View metadata, citation and similar papers at core.ac.uk brought to you by CORE
provided by Elsevier - Publisher Connector
Annals of Physical and Rehabilitation Medicine 58 (2015) 54–59
Available online at ScienceDirect www.sciencedirect.com
Original article
Comparison between tibial nerve block with anaesthetics and
neurotomy in hemiplegic adults with spastic equinovarus foot
Thierry Deltombe *, Corinne Bleyenheuft, Thierry Gustin
Departments of Physical Medicine and Rehabilitation (Deltombe and Bleyenheuft) and Neurosurgery (Gustin),
CHU-UcL Dinant Godinne (universite´ catholique de Louvain), 5530 Yvoir, Belgium
A R T I C L E I N F O A B S T R A C T
Article history: Objective: The aim of the study was to compare the effect of diagnostic motor nerve block with
Received 13 August 2014
anaesthetics and of selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic
Accepted 18 December 2014 adults.
Methods: In this prospective observational study, 30 hemiplegic adults with spastic equinovarus foot
Keywords:
benefited from a diagnostic nerve block with anaesthetics followed by a selective tibial neurotomy
Hemiplegia
performed at the level of the same motor nerve branches of the tibial nerve. Spasticity (Ashworth scale),
Muscle spasticity
muscle strength (Medical Research Council scale), passive ankle dorsiflexion (ROM), gait parameters
Motor nerve block
(10 meters walking test) and gait kinematics (video assessment) were assessed before and after the
Neurotomy
nerve block and two months and two years after selective tibial neurotomy.
Equinovarus foot
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.
ß 2015 Elsevier Masson SAS. All rights reserved.
1. Introduction neurotomy (STN) [4]. Several randomized, double-blind, placebo-
controlled studies have demonstrated that BTXa injections can
Spastic equinovarus foot (SEF) is a common deformity among reduce spasticity, pain and use of walking aids, and increase active
hemiplegic patients, with an incidence estimated at 18% of the ankle dorsiflexion, whereas the effect on gait velocity has been
stroke survivors [1]. The deformity is mainly caused by spasticity of more equivocal [5–8]. However, BTXa has a reversible effect
the triceps surae (soleus and gastrocnemius muscles) and tibialis necessitating repeated injections every four to six months. In such
posterior muscles, sometimes associated with Achilles’ tendon cases, permanent surgical treatment, such as STN, is indicated in
shortening and weakness and/or imbalance of the peronei and order to definitively correct the SEF [9].
tibialis anterior muscles. SEF contributes to poor locomotor STN is a neurosurgical procedure in which the motor nerve
performance after stroke [2]. Moreover, SEF is frequently branches innervating the spastic muscles are partially sectioned.
associated with other gait disturbances such as knee recurvatum This old technique has been reintroduced by French and Belgian
[3]. Patients frequently need ankle-foot orthosis and/or crutch for neurosurgical teams over the last few decades and was improved
walking. Treatment of SEF includes physical therapy, muscle by use of intraoperative electrical stimulation and operating
stretching, orthosis, functional electrical stimulation, chemical microscopes [9–16]. Partial section of the motor nerve branches
neurolysis with phenol or alcohol, botulinum toxin (BTXa) results in a permanent reduction of spasticity by interrupting
injections, tendon transfers and lengthening, and selective tibial afferent (Ia) and efferent (a and g) fibers mediating the spastic
monosynaptic reflex arc. The surgeon carefully spares sensory
fibers to avoid sensory deficit and neuropathic pain. STN is
indicated in case of disabling SEF caused by spasticity of the
* Corresponding author. Tel.: +(32) 81 42 37 72; fax: +(32) 81 42 37 79.
E-mail address: [email protected] (T. Deltombe). gastrocnemius, soleus, tibialis posterior and flexor hallucis longus
http://dx.doi.org/10.1016/j.rehab.2014.12.003
1877-0657/ß 2015 Elsevier Masson SAS. All rights reserved.
