Background: The authors used selective peripheral neurotomy (SPN) on the sciatic and obturator nerves to restore the sitting posture and ambulation in bedridden patients suffering from severe proximal lower limb spasticity. Objective: To study the surgical outcome of sciatic and obturator neurotomies. Methods: All patients with refractory hamstring spasticity who encountered SPN on the hamstring nerve were recruited. Obturator neurotomy was undertaken in some individuals. The clinical assessment included Modified Ashworth Scale (MAS), passive range of motion (PROM), sitting competency and ambulatory condition. These parameters were compared between before and after the surgery by using the Wilcoxon signed-rank test. Results: Among the sciatic neurotomy group (n = 15), the mean pre- and postoperative MAS and PROM were 3.3 and 0.8 (p < 0.01) and 78.3 and 121.7° (p < 0.01), respectively. Those measurements of the obturator nerve surgery group (n = 11) were 3.7 and 1.1 (p < 0.01) as well as 21.0 and 45.0° (p < 0.01), respectively. Seven and 8 of a total of 9 patients had statistically significant improvement in sitting ability (p = 0.016) and ambulation status (p < 0.01), respectively. Conclusion: Bedridden patients who suffer from severe proximal lower limb spasticity have an optimum to return to sitting and ambulate with a wheelchair after SPN of the sciatic and obturator nerves.

Keywords:
Spasticity, Selective peripheral neurotomy, Sitting, Ambulation
1.
Sheean G: The pathophysiology of spasticity. Eur J Neurol 2002;9:3–9.
2.
Abbruzzese G: The medical management of spasticity. Eur J Neurol 2002;9:30–34.
3.
Ward AB: A summary of spasticity management – a treatment algorithm. Eur J Neurol 2002;9:48–52.
4.
Anwar K, Barnes MP: Botulinum toxin injections for spasticity. Oper Tech Neurosurg 2005;7:128–135.
5.
Kwon JY, Kim JS: Selective blocking of the anterior branch of the obturator nerve in children with cerebral palsy. Am J Phys Med Rehabil 2009;88:7–13.
6.
Azouvi P, Mane M, Thiebaut J-B, Denys P, Remy-Neris O, Bussel B: Intrathecal baclofen administration for control of severe spasticity: functional improvement and long-term follow-up. Arch Phys Med Rehabil 1996;77:35–39.
7.
Tabtimsuwan S, Sitthinamsuwan B, Chankaew E: Spasticity: a comprehensive review. Siriraj Med J 2011;63:32–37.
8.
Ochs G, Naumann C, Dimitrijevic M, Sindou M: Intrathecal baclofen therapy for spinal origin spasticity: spinal cord injury, spinal cord disease, and multiple sclerosis. Neuromodulation 1999;2:108–119.
9.
Boviatsis EJ, Kouyialis AT, Korfias S, Sakas DE: Functional outcome of intrathecal baclofen administration for severe spasticity. Clin Neurol Neurosurg 2005;107:289–295.
10.
Bohannon RW, Smith MB: Inter-rater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987;67:206–207.
11.
Johnson GR: Outcome measures of spasticity. Eur J Neurol 2002;9:10–16.
12.
Elovic EP, Simone LK, Zafonte R: Outcome assessment for spasticity management in the patient with traumatic brain injury: the state of the art. J Head Trauma Rehabil 2004;19:155–177.
13.
Sindou MP: History of the neurosurgical treatment for spasticity. Oper Tech Neurosug 2005;7:96–99.
14.
Boop FA: Evolution of the neurosurgical management of spasticity. J Child Neurol 2001;16:54–57.
15.
Sindou MP, Mertens P: Neurosurgery for spasticity. Stereotact Funct Neurosurg 2000;74:217–221.
16.
Sindou MP, Mertens P: Decision-making for neurosurgical treatment of disabling spasticity in adults. Oper Tech Neurosurg 2005;7:113–119.
17.
Decq P, Shin M, Carrillo-Ruiz J: Surgery in the peripheral nerves for lower limb spasticity. Oper Tech Neurosurg 2005;7:136–146.
18.
Lazorthes Y, Sol JC, Sallerin B, Verdié JC: The surgical management of spasticity. Eur J Neurol 2002;9:35–41.
19.
Smyth MD, Peacock WJ: The surgical treatment of spasticity. Muscle Nerve 2000;23:153–163.
20.
