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IC 30: Treatment of Spasticity in the Adult Patient

Moderator(s): Lindley B. Wall, MD

Faculty: Lindley B. Wall, MD, Allan E. Peljovich, MD, MPH, Ida K. Fox, MD, Michelle G. Carlson, MD, Michael S. Bednar, MD

Session Handouts Friday, September 06, 2019

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 – 7, 2019 LAS VEGAS, NV

822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected]

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

Spasticity and in the Adult Patient Lindley B. Wall-Stivers, MD, MSc

Objectives

• Develop a sense for the demographics and prevalence of spasticity and tetraplegia

• Understand the presentation of patients with these conditions

• Learn to evaluate spasticity and tetraplegia in the upper limb

General

• Allot more than 10 minutes

• See the patient more than once

• Understand the desires of the patient

o What they want different, what they need for function

o Specific tasks

• Confirm reality – can not make them normal

• Enlist the assistance of a therapist

Physical Examination

• Document in and out – stepwise

o Strength testing

• Assess tightness and ROM

o (Shoulder)

o Elbow

o Forearm

o Wrist

o Digits o Thumb

Tetraplegia

• Level of injury – C2-4, C5, C6, C7

o Stabilization of injury

• Muscle strength

o Important for tendon transfers

• Joint ROM

o Need free passive motion

• Goal: improve function, self-care

• Social Support, emotional stability

Stroke/ Injury

• Severity of injury

o Usually no improvement in involved extremity

• Assess Joint ROM

o

• Muscle – volitional control, spasticity

• Goal: Reduce pain, improve hygiene, improve aesthetics

Cerebral Palsy

• Assess control over extremity

o Athetosis

• Joint ROM

o Passive and Active ROM

• Muscle • Muscle spasticity

• Goal: function, hygiene care, improve aesthetics

References

1. Gohritz A, Friden J. Tetraplegia management update. J Hand Surg Am

2015;40(12):2489-2500.

2. Tafti MA, SC Cramer, R Gupta. Orthopaedic management of the upper extremity

of patients. J Am Acad Orthop Surg 2008;16:462-470.

3. Leafblad ND, Van Heest AE. Management of the spastic wrist and hand in

. J Hand Surg Am 2015;40(5):1035-1040.

4. Bunata R, Icenogle K. Cerebral palsy of the elbow and forearm. J Hand Surg Am

2014;39(7):1425-1432.

IC 30: Treatment of Spasticity in the Adult Patient The Treatment of Tetraplegia & Spasticity in the Adult Patient ASSH – Las Vegas September 6, 2019

Allan Peljovich, MD, MPH Shepherd Center; Hand & Upper Extremity Center of Georgia; Atlanta Medical Center Orthopedic Residency Program

I. Principles of management a. Level of injury  Disability i. Complete dependency  C4 ii. Nearly independent  C7 b. Hand & upper extremity function important principle of SCI care c. Classification systems i. ASIA/ISCoS ii. International Classification for of the Hand in Tetraplegia (ICT) 1. Precise and specific to tendon transfer based reconstruction iii. What the systems miss? 1. Spasticity 2. Peripheral innervation/denervation d. Challenges to functional restoration i. is extensive ii. Does everyone qualify? 1. No…estimated 50-60% iii. Timing of reconstruction e. Solutions to the challenges of reconstruction i. Distill hand & upper extremity function into its most critical and basic elements ii. Reconstructive techniques 1. Non-operative 2. Surgical a. Tendon transfer based b. transfer based c. Hybrid tendon/nerve transfer d. Functional electrical stimulation i. External vs internal iii. Timing of surgery 1. Neurological stability