T. Deltombe et al. / Annals of Physical and Rehabilitation Medicine 58 (2015) 54–59 55
muscles without associated musculo-tendinous shortening. selective decrease of the spasticity of all the muscles of the calf and
The motor nerve branches innervating the flexor digitorum sensory disturbances which may interfere with gait. The DNB was
longus muscle are spared in order to avoid sensory deficits performed by means of a disposable needle for conduction
because these branches are frequently very close to the sensory anaesthesia, gauge 23 and 100 mm in length (Top Corp., Japan),
fibers innervating the sole of the foot. The most frequently coupled to an EMG apparatus (Nicolet Viking, Nicolet Biomedical,
reported complaints that may justify STN were foot instability Inc., Madison, WI). The motor nerve branches were located
with repetitive ankle sprains, pain related to excessive pressure according to coordinates previously determined in relation to
1
on the toes, and difficulties tolerating ankle foot orthosis. The anatomic landmarks [21]. A 1 mL dose of lidocaı¨ne 2% (Xylocaı¨ne
long-lasting beneficial effect of STN on spasticity, gait speed and 2%) was injected on each motor nerve branch when a clinical
equinovarus deformity in patients with SEF has been suggested in muscular contraction and an EMG detection response (for the
several longitudinal studies [10–12,14,16–18]. A recent rando- soleus and gastrocnemius muscles) were still obtained with a low
mized controlled trial evaluating the effect of BTXa and STN in the stimulation intensity (0.01 ms and 4 mA). The local anaesthetics
SEF confirms the efficacy of the STN to reduce spasticity and to usually act after few minutes allowing to assess the effect on the
improve the ankle kinematics [9]. spasticity of the targeted muscles. The DNB was performed first at
In the assessment of SEF, especially before STN, a selective the superior motor nerve branch to the soleus muscle followed, if
diagnostic nerve block (DNB) with anaesthetics of the motor nerve necessary, by the motor nerve branch to the tibialis posterior and
branches of the tibial nerve innervating the soleus, gastrocnemius to the gastrocnemius muscles. If necessary, the DNB was finally
and tibialis posterior muscles is recommended and preferred to a performed at the tibial nerve. The effect of the DNB lasts for several
non-selective tibial nerve block [13,19–22]. The DNB involves hours.
injecting a small dose (usually 1 mL) of local anaesthetics at the
level of the motor nerve. The nerve block eliminates spasticity after 2.3. Surgical treatment
few minutes and for some hours, allowing assessment of the
respective contribution of the different spastic muscles, the degree STN was performed under general anaesthesia according to
of Achilles’ tendon shortening, and the weakness of the antag- previous description [9,12,14,16,23]. Muscle relaxant drugs were
onistic muscles. Before proposing STN, it is necessary that a not used in order to prevent any interference with the
reduction in the equinovarus deformity following a DNB with intraoperative electrical stimulation. The patient was placed in a
anaesthetics and/or botulinum toxin injections can be demon- prone position and a vertical cutaneous incision was made below
strated [9,11–13,15,16,23]. However, the necessity to perform DNB the crease of flexion of the popliteal fossa. The tibial nerve was
before proposing STN was suggested only by three studies which dissected and the motor nerve branches to the soleus, gastro-
have compared the effect of DNB and STN in respectively two, cnemius, tibialis posterior and flexor hallucis longus were
seven and 11 patients, supporting the need for larger studies identified with intraoperative tripolar electrical stimulation (New-
[13,20,24]. medic, France). The selected motor nerve branches were partially
The aim of the present study was to prospectively evaluate the sectioned over a 5 mm length under the microscope. The extent of
effect of DNB with anaesthetics of the motor nerve branches of the nerve section was determined according to the degree of spasticity
tibial nerve and of STN in the treatment of SEF in hemiplegic adults. and to the peroperative residual muscular contraction under
Our research hypothesis was that the DNB would provide an electrical stimulation. Patients were allowed to walk the day after
identical decrease in spasticity and in equinovarus deformity as surgery and no immobilization or cast was used. During the two
STN and therefore predicts the improvement obtained after STN. years period of the study, patients continued to benefit from a
30 minutes daily rehabilitation program including personal triceps
stretching in load, muscle strengthening and gait rehabilitation.
