TIBIAL NERVE SELECTIVE NEUROTOMY FOR THE TREATMENT OF THE SPASTIC FOOT

  • 1 January 1985
    • journal article
    • research article
    • Vol. 31  (3) , 189-197
Abstract
A large number of patients suffering from various neurological diseases remain disabled because of spastic disorders in their foot. These disorders which are responsible for abnormal postures and painful disturbances for walking and standing, can be corrected by an effective procedure: the so-called Selective Neurotomy of the Tibial Nerve (T.N.), developed in its modern form by Gros in 1972. The procedure aims at sectioning the T.N. branches corresponding to the muscles, the spasticity of which is considered harmful, i.e., the soleus (and/or gastrocnemius) nerves for equinus and ankle clonus, the posterior tibialis branch or varus, and the flexor fascicles for tonic flexion of the toes. The present series consists of 37 operations performed 25 times unilaterally and 6 bilaterally in 31 patients, 17 to 68 yr old (39 on average). In 11 patients spasticity was from spinal cord origin and in the 20 others from vascular or traumatic cerebral damages. The spastic disorders, installed for 2 to 17 yr (4 on average), were due to 1, several or all the following components: equinus, ankle clonus, varus, flexion of the toes. Surgery obtained complete suppression of the disabling spastic components, total pain relief and consequently improvement of the residual voluntary movements by achieving balance between agonist and antagonist muscles, in 33 out of the 37 cases. For all these patients, the beneficial effects were permanent, with 1 to 8 yr follow-up (2.5 yr on average). The 3 incomplete results and the failure were due to insufficient nerve sections. Three patients complained transient hyperesthesia and 2 others reversible hypoesthesia in their foot. In 2 other patients with a tonic flexion of the toes, a certain degree of sensory loss at the plantar skin remained permanent. These complications were considered related to operative injury of the sensory fascicles at the time of the dissection of the motor fascicles inside the distal part of the T.N. nerve trunk at the level of the soleus arcade. They were only observed at the very beginning and since then did not reoccur. Selective Neurotomy of the T.N. is only indicated after intensive and prolonged reeducation programs as well as medical treatments have failed. But it must take place before onset of irreducible articular disturbances and musculo-tendinous retractions; otherwise the effects would be incomplete or the patient would need complementary orthopedic corrections.

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