II. Logistics a. Physical examination i. Skin ii. Musculoskeletal 1. Range of motion a. Is it functional range? i. Assessing for contractures 2. Examining wrist tenodesis effect closely iii. Neurological 1. Sensory 2. Motor 3. Any signs of spasticity? a. Prevalence  65% i. Cervical injuries > Thoracic/Lumbar injuries 1. Higher rate of incomplete injuries, i.e., central cord syndrome b. Nature of spasticity in SCI i. Significance 1. Requires pharmacologic therapy  35% 2. Interferes with function  25% 3. Triggers include system insult, i.e., infections, pressure sores, pain, full bladder, injury a. Sudden onset or increase should trigger a search for the underlying cause 4. Natural progression of untreated spastic muscles a. Spastic contracture  myostatic contracture  articular contracture b. Tremendous value in early treatment to maintain muscle length and joint mobility 5. Co-contraction spasticity a. Incomplete injuries b. Particularly difficult to treat c. Presentation i. Shoulder adduction/internal rotation ii. Elbow flexion/forearm supination 1. Elbow flexion contractures limit ability to self-care a. Abilities affected with contractures > 50 degrees when triceps is present, and > 25 degrees when triceps is weak iii. Intrinsic (affects grasp and release) 1. Intrinsic minus MCP extension (extrinsic extensor) spasticity 2. Intrinsic plus MCP hyperflexion spasticity iv. Random isolated muscle 1. FPL 2. EDC 3. Sometimes functionally advantageous, especially if it can be reliably and reproducibly triggered III. Surgical Reconstruction i. Preoperative planning 1. Securing resources 2. Coordinate and plan post-operative therapy ii. Formulating a plan of care 1. Understanding the individual’s needs and goals 2. Determine their current physical status a. ICT level 3. Reconcile 1 & 2 4. Reconstructive priorities a. Elbow extension b. Forearm position c. Wrist extension d. Lateral pinch and release e. Palmar grasp and release f. Digital intrinsics iii. Particulars of tendon transfer-based 1. Achieving elbow extension a. Biceps to triceps tendon transfer b. Posterior deltoid to triceps transfer 2. Achieving wrist extension a. ICT  1 and wrist extension < BMRC 3/5 i. Brachioradialis (Br) to extensor carpi radialis brevis (ECRB) 3. Achieving lateral pinch a. Author’s prioritized pinch pattern for ICT < 3 unless the patient has preference or need for grasp over pinch b. Flexor pollicis longus (FPL) activation for strength i. Tenodesis when ICT  1 ii. BR most commonly used ICT  2 iii. Pronator teres (PT) utilized if BR is alternately used for digital extension or thumb opposition c. Thumb is positioned to meet the lateral index i. In-situ – only if already positions well ii. Trapeziometacarpal (TMC) arthrodesis 1. Stability adds strength to pinch iii. Opposition-adductorplasty 1. Flexor digitorum sublimis (FDS) ring opponensplasty powered by BR 2. ICT  4 3. Better dexterity 4. Typically performed on the dominant thumb in bilateral reconstructions; otherwise TMC arthrodesis is performed. d. Interphalangeal joint is stabilized for strength & effectiveness i. Split FPL to extensor pollicis longus (EPL) tenodesis 1. Author’s preference ii. ELK (extensor pollicis longus-loop-knot) tenodesis 1. Recently described iii. Arthrodesis discouraged as it creates an inflexible digit e. Forearm/wrist level EPL tenodesis if wrist flexion fails to produce sufficient ‘release’ 4. Achieving palmar grasp a. ICT  3 (results better if ICT  4/5) b. Traditionally a 2-stage procedure i. Lateral pinch incorporated ii. Divided into extensor and flexor phases 1. Surgeries separated by 6-12 weeks 2. Can start with either ‘phase’ a. All stabilizing procedures completed during extension phase, i.e., thumb & intrinsics c. Flexor digitorum profundus (FDP) activated for grasp i. Extensor carpi radialis longus (ECRL) typical donor muscle ii. ‘Reverse cascade’ positioning d. Extensor digitorum communis (EDC) activation for ‘release’ i. Forearm-based tenodesis ii. Br as donor 1. PT used for FPL e. Digital intrinsics reconstructed to preserve MCP flexion & avoid less efficient intrinsic minus hand i. Zancolli lasso if digital tenodesis intact ii. ‘House’ tendon graft tenodesis if there is PIP lag with MCP flexion 5. Single-stage pinch and grasp procedure recently described a. ‘Alphabet’ procedure b. Takes advantage of newer, stronger tendon coaptation techniques that allow early activation of transfers. i. Negates the original need to perform these as 2-stage operations ii. Wrist extension 1. ECU is tenodesed to proximally to ulna to centralize otherwise radially deviating wrist extension iii. Lateral pinch 1. Br – FPL 2. TMC arthrodesis 3. Split FPL – EPL 4. EPL tenodesis iv. Palmar grasp (intrinsic function replaces EDC activation for release) 1. House intrinsic tenodesis for index – small 2. ECRL – FDP iv. What about nerve transfers? 1. Role is unclear, but much promise a. Limited data b. No comparative studies c. Unanswered concerns i. Some transfers ‘seem’ to sacrifice potentially critical muscles, i.e., Brachialis nerve branch 1. Biceps is not the primary elbow flexor 2. Precludes use of elbow extension using biceps transfer (strongest elbow extension) ii. Some described nerve transfers inconsistent with vetted concepts – modifications forthcoming? 