2. Methods This rehabilitation program was the same as performed before the
inclusion in the study. Use of oral antispastic medications was not
2.1. Participants monitored.
The patients were consecutively recruited by an interdisci- 2.4. Test protocol
plinary spasticity group in a referral center of a university hospital
from 1997 to 2005. All the patients benefited from a selective DNB Before and after DNB and two months and two years after STN,
with anaesthetics of the motor nerve branches of the tibial nerve the degree of spasticity, muscle strength, passive range of ankle
innervating the soleus, tibialis posterior Æ gastrocnemius muscles motion, gait parameters and gait kinematics were assessed by the
and from a STN performed at the same nerves. Inclusion criteria were same unblinded therapist. The degree of spasticity was measured
a stroke history or trauma of more than one year, an age over 18 years, at the triceps surae, tibialis posterior, quadriceps and hamstring
an ability to walk without shoes, the presence of a disabling SEF muscles by using the modified Ashworth scale [25]. The muscle
improved by DNB with anaesthetics and a passive ankle dorsal range strength was measured at the quadriceps, hamstring, tibialis
of motion with flexed knee at neutral angle after DNB. Exclusion anterior, peronei and triceps muscles by using the MRC (Medical
criteria were a previous history of surgery or injection with phenol Research Council graded 0–5) scale in sitting position. The passive
and injection with BTXa in the last 6 months and the need for a tendon range of ankle motion (ROM in degrees) was measured with a
surgery in addition to neurotomy. Our institutional review board goniometer with the knee in the flexed (soleus) and extended
approved the study and informed consent was obtained from all the (soleus and gastrocnemius) position taking the tibia, the center of
patients. the heel and the first metatarsophalangeal joint as landmarks. Gait
parameters (gait speed, step cadence and step length) were
2.2. Diagnostic nerve block with anaesthetics obtained during a 10-meter walking test. Gait kinematics (equinus,
varus and knee flexion both in swing and stance phase) was
The DNB with anaesthetics was performed at the level of the measured using video analysis and expressed in degrees; the gait
different motor nerve branches of the tibial nerve until the triceps was recorded with a digital camera recorder and analysed on a
spasticity had disappeared. If possible, a selective DNB was 20 inches screen. The following landmarks were used: the trunk
preferred to a global tibial nerve block, which induces a non and the femur for the hip, the femur and the tibia for the knee, the
56 T. Deltombe et al. / Annals of Physical and Rehabilitation Medicine 58 (2015) 54–59
tibia – center of the heel – first metatarsophalangeal joint for nerve branch innervating the flexor hallucis longus while it was
equinus and the tibia and the calcaneus for varus. Adverse effects not blocked by means of a selective or tibial nerve block. STN
of DNB and STN were monitored and recorded. involved the soleus nerve in all cases (median percentage of
section 75 [75;80]), the medial and lateral gastrocnemius nerves in
3. Statistical analysis 16 cases (median percentage of section 75 [52;75]), the tibialis
posterior nerve in 26 cases (median percentage of section
Numerical parameters are expressed as medians with first and 70 [50;80]), and the flexor hallucis longus nerve in 22 cases
third quartiles into brackets and as mean Æ standard deviations for (100% section in all cases).
some selected parameters. Differences in the parameters at the Tables 1–3 show spasticity, muscle strength, passive ankle
various time points were compared globally by a Friedman test, range of motion, gait parameters and kinematic parameters before
followed by Wilcoxon signed rank tests for two by two selected and after the DNB, and two months and two years after STN.
comparisons in case of significant heterogeneity. All tests were two- There was a statistically significant and similar decrease in
tailed and were performed by SPSS 15.0 statistical software (SPSS Inc., triceps and tibialis posterior spasticity, in triceps clonus and in
Chicago, USA). As correction for multiple tests, a p value less than equinus and varus in swing and stance phase after DNB and two
0.01 was considered as statistically significant. months and two years after STN. In contrast, there were no changes
in quadriceps and hamstring spasticity and in hip and knee flexion
4. Results during gait. There was statistically significant decrease in triceps
muscle strength and increase in passive ankle dorsiflexion after
Out of a population of 144 consecutive hemiplegic patients with DNB and two months after STN while both parameters returned to
SEF who benefited from a DNB 49 patients met the inclusion and baseline values two years after STN. Finally, the gait speed and the
exclusion criteria and were operated from STN. Thirty of the tibialis anterior strength were unchanged after DNB but were
49 patients completed the study with a 2-year follow-up: 1 patient increased two months and two years after STN and two years after
died from a cause unrelated to surgery, eight patients underwent a STN, respectively.
split anterior tibialis tendon transfer (SPLATT procedure) to correct There were no serious adverse effects after DNB or STN and no
a varus in swing phase related to imbalance between tibialis patient suffered from any permanent additional sensory loss and/
anterior and peronei muscles and 10 patients were lost for follow- or neuropathic pain.
