orthop. 112:66, 1975. 7. Feurer, H., Homer, T. G., DeMyer, W. E., and Campbell, R. L.: Anatomical and histological lesions in Bischof's myelotomy in dogs, Surg. Forum 23:438, 1972. 8. Frailoli, B., and Guidetti, B.: Posterior partial rootlet section in the treatment of spasticity, J. Neurosurg. 46:618, 1977. 9. Freeman, L. W., and Heimburger, R. F.: The surgical relief of spasticity in paraplegic patients: peripheral nerve section, posterior rhizotomy and other procedures, J. Neurosurg. 5:556, 1948. 10. Gros, C., Quaknine, G,, Vlahovitch, B., et ah: La radicotomie selective post6rieure dans le traitement neuro-chirurgical de l'hypertonie pyramidale, Neurochirurgie 13:505, 1967. 11. Ivan, L. P., and Wiley, J. J.: Myelotomy in the management ofspasticity, Clin. Orthop. 108:52, 1975. 12. Jonsson, B., Ladd, H., Afzelius-Frisk, I., and Lindburg-Broman, A.: The effects of Dantrium on spasticity in hemiplegic patients, Acta Neurol. Scan& 51:385, 1975. 13. Kelley, R. E., and Gautier-Smith, P. C.: Intrathecal phenol in the treatment of reflex spasms and spasticity, Lancet 2:1102, 1959. 14. Kennemore, E.: Management of spasms and spasticity in spinal cord and brain injured patients by percutaneous radi0frequency rhizotomy, Am. Assoc. Neuroi. Surg. Proc. #81, 1977. 15. Kirschner, M.: Die Behandlung der trigeminus Neuralgie (nach Erfahrungen an 11,113 Kranken), Mfinchen Med. Wschr. 89:235, 1942. 16. Laha, R. K., Dujovny, M., and Osgood, C. P.: Dorsal longitudinal myelotomy, Paraplegia 14:189, 1976. 17. Laitinen, L., and Singounas, E.: Longitudinal myelotomy in the treatment of spasticity of the legs, J, Neurosurg. 36:536, 1971. 18. Letcher, F. S., and Goldring, S.: The effect ofradiofrequency current and heat on peripheral nerve action potential in the cat, J. Neurosurg. 29:42, 1968. 19. McCarty, C. S.: The treatment of spastic paraplegia by selective cordectomy, J. Neurosurg. 11:539, 1954. 20. Moyes, P. D.: Longitudinal myelotomy for spasticity, J. Neurosurg. 31:615, 1969. 21. Munro, D.: The rehabilitation of patients totally paralyzed below the waist: anterior rhizotomy for spastic paraplegia, N. Engl. J. Med. 233:453, 1945. 22. Siegfried, J., Vosmansky, M.: Technique of the controlled thermocoagulation oftrigeminal ganglion and spinal roots. Advances and technical standards in neurosurgery, 2:199, 1975. 2"3. Sweet, W. H., and Wepsic, J. G.: Controlled thermocoagulation of trigeminal ganglion and rootlets for differential destruction of pain fibers. Part 1. Trigeminal Neuralgia, J. Neurosurg. 30:143, 1974. 24. Uematsu, S.: Percutaneous radiofrequency rhizotomy, Surg. Neurol. 2:319, 1974. 25. Yamada, S., Perot, P. L., Jr., Ducker, T. B., and l~ockard, I.: Myelotomy for control of mass spasm in paraplegia, J. Neurosurg. 45:683, 1976.
253
A
fL~1~ t
/
/
,f
!
/
!
J
!
'
,/
cs\
1,, ~
l
!
I 1
i
/
,t E
Fig 28.-Diagrammatic representation of miscellaneous flaps. A, transverse flap, across the back for sacral ulcer. Usually safe to rotate in one stage. B, anteriorly based thigh flap, for trOchanteric ulcer. C,bipedicle flap for trochanteric ulcer, rarely used. D, "saddle flap"; this flap lies over the pressure area with patient in sitting position. E, turn-over flexor digitorum brevis muscle flap for heel ulcer. Split-thickness skin graft to cover muscle.