1. Tip pinch (AIN activation) instead of lateral pinch 2. Utilizing ECRB for donor nerve creates less desirable radial deviation-wrist extension 3. Brachialis donor sacrifices the strongest elbow flexor and could have implications for manual wheelchair use iii. Reliability unclear, and depends upon the specific donor nerve 1. Tendon transfer rupture rates are < 10% a. And, can be salvaged 2. Donor and recipient muscle may be permanently denervated by the time a failure is recognized 2. Nerve transfer advantages a. Greatest advantage is ease of immediate post-operative state. b. Possibility of innervating more than one muscle with one donor i. Cannot be accomplished with tendon transfers ii. Unclear how effective and strong these are c. Splints/casts not needed. i. Normally 3+ weeks for grasp pattern reconstructions; 4-8 weeks for elbow extension 3. Disadvantages relative to tendon transfer a. Reliability may be lower b. The need for a peripherally innervated recipient which is not always present by the time a patient is ready and decides to proceed with surgery. c. Takes year(s) for maximum strength d. Not reversible, and some burn bridges for tendon transfer salvage i. Brachialis as donor ii. ECRB as donor leaves a single wrist extensor 4. Authors believe there is still much to learn and study, and continue to emphasize tendon transfer-based reconstructions. a. Future avenues? i. Utilize nerve transfers to augment reconstructions (hybrid) 1. PIN supinator – PIN EDC/EPL/EIP is a favorite b. Do people need strong elbow extension? i. Curious about nerve transfers to create elbow extension 1. As strong as tendon transfers? 2. As reliable? v. Treating Spasticity 1. By far, the minority of individuals seeking reconstruction 2. Non-operative treatment is optimized a. Regular home program of stretching and motion i. Splint/braces to maintain stretch/positioning b. Oral medication i. ii. iii. iv. c. Neuromuscular blockade i. Onabotulinum-A ii. Phenol d. Intrathecal baclofen 3. Principles of surgical treatment a. Fundamental tendon/nerve transfer principles are maintained i. Donor muscles are strong, non-critical and under voluntary control ii. Recipient muscle/tendon/functions retain sufficient passive mobility and stability iii. Donor are under normal voluntary control, and normal control b. Spastic muscles treated independent of other procedures if the muscles are potential donors or recipients; or, if the posturing limits function i. Foundation for reconstruction is first established in a stand-alone procedure 1. Reconstruction would require second, separate surgery ii. Techniques 1. Muscle lengthening a. Elbow flexor lengthening 2. Muscle release a. Intrinsics b. Extrinsic wrist extensors 3. Consider selective neurectomy for selective intrinsic spasticity iii. Rehabilitation is critical to optimize suppleness 1. Early motion/splinting protocols 2. Transition to night splinting at 3-6 months c. Spastic muscles can be treated concurrent with reconstructions if posturing does not inhibit function, the reconstructions, or the necessary rehabilitation i. Shoulder internal rotation/adduction ii. Elbow flexor lengthening in the setting of lateral pinch procedure iii. Osteotomies secured with rigid internal fixation 1. Forearm osteotomy iv. Tendon coaptations strong enough to allow early motion rehabilitation protocols 4. Example: the forearm supination contracture a. Imbalance between biceps/supinator and paralyzed pronator i. Higher level tetraplegia (ICT 1-3) ii. Metamere subtype influences nature of contracture 1. Small metamere (Type 1) a. Spastic supinators i. Simultaneous elbow flexion contracture b. Presents early in injury 2. Large metamere (Type 2) and Intermediate metamere (Type 3a) with proximal denervation a. Lower paralysis of the pronator teres b. Presents late after injury b. May become fixed as interosseous membrane contracts in the already shorter position of supination i. Therapy will not stretch the membrane c. Limits already impaired upper limb i. Posture is non-functional ii. Shoulder abduction cannot overcome the contracture iii. Leads to wrist extension contracture, also non-functional d. Surgical treatment is often part of a single-stage reconstructive operation associated with tendon/nerve transfers i. Most commonly: forearm osteotomy with interosseous membrane (IOM) release 1. Radius only a. Near junction of pronator/FPL b. Secured with plate/screws c. Statically about 10-20 degrees of forearm pronation d. Set to allow about 50 degrees of pronation 2. Improves resting posture for hand function a. Improves voluntary pronation through combination of shoulder abduction/Br contraction 3. Does not eliminate supination a. Still within a functional range ii. Alternative: distal biceps tendon re-routing transfer with IOM release iii. In rarer case of a fully correctable posture with minimal spasticity, consider weaving the Br around the radius prior to tendon transfer to create a pronation moment