up. The population included 17 males and 13 females. Hemiplegia
affected the right side in 13 patients and the left side in 17 patients. 5. Discussion
The etiology of hemiplegia was ischemic in 18 cases, haemorrhagic
in seven cases and traumatic in five cases. Mean age at enrolment In the assessment of SEF, a tibial DNB (or, if possible, a DNB of
was 45 Æ 14 years (range 20–69 years) and time from stoke or trauma selective motor nerve branches of the tibial nerve) represents the
to enrolment was 48 Æ 56 months (range, 15–218 months). best practice before a permanent treatment of spasticity, such as
The DNB was performed selectively at the level of the motor STN, should be proposed [9,11–16,23]. Firstly, the DNB, by inducing
nerve branch of the soleus in 28 cases, of the tibialis posterior in a transient suppression of the spasticity, helps to determine the
25 cases, of the flexor hallucis longus in 10 cases and of the contribution of the triceps surae–Achilles’ tendon complex short-
gastrocnemius in two cases. The DNB was performed at the level of ening and/or of the dorsiflexor weakness to the SEF deformity. For
the tibial nerve (innervating the soleus, gastrocnemius, tibialis instance, if the SEF in stance phase remains unchanged after DNB, we
posterior and flexor digitorum muscles) as a first procedure in two can conclude that the deformity is related to muscle contracture
cases and after selective motor nerve branch block in 10 cases. STN rather than to spasticity. If the SEF in swing phase is improved after
was performed at the same motor nerve branches as those selected DNB, this indicates that dorsiflexor muscles activation was limited
during the DNB. In six cases, the neurotomy involved the motor by the calf spasticity and could, therefore, be improved by an
Table 1
Spasticity (Ashworth scale), muscle strength (MRC scale) and passive ankle range of motion (ROM) (median) before and after diagnostic nerve block (DNB) and two months
and two years after selective tibial neurotomy (STN).
Baseline DNB STN 2 months STN 2 years
Spasticity (Ashworth)
Triceps surae 3 [3;4] 1 [0;1] 0 [0;1] 1 [0;1]
* * *
P < 0.001 P < 0.001 P < 0.001
**
P = 0.003
Tibialis posterior 1 [0;2] 0 [0;1] 0 [0;0] 0 [0;0]
* * *
P < 0.001 P < 0.001 P < 0.001
Quadriceps 2 [1;2] 2 [1;2] 2 [1;2] 2 [1;2]
Hamstrings 2 [1;2] 2 [1;2] 1 [1;2] 1 [1;2]
Muscle strength (MRC)
Triceps surae 3 [2;4] 1 [0;3] 1 [1;2] 3 [2;4]
* * **
P < 0.001 P < 0.001 P < 0.001
Tibialis anterior 4 [3;4] 4 [3;4] 4 [3;4] 4 [4;4]
*
P = 0.004
**
P = 0.01
Passive ankle dorsiflexion (degrees)
Flexed knee 5 [0;10] 10 [5;15] 15 [10;20] 10 [10;15]
* *
P < 0.001 P < 0.001
Extended knee 0 [-10; 5] 0 [0;10] 5 [0;10] 5 [–5;10]
* *
P < 0.001 P < 0.001
**
P = 0.002
P values not shown are not significant.
*
Significant difference versus pretreatment values.
**
Significant difference months versus post block values.
T. Deltombe et al. / Annals of Physical and Rehabilitation Medicine 58 (2015) 54–59 57
Table 2
Gait parameters (10 meters walking test) (means Æ SD and median) before and after diagnostic nerve block (DNB) and two months and two years after selective tibial neurotomy
(STN).
Baseline DNB STN 2 months STN 2 years
Gait parameters (10 m walking test)
Gait speed (m/s) 0.5 Æ 0.3 0.6 Æ 0.3 0.6 Æ 0.3 0.7 Æ 0.3
0.5 [0.3; 0.7] 0.5 [0.3;0.7] 0.5 [0.4;0.8] 0.7 [0.4;1.0]
* *
P = 0.004 P < 0.001
** **
P = 0.004 P = 0.002
P values not shown are not significant.
*
Significant difference versus pretreatment values.