Sitthinamsuwan B, Nunta-Aree S, Nitising A, Tabtimsuwan S: The neurosurgical treatment of spasticity – an overview. Neurol Surg 2010;1:44–60.
21.
Sitthinamsuwan B, Chanvanitkulchai K, Nunta-aree S, Kumthornthip W, Pisarnpong A, Ploypetch T: Combined ablative neurosurgical procedures in a patient with mixed spastic and dystonic cerebral palsy. Stereotact Funct Neurosurg 2010;88:187–192.
22.
Sindou MP, Simon F, Mertens P, Decq P: Selective peripheral neurotomy (SPN) for spasticity in childhood. Child Nerv Syst 2007;23:957–970.
23.
Sitthinamsuwan B, Nunta-aree S: Functional peripheral nerve surgery. Siriraj Med J 2010;62:106–111.
24.
Decq P, Filipetti P, Cubillos A, Slavov V, Lefaucheur JP, Nguyen JP: Soleus neurotomy for treatment of the spastic equinus foot. Neurosurgery 2000;4:1154–1160.
25.
Jang SH, Park SM, Kim SH, Ahn SH, Cho YW, Ahn MO: The effect of selective tibial neurotomy and rehabilitation in a quadriplegic patient with ankle spasticity following traumatic brain injury. Yonsei Med J 2004;45:743–747.
26.
Buffenoir K, Roujeau T, Lapierre F, Menei P, Menegalli-Boggelli D, Mertens P, Decq P: Spastic equinus foot: multicenter study of the long-term results of tibial neurotomy. Neurosurgery 2004;55:1130–1137.
27.
Deltombe T, Detrembleur C, Hanson P, Gustin T: Selective tibial neurotomy in the treatment of spastic equinovarus foot: a 2-year follow-up of three cases. Am J Phys Med Rehabil 2006;85:82–88.
28.
Collado H, Bensoussan L, Viton JM, Milhe De Bovis V, Delarque A: Does fascicular neurotomy have long-lasting effects? J Rehabil Med 2006;38:212–217.
29.
Rousseaux M, Buisset N, Daveluy W, Kozlowski O, Blond S: Long-term effect of tibial nerve neurotomy in stroke patients with lower limb spasticity. J Neurol Sci 2009;278:71–76.
30.
Kim JH, Lee JI, Kim MS, Kim SH: Long-term results of microsurgical selective tibial neurotomy for spastic foot: comparison of adult and child. J Korean Neurosurg Soc 2010;47:247–251.
31.
Deltombe T, Gustin T: Selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic patients: a 2-year longitudinal follow-up of 30 cases. Arch Phys Med Rehabil 2010;91:1025–1030.
32.
Palacio A, Milliez PY, Le Jean T, Demangeon S, Verfaille S, Le Guern H, Biga N, Beuret-Blanquart F: Direct neurectomy of the motor branches of the tibial nerve in hemiplegic adults: an assessment with a mean follow-up period of 11 years. Ann Phys Rehabil Med 2010;53:417–433.
33.
Bollens B, Deltombe T, Detrembleur C, Gustin T, Stoquart G, Lejeune TM: Effects of selective tibial nerve neurotomy as a treatment for adults presenting with spastic equinovarus foot: a systematic review. J Rehabil Med 2011;43:277–282.
34.
Decq P, Filipetti P, Feve A, Saraoui A: Selective peripheral neurotomy of the hamstring branches of the sciatic nerve in the treatment of spastic flexion of the knee. A propos of a series of 11 patients. Neurochirurgie 1996;42:275–280.
35.
Abdennebi B, Bougatene B: Selective neurotomies for relief of spasticity focalized to the foot and to the knee flexors. Results in a series of 58 patients. Acta Neurochir (Wien) 1996;138:917–920.
36.
Park YB, Kim SH, Kim SW, Chang CH, Cho SH, Jang SH: Microsurgical selective obturator neurotomy for spastic hip adduction. J Korean Neurosurg Soc 2007;41:22–26.
37.
Carpenter EB: Role of nerve blocks in the foot and ankle in cerebral palsy: therapeutic and diagnostic. Foot Ankle 1983;4:164–166.
38.
Decq P, Cuny E, Filipetti P, Fève A, Kéravel Y: Peripheral neurotomy in the treatment of spasticity. Indications, techniques and results in the lower limbs. Neurochirurgie 1998;44:175–182.
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2012
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