1-78 References

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Instructional Course: IC30: Treatment of Spasticity in the Adult Patient Date: 9/6/2019 Session Time: 3:30 PM - 4:30 PM Moderator: Lindley B. Wall, MD

Talk Title: Nerve Transfers in Tetraplegia

Ida K. Fox, MD Division of Plastic Surgery Washington University School of Medicine VA St. Louis Healthcare System, St. Louis, MO [email protected]

Disclosures:

Current and recent research funding from the Department of Defense office of the Congressionally Directed Medical Research Programs (CDMRP) Fiscal Year 2016 Spinal Cord Injury Research Program (SCIRP) Investigator-Initiated Research Award and from the Craig H. Neilsen Foundation Spinal Cord Injury Research on the Translation Spectrum (SCIRTS) Grant.

The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

1

Nerve transfers may be used in tetraplegia or cervical level spinal cord injury (SCI) to restore function.

A variety of nerve transfers have been described:

Table Nerve transfers for spinal cord injury: a summary of available nerve transfers possible in spinal cord injury with associated reported literature (as published in: Hill EJR, Fox IK: Current best peripheral nerve transfers for spinal cord injury, Plastic and Reconstructive Surgery, 143(1):184e-198e, January 2019. NERVE TRANSFER OPTIONS FOR SPINAL CORD INJURY

Function Nerve transfer Outcomes and Literature

Extension Axillary (teres The teres minor branch of axillary nerve is transferred to the minor branch) to triceps branch of the radial neve to restore elbow extension.

ELBOW triceps branch Bertelli and van Zyl groups report some M4 triceps function without downgrading of shoulder function[1, 2].

Axillary (selective A deltoid branches of axillary nerve is transferred to a triceps deltoid branches) branch of radial nerve. Bertelli shows 5/7 subjects regain M4 to triceps branch function, and 2/7 M3 function.[3]Our group’s results are mixed; further investigation is needed.[4]

Extension Brachialis N to The brachialis branch of musculocutaneous nerve is ECRL branch transferred to ECRL. A case report showed antigravity wrist

WRIST extension at 5 months post-surgery, with resulting tenodesis hand function.[5] Our group has performed two - no long term follow up is available at this time.

Supinator N to Supinator branch of radial nerve is used to transfer to ECU extensor carpi branch. A case report showed improved wrist stability ulnaris (ECU) without antigravity wrist extension. We do not recommend branch this selective transfer; transfer to the PIN as a whole is more useful and the finger extensors, which cross the wrist, can serve to augment weak wrist extension. [4]

Flexion Brachialis N to Brachialis branch of musculocutaneous nerve is transferred AIN/FDS to branches of the median nerve, including anterior

HAND interosseous nerve, or a combination of AIN and the FDS fascicles with promising results from within our group and internationally [2, 4, 6, 7]

Brachioradialis N Similarly, brachioradialis branch of musculocutaneous nerve to AIN may be transferred to AIN.[8] However, the authors prefer to preserve brachioradialis as a donor for salvage tendon transfer options to restore pinch function.

2

ECRB N to AIN This is an attractive option as it provides a shorter distance to target for nerve regeneration and good results have been reported. However, the authors have concerns about harvesting ECRB, which may not downgrade wrist extension power, but will result in more radial deviation on wrist extension, which can negatively affect tenodesis function. This also preclude future salvage tendon transfers using ECRL as a donor to restore finger flexion.[8, 9]

Musculocutanous An historical transfer, with potential for significant to median N downgrading of pronation or wrist flexion.[10, 11] transfer

Extension Supinator N to PIN Supinator branch of radial nerve is transferred to the posterior interosseous nerve, restoring APB, EPL, EIP, EDC function. This transfer is well established and reliable.[2, 12-14] It may, however, overpower the hand closing phase. Also, some may not be candidates for this transfer as the recipient may be in the zone of direct LMN depending on injury pattern[15]. Harvest of the supinator precludes later biceps to triceps tendon transfer as the biceps is the only remaining forearm supinator after supinator nerve harvest.

3

• These nerve transfer coapt a donor nerve that is under volitional control to a nonfunctioning recipient that is not under volitional control.

• The reason for recipient dysfunction varies.[16] In cases where the recipient has an intact lower motor neuron (LMN) and where (UMN) control is ‘blocked’ by the SCI, spasticity may be present. See figure.

• The nerve transfer can effectively restore volitional control and, by the necessity of an iatrogenic lower motor neuron injury (in order to do the coaptation of the donor to recipient nerve, you must cut and splice these together) also treat the spasticity.

4

Examples:

• Transfer of any available nerve branches of brachialis donor to o Nerve to FCR (if spastic) (do not transect if this branch is under volitional control) ▪ Effect—can help rebalance weak wrist extension in the immediate post- operative phase ▪ Of note—may not want to use expendable donor for this less important function o Nerve to FDS and anterior interosseous nerve ▪ Effect—immediately post-operatively may lead to loss of some tone and secondary downgrading of tenodesis driven hand flexor phase function ▪ Of note—can get return of AIN and FDS function after this transfer, can take years; can be subtle and lead to ‘augmented tenodesis’ rather then strong pinch and grasp function ▪ Of note—the presence of spasticity in the corresponding muscles groups seen on exam preoperatively provides valuable information about the status of the LMN if one is considering late (even years post- SCI) nerve transfer