**
Significant difference versus block values.
appropriate spasticity treatment. Secondly, a selective DNB helps to 10-meter walking test after soleus DNB and one month after STN.
differentiate the respective contribution of the different spastic In contrast, kinematic parameters (equinus and varus) and passive
muscles (soleus, gastrocnemius, tibialis posterior, flexor digitorum ankle dorsiflexion were improved after STN but not after DNB
and less frequently the fibularis muscles) tothe SEF [26]. For example, [20]. In two patients, Bleyenheuft et al. noted a similar near-
if the triceps clonus and SEF deformity disappear after a selective DNB normalization of elastic and viscous stiffness of ankle plantar flexor
of the soleus motor nerve branch, this means that the soleus muscles after soleus DNB and seven months after STN [24]. In a
spasticity only is responsible for the SEF. Decq et al. showed that series of 11 patients, Deltombe et al. showed that the triceps
soleus spasticity was exclusively responsible for the SEF in 75% of spasticity and equinovarus in swing and stance phase were
cases [27]. Buffenoir et al. have also shown that the triceps stretch similarly improved after DNB and one year after STN, suggesting
reflex and Achilles’ tendon reflex were reduced after soleus DNB but the predictive value of DNB before STN in terms of improvement in
not after gastrocnemius DNB and Bleyenheuft et al. noted a spasticity and ankle kinematics parameters [13].
normalization of the elastic and viscous stiffness of the ankle plantar In this study, the decrease in triceps and tibialis posterior
flexor muscles after soleus DNB confirming the predominant role of spasticity and the reduction in equinus and varus in swing and
soleus spasticity in SEF [19,24]. Such an improvement after soleus stance phase were similarly observed after DNB and two months
DNB indicates that only the soleus spasticity has to be treated with and two years after STN. This confirms the results obtained in
BTXa injection or STN while sparing the gastrocnemius muscles may previous study with shorter follow-up [13,20]. No changes
help to keep sufficient triceps strength and to preserve propulsion were observed in quadriceps or hamstring spasticity or in hip
during the push-off phase of gait. In contrast, a global tibial DNB and knee flexion during gait. In this cohort, a distal treatment of the
induces a decrease in spasticity of all the muscles innervated by the spasticity does not seem to have any proximal effect. DNB failed to
tibial nerve (gastrocnemius, soleus, tibialis posterior and flexor predict the slight improvement in tibialis anterior muscle strength
digitorum muscles), which does not permit to determine the and gait speed that was observed two years after STN. We attribute
responsibility of these different muscles in the SEF deformity. this to the fact that improvement in these parameters requires a
Furthermore, a tibial DNB also involves the sensory fibers innervating prolonged neurological rehabilitation program. This hypothesis is
the sole of the feet leading to a sensory deficit, which may interfere reinforced by the observation that tibialis anterior muscle strength
with gait [28]. Lastly and most importantly, the DNB can predict the was not improved two months after STN. As the proximal
functional improvement that can be expected from treatment of (quadriceps and hamstrings) spasticity stay unchanged all along
spasticity. This aspect is crucial for the patient as it allows him/her to the study, a proximal reduction of the spasticity consecutive to a
see and to feel what could be achieved with surgery. distal treatment cannot explain the gait speed improvement
As STN is a surgical and permanent treatment for SEF, it is observed.
important to determine if the improvements obtained after DNB BTXa injection can be used instead of DNB as a long-lasting
and STN are similar. This is essential to promote the use of DNB as a block before performing STN. However, as the effect of BTXa is not
mandatory screening tool before performing STN. A few studies, immediate and occurs after several days or weeks, assessment will
with limited follow-up and numbers of patients, have been be delayed. Moreover, Rousseaux et al. showed that STN was more
conducted to compare the effect of DNB and STN. In 7 patients, effective than BTXa injection to decrease spasticity [15].
Buffenoir et al. showed a similar reduction in the triceps surae Several studies have shown that the reduction in spasticity
stretch reflex score and in the mean walking time during the observed after soleus DNB and STN was correlated to the soleus
Table 3
Kinematic parameters (video analysis) in swing (SwP) and stance (StP) phases (median) before and after diagnostic nerve block (DNB) and two months and two years after
selective tibial neurotomy (STN).
Gait kinematics (video) (degrees) Baseline DNB STN 2 months STN 2 years
Equinus (SwP) 20 [15;25] 15 [10;20] 10 [10;20] 15 [10;20]
* * *
P = 0.01 P = 0.001 P = 0.004
Equinus (StP) 5 [–5;15] –5 [–10;10] –10 [–15;0] –5 [–10;10]
* * *
P < 0.001 P < 0.001 P < 0.001
**
P = 0.008
varus (SwP) 20 [15;25] 10 [10; 20] 10 [0;15] 15 [10;20]
* * *
P < 0.001 P < 0.001 P < 0.001
**
P < 0.001
varus (StP) 10 [0;20] 0 [–5;0] 0 [–5;0] 0 [–5;5]
* * *
P < 0.001 P < 0.001 P < 0.001
P values not shown are not significant.