radicular response with low-voltage repetitive stimulation. In 1977, Kennemore ~4 reported on a series of 25 patients with lower extremity spasticity who were treated with radiofrequency rhizotomies. The good clinical results obtained were believed to be due to reduced C fiber input to the intrinsic activity of the injured spinal cord. Although a number of cases required repeated procedures, the ~initial results have encouraged us to use this technique. To date, we have treated 15 patients, with a follow-up period of up to 1 year. All patients were initially given baclofen, but no significant relief of spasticity was obtained. Immediately following the radiofrequency rhizotomy, however, the spasticity was favorably altered in all 15 cases. Although some degree of spasticity returned after about 8 weeks, all patients responded to baclofen, often in moderate dosages, when no benefit had been noted preoperatively. A repeat procedure can be performed to bring about ease and relief of the spasticity. 250
Spasticity Flexor Spasm
,EL,EF ,( . . . . i Dorsal Lo,,giludlnal
J
f .
~'"7--'-~1 v
Yes
"
"
'
JMvolo~o-~y
__|Percutaneous
J
|
sue GEeYI-----~l,o~o,oquo.,yl IRhi'Ot°', y _ I
RELIEF
Fig 29.-Schematic representation of sequential options for the treatment of spasticity.
Our experience has shown t h a t the creation of percutaneous radiofrequency lesions of t h e lower t h o r a c o l u m b a r and upper sacral roots is a safe and effective technique to alter lower extremity spasticity. It has been useful where total relief of spasticity is required, such as in the closure of decubitus ulcers, where 2 or 3 weeks are needed for healing of the operative wound, In cases of failure, a Bischof myelotomy is recommended as an a l t e r n a t i v e procedure. In 1951, Bischof~ described t h e technique of longitudinal myelotomy in t h e t r e a t m e n t of'lower e x t r e m i t y spasticity. Since Bischofs description of a more physiologic approach for the relief of spasticity with preservation of residual function, several a u t h o r s have applied the techniques with encouraging results2.1~, 17, 25 The operation involves separation of the anterior from t h e posterior h a l f of t h e spinal cord at t h e T11 - $1 s e g m e n t s in t h e central grey, t h e r e b y i n t e r r u p t i n g the poly- and monosynaptic reflex arcs as well as t h e collaterals of Kolliker. 3' 7 We have followed the dorsal midline approach for its suggested advantages, especially the possible sparing of the connections between the p y r a m i d a l t r a c t and the anterior horn cells. P r e s e r v a t i o n of the motor p a t h w a y s m a y allow motor function recovery after myelotom:~, as noted by Laitinen and Singounas. 2~ Persistence or recurrence of spasticity after t h e first myelotomy were noted in 4 of our 24 patients. The m y e l o t o m y was subseq u e n t l y repeated with satisfactory results in 2 of 3 of these cases. The poor clinical results in t h e r e m a i n i n g 2 cases were a t t r i b u t e d to the presence of fixed contractures of t h e hip and knee joints. Ivan and Wylie I~ have suggested t h a t a resection of t h e joints in such cases m a y offer better results. Several authors have noted preservation of residual sensory function p o s t o p e r a t i v e l y , if such was the s t a t u s before operationY ° An increased sensory i m p a i r m e n t following operation has also been observed. In most cases, sensations w e r e recovered 251
Fig 30.-Thermoprobe placed in the intervertebral forarnen.