• Transfer of supinator branches to posterior interosseous nerve o Effect— immediately post-operatively may lead to loss of some tone and secondary downgrading of tenodesis driven hand extensor phase function o Of note—the presence of spasticity in the corresponding muscles groups seen on exam preoperatively provides valuable information about the status of the LMN if one is considering late (even years post-SCI) nerve transfer

• Things I have tried but do not recommend: o Nerve transfer to deep motor branch of ulnar nerve ▪ ineffective at restoration of function ▪ did decrease intrinsic muscle spastiticty ▪ I would consider (instead) direct tenotomies of specific tendons ▪ Could consider preop block or botox to help guide surgical decision- making

• There may be other options (theoretically) for nerve transfer to treat spasticity but, unfortunately, the paucity of available donor nerves remains an issue in this population

5

1. Bertelli, J.A., M.F. Ghizoni, and C.P. Tacca, Transfer of the teres minor motor branch for triceps reinnervation in tetraplegia. J Neurosurg, 2011. 114(5): p. 1457-60. 2. van Zyl, N., et al., Upper limb reinnervation in C6 tetraplegia using a triple nerve transfer: case report. J Hand Surg Am, 2014. 39(9): p. 1779-83. 3. Bertelli, J.A., et al., Transfer of axillary nerve branches to reconstruct elbow extension in tetraplegics: a laboratory investigation of surgical feasibility. Microsurgery, 2011. 31(5): p. 376-81. 4. Fox, I.K., et al., Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury: Update and Preliminary Outcomes. Plast Reconstr Surg, 2015. 136(4): p. 780-92. 5. Friden, J. and A. Gohritz, Brachialis-to-extensor carpi radialis longus selective nerve transfer to restore wrist extension in tetraplegia: case report. J Hand Surg Am, 2012. 37(8): p. 1606-8. 6. Fox, I.K., et al., Use of peripheral nerve transfers in tetraplegia: evaluation of feasibility and morbidity. Hand (N Y), 2015. 10(1): p. 60-7. 7. Mackinnon, S.E., A. Yee, and W.Z. Ray, Nerve transfers for the restoration of hand function after spinal cord injury. J Neurosurg, 2012. 117(1): p. 176-185. 8. Bertelli, J.A. and M.F. Ghizoni, Nerve transfers for restoration of finger flexion in patients with tetraplegia. J Neurosurg Spine, 2017. 26(1): p. 55-61. 9. Bertelli, J.A., et al., Transfer of the distal terminal motor branch of the extensor carpi radialis brevis to the nerve of the flexor pollicis longus: an anatomic study and clinical application in a tetraplegic patient. , 2012. 70(4): p. 1011-6. 10. Benassy, J., Transposition of the musculo-cutaneous nerve upon the median nerve. Case report. Med Serv J Can, 1966. 22(7): p. 695-7. 11. Kiwerski, J., Recovery of simple hand function in tetraplegia patients following transfer of the musculo-cutaneous nerve into the median nerve. Paraplegia, 1982. 20(4): p. 242-7. 12. Bertelli, J.A. and M.F. Ghizoni, Nerve transfers for elbow and finger extension reconstruction in midcervical spinal cord injuries. J Neurosurg, 2015. 122(1): p. 121-7. 13. Bertelli, J.A., et al., Transfer of supinator motor branches to the posterior interosseous nerve to reconstruct thumb and finger extension in tetraplegia: case report. J Hand Surg Am, 2010. 35(10): p. 1647-51. 14. Cain, S.A., et al., Review of Upper Extremity Nerve Transfer in Cervical Spinal Cord Injury. J Brachial Plex Peripher Nerve Inj, 2015. 10(1): p. e34-e42. 15. Fox, I.K., et al., The Use of Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury. PM R, 2018. 10(11): p. 1173-1184 e2. 16. Coulet, B., Y. Allieu, and M. Chammas, Injured metamere and functional surgery of the tetraplegic upper limb. Hand Clin, 2002. 18(3): p. 399-412, vi.

6

Treatment of Spasticity in the Adult Patient: Cerebral Palsy in the Skeletally Mature

Michelle G. Carlson, MD Hospital for Special Surgery

Disclosures

• No relationships with commercial interests related to this presentation existed during the past 12 months.