*
Significant difference versus pretreatment values.
**
Significant difference months versus post block values.
58 T. Deltombe et al. / Annals of Physical and Rehabilitation Medicine 58 (2015) 54–59
Hmax/Mmax ratio, suggesting that local anaesthetics and neurot- improvement observed two years after STN. STN is an effective and
omy also affect the Ia fibers mediating the myotatic reflex and not persistent treatment for SEF considered as an appropriate
only the a motor fibers mediating voluntary contraction alternative to BTXa, which is the only treatment for SEF for which
[13,18,29]. Indeed, if DNB and STN affected a motor fibers only, efficacy has been proved in a double blind randomized controlled
Hmax and Mmax amplitudes should be similarly decreased and the trial versus placebo. Unfortunately, BTX is a reversible and costly
Hmax/Mmax ratio should remain unchanged. The permanent treatment that has to be repeated in order to maintain functional
reduction in spasticity observed after STN is due to the section of benefit, supporting the need for a permanent surgical solution,
the afferent Ia fibers, and is correlated to a decrease in the Hmax/ such as STN.
Mmax ratio. As the Ia fibers are not able to sprout and reconnect at
the level of the spinal cord, the spasticity reduction is permanent.
Disclosure of interest
This phenomenon also explains the permanent disappearance of
clonus after STN. Partial interruption of the g efferent fibers also
The authors declare that they have no conflicts of interest
participates to the weakening of the hyperactive myotactic reflex
concerning this article.
arc. On the other hand, section of the a motor fibers during STN
Financial disclosure statements have been obtained.
induces a transient decrease in triceps muscle strength correlated to
a reduction in the motor unit number estimation (MUNE). Reduction References
in triceps strength was similar after DNB and two months after STN
so that the effect of triceps muscle strength reduction on gait (talus [1] Verdie C, Daviet JC, Borie MJ, Popielarz S, Munoz M, Salle JY, et al. Epidemiology
of pes varus and/or equinus one year after a first cerebral hemisphere stroke: a
in stance phase, lack of propulsion during toe-off phase of gait) can
propos of a cohort of 86 patients. Ann Readapt Med Phys 2004;47:81–6.
be predicted. Moreover, a collateral reinnervation process occurs
[2] Lin PY, Yang YR, Cheng SJ, Wang RY. The relation between ankle impairments
after STN, explaining a recovery in triceps muscle strength and gait velocity and symmetry in people with stroke. Arch Phys Med Rehabil
2006;87:562–8.
correlated to a return of the Mmax amplitude to baseline values
[3] Bleyenheuft C, Bleyenheuft Y, Hanson P, Deltombe T. Treatment of genu
after eight to 12 months [13,18]. Importantly, thanks to the
recurvatum in hemiparetic adult patients: a systematic literature review.
persistant rehabilitation program including triceps stretching, Ann Phys Rehabil Med 2010;53:189–99.
[4] Deltombe T, Gustin T, De Cloedt P, Vandemeulebroecke M, Hanson P. The
STN does not induce muscular contracture as the passive ankle
treatment of the spastic equinovarus foot after stroke. Crit Rev Phys Rehabil
dorsiflexion stay unchanged before and two years after STN. As
Med 2007;19:195–212.
spasticity and equinovarus were reduced at a similar degree after [5] Burbaud P, Wiart L, Dubos JL, Gaujard E, Debelleix X, Joseph PA, et al. A
DNB and STN, whereas the Hmax/Mmax ratio decreased more after randomised, double blind, placebo controlled trial of botulinum toxin in the
treatment of spastic foot in hemiparetic patients. J Neurol Neurosurg Psychia-
STN than after DNB, Deltombe et al. suggested that a 50% section
try 1996;61:265–9.
during STN may be enough to correct the SEF [13]. This hypothesis
[6] Mancini F, Sandrini G, Moglia A, Nappi G, Pacchetti C. A randomised, double-
must however be confirmed by a prospective study. blind, dose-ranging study to evaluate efficacy and safety of three doses of
botulinum toxin type A (Botox) for the treatment of spastic foot. Neurol Sci
DNB can be performed in an outpatient. It takes approximately
2005;26:26–31.