spontaneously. '7 In our cases with p a r t i a l sensory loss, some preservation of sensation in the lower l i m b s was noted postoperatively. Several authors h a v e noted preservation, i m p r o v e m e n t or worsening of b l a d d e r function after myelotomy. '7' '-'~ No signific a n t b l a d d e r function i m p r o v e m e n t was noted in a n y of our pat i e n t s after myelotomy. A deterioration of bladder function was noted in the i m m e d i a t e postoperative period i n 3 of our p a t i e n t s who wore Condom catheters. It has been suggested tha t u n i l a t e r a l downward extension of the myelotomy from t h e $ 1 - 5 se gme nts m a y be done for spastic bladder. A l t h o u g h o u r longest follow-up h a s been: only slightly longer t h a n 4 years, we believe t h a t dorsal l o n g i t u d i n a l mye lotomy is a n effective m e a s u r e in controlling severe lower e x t r e m i t y spasticity w h e n previous p h y s i o t h e r a p y or p e r c u t a n e o u s rhizotomy h a v e failed. In the presence of severe j o i n t contractures, the previous t r e a t m e n t s m a y not be successful in i m p r o v i n g the p a t i e n t ' s condition. REFERENCES 1. Benedetti, A., Carbonin, C., and Colombo, F.: Extended posterior cervical rhizotomy for severe spastic syndromes 'with dyskinesias, Appl. Neurophysiol. 40:41, 1977178. 2. Bischof, W.: Die longitudinale Myelotomie, Zentrabl. Neurochir. 2:79, 195. 3. Bischof, W.: Zur dorsalen longitudinalen Myelot0mie, Zentrabl. Neurochir. 28:123, 1967. 4. Cusick, J. F,, Larson, S. J., and Sances, J. A.: The effect of T-myelotomyon spasticity. Surg, Neurol. 6:289, 1976. 5. Davidoff,R. A.: Pharmacology of spasticity, Neurology 28:46, 1978. 252
6. Davis, R.: Spasticity following spinal cord injury, Clin. Orthop. 112:66, 1975. 7. Feurer, H., Homer, T. G., DeMyer, W. E., and Campbell, R. L.: Anatomical and histological lesions in Bischof's myelotomy in dogs, Surg. Forum 23:438, 1972. 8. Frailoli, B., and Guidetti, B.: Posterior partial rootlet section in the treatment of spasticity, J. Neurosurg. 46:618, 1977. 9. Freeman, L. W., and Heimburger, R. F.: The surgical relief of spasticity in paraplegic patients: peripheral nerve section, posterior rhizotomy and other procedures, J. Neurosurg. 5:556, 1948. 10. Gros, C., Quaknine, G,, Vlahovitch, B., et ah: La radicotomie selective post6rieure dans le traitement neuro-chirurgical de l'hypertonie pyramidale, Neurochirurgie 13:505, 1967. 11. Ivan, L. P., and Wiley, J. J.: Myelotomy in the management ofspasticity, Clin. Orthop. 108:52, 1975. 12. Jonsson, B., Ladd, H., Afzelius-Frisk, I., and Lindburg-Broman, A.: The effects of Dantrium on spasticity in hemiplegic patients, Acta Neurol. Scan& 51:385, 1975. 13. Kelley, R. E., and Gautier-Smith, P. C.: Intrathecal phenol in the treatment of reflex spasms and spasticity, Lancet 2:1102, 1959. 14. Kennemore, E.: Management of spasms and spasticity in spinal cord and brain injured patients by percutaneous radi0frequency rhizotomy, Am. Assoc. Neuroi. Surg. Proc. #81, 1977. 15. Kirschner, M.: Die Behandlung der trigeminus Neuralgie (nach Erfahrungen an 11,113 Kranken), Mfinchen Med. Wschr. 89:235, 1942. 16. Laha, R. K., Dujovny, M., and Osgood, C. P.: Dorsal longitudinal myelotomy, Paraplegia 14:189, 1976. 17. Laitinen, L., and Singounas, E.: Longitudinal myelotomy in the treatment of spasticity of the legs, J, Neurosurg. 36:536, 1971. 18. Letcher, F. S., and Goldring, S.: The effect ofradiofrequency current and heat on peripheral nerve action potential in the cat, J. Neurosurg. 29:42, 1968. 19. McCarty, C. S.: The treatment of spastic paraplegia by selective cordectomy, J. Neurosurg. 11:539, 1954. 20. Moyes, P. D.: Longitudinal myelotomy for spasticity, J. Neurosurg. 31:615, 1969. 21. Munro, D.: The rehabilitation of patients totally paralyzed below the waist: anterior rhizotomy for spastic paraplegia, N. Engl. J. Med. 233:453, 1945. 22. Siegfried, J., Vosmansky, M.: Technique of the controlled thermocoagulation oftrigeminal ganglion and spinal roots. Advances and technical standards in neurosurgery, 2:199, 1975. 2"3. Sweet, W. H., and Wepsic, J. G.: Controlled thermocoagulation of trigeminal ganglion and rootlets for differential destruction of pain fibers. Part 1. Trigeminal Neuralgia, J. Neurosurg. 30:143, 1974. 24. Uematsu, S.: Percutaneous radiofrequency rhizotomy, Surg. Neurol. 2:319, 1974. 25. Yamada, S., Perot, P. L., Jr., Ducker, T. B., and l~ockard, I.: Myelotomy for control of mass spasm in paraplegia, J. Neurosurg. 45:683, 1976.
253