Upper Extremity Challenges in CP

• Evaluation • Surgery • Rehabilitation

1 History

Involvement Other Rx Hemi vs Quad Botox, Surgery

Type of Tone Medical History spastic, athetoid Sz, MR, true CP low

Examination: ROM

• PROM • AROM • Functional ROM • Position at Rest • Associated Reactions

Examination: Sensibility

• Stereognosis • 2 point Discrimination • Neglect

2 Examination: Function • Functional Use • Jebson • Quest/Melbourne • SHUE • ADL Scale • EMG • Videotape

EMG: Phasic Control Norm Patient

EMG: Functional Grading Norm Patient

3 Goals for Surgical Intervention

Aesthetics Hygiene

Functional Improvement

Guidelines for Surgical Intervention

• Voluntary Hand Use • Sensibility • IQ • Athetosis

Athetosis

• Look for predominant deformity

4 Options for Surgical Intervention

Release / Lengthen Muscle Tenodese

Transfer / Reroute

Joint Arthrodese

Develop Operative Plan

Shoulder Elbow

Wrist Hand

Evaluating the Patient: The Four Step Program Revisit with Patient to go over operative plan - home Therapist input appreciated Conference with Therapist and Surgeon on video Videotaping +/- Dynamic EMGs Initial Consultation

5 Impact of Video Review on Surgical Procedure Determination for Patients with Cerebral Palsy JHS 34A: 1225 (2009)

Michelle Carlson, M.D., Laura Spincola EdD, CHES, Jennifer Lewin, OTR/L, Erin McDermott, B.A.

Cost of Video

• Therapy Time: 1 – 1.5 hours • Cost: $225 • Surgeon Time: ½ hour

Impact of Video

• Three quarters of all patients (68 patients, 72 %) had a change from video evaluation that carried through to surgery. • Only 26 patients (28 %) did not have a change in the final surgical plan based on video evaluation • Most common changes are for the wrist, thumb and digits

6 How about Botox ?

Electrical Stimulation ?

Constraint Induced Therapy ?

Surgical Treatment of the Upper Extremity in Cerebral Palsy

Elbow

• Static Contracture • fixed contracture > 40 deg

• Dynamic Posture • fixed contracture < 40 deg • dynamic posture > 40 deg

7 Elbow Static Contracture Treatment Options

• Musculocutaneous Neurectomy • Elbow Flexor Lengthening • Flexor-Pronator Slide

Elbow Static Contracture

Lacertus Fibrosis Transection

8 Biceps Z-Lengthening

Brachialis Myotomy

Brachioradialis Release

9 Post-Release

Intra-operative Extension

Post Operative Range of Motion

10 PRE-OP POST-OP

Elbow

• Dynamic Posture

11 EMG: Functional Grading Norm Patient

Fractional Lengthening of the Elbow Flexors • Transverse antecubital incision

• Lacertus fibrosus transected • Fractional lengthening of the biceps

12 • Biceps retracted • Fractional lengthening of brachialis • Proximal Brachioradialis release

PRE-OP POST-OP

PRE-OP POST-OP

Passive Flexion 144 Passive Flexion 144 Active Flexion 141 Active Flexion 137

13 PRE-OP POST-OP

Passive Extension -8 Passive Extension -3 Active Extension -23 Active Extension -7

Active Active Passive Passive Ambulation/ Surgical Flexion ExtensionMean Flexion Extension Posture Angle Author N Age Indications Surgical Procedure Pre Post Pre Post Pre Post Pre Post Pre Post lacertus fibrosis transection, Mital MA flexion biceps z-lengthening, brachialis most JBJS 1979 contracture fractional lengthening, patients 32 12y >30° capsulotomy 98° 95° -48° -10° 80° "improved"

Manske PR, flexion Langewisch KR, posture Strecker WB, angle >50° lacertus fibrosus transection, Albrecht MM 8.7y with no brachialis fractional JPO 2001 (20- fixed flexion lengthening, denuding biceps 42 209m) contracture tendon 133° 133° 43° 27° 104° 55°

fixed partial lengthening of the contracture biceps and brachialis, proximal Carlson MG, Hearns 57 10y <45° release of the bracioradialis 141° 137° -23° -7° 144° 144° -8° -3° 89° 32° Early KA, Inkellis EI, full elbow release with biceps z- Leach ME fixed lengthening, partial brachialis JHS 2012 contracture myotomy, brachioradialis 17 14y ≥45° proximal release 142° 123° -77° -39° 144° 141° -59° -22° 96° 45°

Dy CJ, Pean CA, Hearns KA, Swanstrom MM, Late Janowski JC, fixed partial lengthening of the Carlson MG contracture biceps and brachialis, proximal JHS 2013 23 9y <45° release of the bracioradialis 141° 133° -23° -11° 144° 143° -7° -5° 88° 25°

Effect of Age on Contracture • Significant and direct correlation between increasing age and degree of preop elbow contracture

• Patients > 12 years old were 5.5 times as likely to have a fixed contracture (passive extension ≥45 ) than patients younger than 12 years (OR, 5.50; 95% CI, 1.59-18.97) ⁰ • Average age of patients requiring full elbow release was higher than those who had a partial lengthening (14 vs 10 years)

14 Forearm Pronation Deformity

Active supination < neutral, Passive supination limited Pronator Release No active supination No active pronation ? Pronator Rerouting No active supination Good active pronation