30 minutes to perform DNB and clinical assessment. The only
[7] Pittock SJ, Moore AP, Hardiman O, Ehler E, Kovac M, Bojakowski J. et al. A
equipment necessary is a needle for conduction-anaesthesia double-blind randomised placebo-controlled evaluation of three doses of
botulinum toxin type A (Dysport) in the treatment of spastic equinovarus
coupled to a portable electrical stimulator or to an EMG apparatus.
deformity after stroke. Cerebrovasc Dis 2003;15:289–300.
The precise anatomical location of the motor nerve branches of the
[8] Wissel J, Ward A, Erztgaard P, Bensmail D, Hecht M, Lejeune T, et al. European
tibial nerve has been previously described using CT scanner and Consensus table on the use of Botulinum Toxin Type A in adult spasticity. J
Rehab Med 2009;41:13–25.
cadaver studies [21,30]. DNB is also a safe technique. Filipetti et al.
[9] Bollens B, Gustin T, Stoquart G, Detrembleur C, Lejeune T, Deltombe T. A random-
reported five painful procedures and two haematomas in a study of
ized controlled trial of selective neurotomy versus botulinum toxin for spastic
815 blocks [22]. Parziale et al. reported development of a equinovarus foot after stroke. Neurorehabil Neural Repair 2013;27:695–703.
[10] Bollens B, Deltombe T, Detrembleur C, Gustin T, Stoquart G, Lejeune T. Effects
compartment syndrome in the volar forearm after a median DNB
of selective tibial nerve neurotomy as a treatment for adults presenting with
performed under anticoagulant therapy [31]; anticoagulant therapy
spastic equinovarus foot: a systematic review. J Rehabil Med 2001;43:277–82.
should, therefore, be discontinued before performing DNB. Finally, [11] Decq P, Filipetti P, Cubillos A, Slavov V, Lefaucheur JP, Nguyen JP. Soleus
in a series of 110 tibial DNBs, Deltombe et al. reported one avulsion of neurotomy for treatment of the spastic equinus foot. Groupe d’e´valuation et de
traitement de la spasticite´ et de la dystonie. Neurosurgery 2000;47:1154–61.
the calcaneus at the insertion of the Achilles’ tendon attributed to
[12] Deltombe T, Detrembleur C, Hanson P, Gustin T. Selective tibial neurotomy in
overstretching [32]. In our study, no serious adverse effect and, in
the treatment of spastic equinovarus foot: a 2-year follow-up of three cases.
particular, additional permanent sensory deficit and/or neuropathic Am J Phys Med Rehabil 2006;85:82–8.
[13] Deltombe T, Jamart J, Hanson P, Gustin T. Soleus H reflex and motor unit
pain were observed.
number estimation after tibial nerve block and neurotomy in patients with
This study has several limitations. Firstly, the patient and the
spastic equinus foot. Neurophysiol Clin 2008;38:227–33.
investigator were not blinded. Secondly, in six cases, STN was [14] Deltombe T, Gustin T. Selective tibial neurotomy in the treatment of spastic
equinovarus foot in hemiplegic patients: a 2-year longitudinal follow-up of
performed at the level of the motor nerve branch innervating the
30 cases. Arch Phys Med Rehab 2010;91:1025–30.
flexor hallucis longus without previous selective DNB on this
[15] Rousseaux M, Buisset N, Daveluy W, Kozlowsli O, Blond S. Comparison of
branch. Thirdly, we used video as a gait kinematics analysis tool, botulinum toxin injection and neurotomy in patients with distal lower limb
spasticity. Eur J Neurol 2008;15:506–11.
but the reliability of this procedure in stroke patients has never
[16] Rousseaux M, Buisset N, Daveluy W, kozlowski O, Blond S. Long term effect of
been published. Finally, our study mainly focused on the body
tibial nerve neurotomy in stroke patients with lower limb spasticity. J Neurol
function and structure level (spasticity, strength, gait kinematics) Sci 2009;278:71–6.
