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Annals of Physical and Rehabilitation Medicine 58 (2015) 54–59

Available online at ScienceDirect www.sciencedirect.com

Original article

Comparison between tibial block with anaesthetics and

neurotomy in hemiplegic adults with spastic equinovarus

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 . 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 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 surae (soleus and gastrocnemius muscles) and tibialis necessitating repeated injections every four to six months. In such

posterior muscles, sometimes associated with Achilles’ 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 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 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 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 . 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

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 , the center of

patients. the 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 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 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 ) 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

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