Pronator Release

Pronator Rerouting

15 Pronator Rerouting

Modified Sugar Tong

• Addresses the forearm, wrist and thumb

Wrist Flexion Deformity

• Weak wrist extensors • Tight wrist flexors • Wrist capsular contracture

16 Wrist Flexion Deformity

Static static flexion contracture >45

Dynamic no static contracture active extension < 0

Functional active extension to > 0 dynamic posture < 0

Static Wrist Flexion Deformity

• Wrist Fusion • Epiphyseal, with PRC, wedge resection

Post-op Pre-op

Dynamic Wrist Flexion Deformity

• Transfer to Improve Extension • FCU to ECRB • ECU to ECRB • PT to ECRB • BR to ECRB

17 FCU to ECRB

Use the Tendon Stripper!

FCU to ECRB

18 Functional Wrist Flexion Deformity

• Release to Improve Extension • FCU

DIGITS

• Extension Testing • Active and Passive with wrist in neutral

Tenodesis

19 Weak Digital Extension

• FCU to EDC

Flexor Tendon Tightness

Fractional Tendon Lengthening

20 Fractional Flexor Tendon Lengthening

Thumb – in – Palm Deformity

• Thumb intrinsic release • Abductorplasty / Extensorplasty • EPL rerouting • BR to EPB (or rerouted EPL) • MP capsulodesis

21 Adduction Release

• Double opposing Z-plasty

Adduction Release

• Release of Adductor tendon from insertion at metacarpal

Adduction Release

• Subperiosteal release of first dorsal interosseous • Adductor reattachment in midshaft of metacarpal

metacarpal adductor

22 Creation of Pulley from Abductor Slip

• Normal EPL

• Rerouted EPL

Brachioradialis to EPB

23 Web Space Improvement

• Adductor release • Passive Web 3 deg • Active Web 20 deg

• Abduction augmentation • Passive Web 17 deg • ActiveWeb 37 deg (p<0.001)

EPL Rerouting

Surgical Treatment of Swan-neck Deformity in Hemplegic Cerebral Palsy (no MP flexion) Carlson, et al: JHS 32A (9) 2007

24 Literature Review

• Sublimis tenodesis • Swanson JBJS 1960

• Lateral band sectioning/displ • Goldner JBJS 1953

Courtesy of Ann Van Heest, MD

Central Slip Tenotomy (Carlson et al, JHS 2007)

Central Slip Tenotomy

• PIP joint pinned in 10 degrees of flexion with 0.035 kirschner wire for four weeks • Active extension begun at four weeks with figure of eight splint

25 Change in Deformity 16 14 12 10 # fingers 8 6 Pre-op 4 Post-op 2 Pre 38 (+/-10.5) 0 40 30 20 10 0 -10 Post 6 (+/-10) Diff 32 (+/- 14) Swan-neck Deformity p<0.001 (degrees)

Post-operative Deformity

Deformity < 10 degrees (92%) Deformity > 10 degrees (8%)

Pre-op

Post-op

Incision

26 Intrinsic Fractional Lengthening (for MP flexion)

• Incision distal palmar crease • Fractional lengthening of intrinsics

Carlson EJ, Carlson MG. Treatment of swan neck deformity in cerebral palsy. J Hand Surg Am. 2014 Apr; 39(4):768-772

27 ICL #30 Treatment of Spasticity in the Adult Patient: Treatment of Stroke and TBI Contractures and Spasticity

Michael S. Bednar, M.D. Loyola University – Chicago

1) Introduction a) Stroke i) Incidence: 1/1,000 with 250,000 survivors per year ii) After first CVA, survival (1) 73% at year 1 (2) 39% at year 5 (3) 11% at year 10 iii) >2 million people in USA with permanent neurologic deficits 2nd to CVA in USA b) i) Incidence: 1.5 million Americans per year ii) 50,000 die iii) 80% have good to moderate neurologic recovery iv) 33% require assistance with ADL's >1 year after injury v) Most injuries occur in patients <45 yo, life span is normal vi) Estimated life time cost of TBI treatment - $56 billion in 1995 2) Impairments from Stroke a) Motor i) from 24 hours to several weeks (1) Longer times = poorer prognosis for functional recovery ii) Muscle tone increases (1) Stronger for elbow, wrist and finger flexors, forearm pronator (2) Increased tone leads to increased spasticity (a) (b) (3) Voluntary movements return first in proximal muscles (shoulder to hand) (4) Grading muscle control (from Keenan in Green's Operative Hand Surgery, 6th ed)