[17] Palacio A, Milliez PY, Le Jean T, Demangeon S, Verfaille S, Le Guern H, et al.
of the International Classification of Functioning (ICF) and did not
Direct neurectomy of the motor branches of the tibial nerve in hemiplegic
investigate activity and participation domains [33].
adults: an assessment with a mean follow-up period of 11 years. Ann Phys
In conclusion, when performed at the same motor nerve Rehabil Med 2010;53:417–33.
branches, tibial DNB with anaesthetics and STN equally decrease [18] Roujeau T, Lefaucheur JP, Slavov V, Gherardi R, Decq P. Long term course of the H
reflex after selective tibial neurotomy. J Neurol Neurosurg Psychiatry 2003;74:
triceps spasticity and correct equinovarus deformity. Therefore,
913–7.
using DNB prior to STN can be described as a valuable screening
[19] Buffenoir K, Decq P, Lefaucheur JP. Interest of peripheral anesthetic blocks as a
tool before STN. DNB helps us to determine the respective diagnosis and prognosis tool in patients with spastic equines foot: a clinical
and electrophysiological study of the effects of block of nerve branches to the
responsibility of several spastic muscles and of contracture in
triceps surae muscle. Clin Neurophysiol 2005;116:2596–600.
the deformity and to allow the patient to feel what could be
[20] Buffenoir K, Rigoard P, Jefaucheur JP, Filipetti P, Decq P. Lidocaine hyperse-
achieved with STN. DNB fails to demonstrate the gait speed lective motor blocks of the triceps surae nerves. Role of the soleus versus
T. Deltombe et al. / Annals of Physical and Rehabilitation Medicine 58 (2015) 54–59 59
gastrocnemius on triceps spasticity and predictive value of the soleus motor [27] Decq P, Cuny E, Filipetti P, Keravel Y. Role of soleus muscle in spastic equinus
block on the result of selective tibial neurotomy. Am J Phys Med Rehabil 2008; foot. Lancet 1998;352:118.
87:292–304. [28] Arendzen J, van Duijn H, Beckmann M, Harlaar J, Vogelaar T, Prevo A. Diag-
[21] Deltombe T, De Wispelaere JF, Gustin T, Jamart J, Hanson P. Selective blocks of the nostic blocks of the tibial nerve in spastic hemiparesis. Scand J Rehab Med
motor nerve branches to the soleus and tibialis posterior muscles in the man- 1992;24:75–81.
agement of the spastic equinovarus foot. Arch Phys Med Rehabil 2004;85:54–8. [29] Feve A, Decq P, Filipetti P, Verroust J, Harf A, N’Guyen JP, et al. Physiological
[22] Filipetti P, Decq P. Interest of anesthetic blocks for assessment of the spastic effects of selective tibial neurotomy on lower limb spasticity. J Neurol Neu-
patient. A series of 815 motor blocks. Neurochirurgie 2003;49:226–38. rosurg Psychiatry 1997;63:575–8.
[23] Buffenoir K, Roujeau T, Lapierre F, Menei P, Menegalli-Boggelli D, Mertens P, [30] Sook Kim H, Hye Hwan J, Lee PK, Kwon JY, Yeon Oh-Park M, Moon Kim J,
et al. Spastic equinus foot: multicenter study of the long-term results of tibial et al. Localization of the motor nerve branches and motor points of the
neurotomy. Neurosurgery 2004;55:1130–7. triceps surae muscles in Korean cadavers. Am J Phys Med Rehabil 2002;81:
[24] Bleyenheuft C, Detrembleur C, Deltombe T, Fomekong E, Lejeune T. Quantita- 765–9.
tive assessment of anaesthetic nerve block and neurotomy in spastic equinus [31] Parziale JR, Marino AR, Herndon JH. Diagnostic peripheral nerve resulting in
foot: a review of 2 cases. J Rehab Med 2008;40:879–81. compartment syndrome. Am J Phys Med Rehabil 1988;67:82–4.
[25] Bohannon EW, Smith MB. Interrater reliability of a modified Ashworth scale of [32] Deltombe T, Nisolle JF, De Cloedt P, Hanson P, Gustin T. Tibial nerve block with
muscle spasticity. Phys Ther 1987;67:206–7. anesthetics resulting in Achilles tendon avulsion. Am J Phys Med Rehabil
[26] Thevenon A, Serafi R, Fontaine C, Grauwin MY, Buisset N, Triffeau V. An 2004;83:331–4.
unusual cause of foot clonus: spasticity of fiularis longus muscle. Ann Phys [33] World Health Organization. The International Classification of Functioning,
Rehabil Med 2013;56:482–8. Disability and Health-ICF. Geneva: WHO; 2001.