Grade Motor Control Description

1 Flaccid Hypotonic, no active motion

2 Rigid Hypertonic, no active motion

3 Reflexive mass pattern Mass flexion or extension in (synergy) response to stimulation

4 Volitional mass pattern Patient-initiated mass flexion or extension movement

5 Selective with pattern Slow volitional movement of overlay specific joints; physiologic stress results in mass action

6 Selective Volitional control of individual joints

(5) Require Grade 5-6 control for functional use b) Sensory i) Sensory impairment is poor prognostic sign, even with motor is minimally involved ii) Lesions in parietal lobe lead to lack or awareness of involeved side iii) Disturbances in visual perection may lead to inability to perform ADL's c) Cognitive i) Decrease mentation, learning ability, and short term memory lead to lack of attention span and little motivation for recovery 3) Impairments from TBI a) Missed injuries i) TBI usually part of multisystem trauma ii) 11% incidence of missed fractures, most common in upper extremity iii) 34% incidence of missed peripheral nerve injuries iv) 10% incidence of brachial plexus injury b) Aggitation i) As patients emerge from coma, period of confusion and poor compliance c) Motor i) Upper motor neuron syndrome (1) Increased muscle tone and rigidity (2) Synergy motion 4) Severe spasticity leads to: a) Joint contractures b) Pressure sores c) Skin hygiene d) Malunion of healing fractures e) Joint subluxation f) Peripheral neuropathy i) Carpal tunnel syndrome ii) Cubital tunnel syndrome g) Heterotopic ossification (TBI) 5) Role for surgical treatment a) Wait for neurologic recovery i) 12 months in Stroke ii) 18 months in TBI b) Treat spasticity earlier with i) Therapy and splinting ii) Oral medications and baclofen pump iii) Phenol nerve blocks and injections (allows assessment of antagonist muscles) c) Major functional issues i) Elbow flexion (1) Volitional control (a) Biceps (i) Dynamic deformity - proximal musculotendinous lengthening of long and short heads of biceps (ii) Static deformity – Z lengthening (b) Brachialis - musculotendinous lengthing (c) Brachioradialis - musculotendinous lengthing (2) No volitional control (a) Biceps – distal tendon release (b) Brachialis – partial to complete release (c) Brachioradialis – release from origin (3) Ulnar nerve – consider transposition ii) Forearm pronation (1) Tendon lengthening or release (2) Forearm osteotomy iii) Wrist flexion (1) Evaluation (a) Assess wrist and finger flexors by assessing wrist extension tightness with hand passively held in a fist versus fingers extended (b) Assess FDP from FDS tightness by examining DIP flexion (c) Assess volitional control of flexors and extensors (2) Treatment (a) Botulinum toxin injections to assess role of spastic muscles and determine strength of antagonistic muscles (b) Fractional lengthening of PL, FCR, FCU (c) For severe wrist flexion interfering with hygiene and putting on clothes, PRC and wrist fusion with plate fixation iv) Clenched fist (1) Evaluation (a) Assess FDP from FDS tightness by examining DIP flexion (b) Assess volitional control of flexors and extensors (present in 50% of patients with spastic clenched fist) (c) Assess for intrinsic spasticity (2) Treatment (a) Median nerve block at elbow followed by ulnar nerve block at elbow (b) Botulinum toxin injections, especially for intrinsics muscles (c) Fractional lengthening for patients with volitional flexor control (d) Sublimis to Profundus for patients with no volitional control and hygiene issues of the palm (e) Intrinsic lateral band release and ulnar motor neurectomy v) Thumb in palm (1) Evaluation (a) Assess both FPL and thenar muscles (2) Treatment (a) Ulnar nerve block at wrist to assess involvement of thenar muscles (b) Botulinum toxin injections and splinting (c) FPL lengthening and thenar muscle slide

References

Adekoya N et al. Surveillance for traumatic brain injury deaths—United States, 1989- 1998,MMWR Surveill Summ 51:1-14,2002.

Botte M J et al. Approaches to senior care #2: orthopaedic management of the stroke patient. Part I. Pathophysiology, limb deformity, and patient evaluation,Orthop Rev 17:637-647,1988.

Botte M J et al. Approaches to senior care #3: orthopaedic management of the stroke patient. Part II. Treating deformities of the upper and lower extremities,Orthop Rev 17:891-910,1988.

Keenan MA: Management of the spastic upper extremity in the neurologically impaired adult. Clin Orthop. 233:116-125 1988

Keenan MA: Surgical decision making for residual limb deformities following traumatic brain injury. Orthop Rev. 17:1185-1192 1988

Keenan MA, et al.: Results of fractional lengthening of the finger flexors in adults with upper extremity spasticity. J Hand Surg [Am]. 12:575-581 1987 Keenan MA, et al.: Results of transfer of the flexor digitorum superficialis tendons to the flexor digitorum profundus tendons in adults with acquired spasticity of the hand. J Bone Joint Surg Am. 69:1127-1132 1987

Waters RL, Keenan MA: Surgical treatment of the upper extremity after stroke. Chapman M Operative Orthopaedics