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Procedures that are available to restore function after stroke include the selective peripheral neurotomy to reduce spasticity, tendon lengthening, tendon transfers, and even at times nerve transfers. When a patient presents to determine whether they are a candidate for surgery, there are several assessments that must be undertaken. First is we must determine whether or not the patient has full passive range of motion across the joints we're looking to recover. If a patient is limited by a fixed shorting that is a muscle and tendon group that has shortened and can no longer be straightened to its full length, a different procedure must be considered. The only way to achieve that full length then is often the lengthening of that tendon or the complete dividing of that tendon. If a patient can pass the we'd be moved through the entire full passive range of motion, we then try to determine the efficacy of cutting the nerve or lengthen the tendon to simply reduce spasticity. This can sometimes be determined by injecting local anesthetic at the site of the nerve or muscle to relax that muscle temporarily. It could also be determined by using botulinum toxin or botox into the muscle we're looking to relax. By doing so, we can model what the intervention will produce by causing relaxation temporarily of that muscle in seeing how this affects the overall functioning of the limb. Additionally, sometimes we can use EMG or nerve testing studies by placing needles into the muscles of interest in finding out whether these muscles are contributing to the attempted function or resisting the attempted function. If the muscles are resisting the attempted function, then we determined that these are muscles that should be downgraded or eliminated if the muscles are contributing to the intended function that we want to make sure that these move well in her unimpeded. In certain cases, we determine that there are muscles that have functioned and it can be controlled well by the patient, but they aren't achieving a useful movement. For example, turning the palm up and turning the palm down can sometimes be maintained that a patient after a stroke, but they don't have the ability to open and close the fingers. If we determined this to be the case, sometimes we can use these nerves in the nerve transfer so that the function now is moved to something that is much higher priority. That is a grasp and release of the hand. So the patient's function that was not useful now becomes a function that is useful. These procedures are all used together in concert to achieve the best function of a limb that we can accomplish.
Procedures that are available to restore function after stroke include the selective peripheral neurotomy to reduce spasticity, tendon lengthening, tendon transfers, and even at times nerve transfers. When a patient presents to determine whether they are a candidate for surgery, there are several assessments that must be undertaken. First is we must determine whether or not the patient has full passive range of motion across the joints we're looking to recover. If a patient is limited by a fixed shorting that is a muscle and tendon group that has shortened and can no longer be straightened to its full length, a different procedure must be considered. The only way to achieve that full length then is often the lengthening of that tendon or the complete dividing of that tendon. If a patient can pass the we'd be moved through the entire full passive range of motion, we then try to determine the efficacy of cutting the nerve or lengthen the tendon to simply reduce spasticity. This can sometimes be determined by injecting local anesthetic at the site of the nerve or muscle to relax that muscle temporarily. It could also be determined by using botulinum toxin or botox into the muscle we're looking to relax. By doing so, we can model what the intervention will produce by causing relaxation temporarily of that muscle in seeing how this affects the overall functioning of the limb. Additionally, sometimes we can use EMG or nerve testing studies by placing needles into the muscles of interest in finding out whether these muscles are contributing to the attempted function or resisting the attempted function. If the muscles are resisting the attempted function, then we determined that these are muscles that should be downgraded or eliminated if the muscles are contributing to the intended function that we want to make sure that these move well in her unimpeded. In certain cases, we determine that there are muscles that have functioned and it can be controlled well by the patient, but they aren't achieving a useful movement. For example, turning the palm up and turning the palm down can sometimes be maintained that a patient after a stroke, but they don't have the ability to open and close the fingers. If we determined this to be the case, sometimes we can use these nerves in the nerve transfer so that the function now is moved to something that is much higher priority. That is a grasp and release of the hand. So the patient's function that was not useful now becomes a function that is useful. These procedures are all used together in concert to achieve the best function of a limb that we can accomplish.
There are two primary effects to these procedures. One is the muscle that is being targeted has it's direct and immediate effect and the other is a more global effect of relaxing the entire limb or even relaxing the entire hemiplegic body to some degree. For example, when we undertake a tibial neurotomy to straighten the foot out and cause that the heel to land on the ground when the patient is walking, they'll often also experienced some relaxation of the proximal muscles. The leg swings easier, they can stand from a chair easier and they have less difficulty walking than they did previously from the proximal aspect, not just the distal aspect. Because of this, we like to undertake these procedures in a stepwise fashion. We will do the most egregious or the most troublesome muscle group first and then look at the global effect that it's accomplished over the next three to six months. Once the patient is plateaued in their recovery. Once again, we'll move on to the second step or the second most problematic muscle group and repeat the same process. Because of this, a patient may undergo four to six procedures before we've completed accomplishing everything we can with our functional recovery.
The same dysfunction that takes place in the foot can take place further up the leg, so sometimes the patient's legs, will scissor. That is the adductors where muscles that pull the legs towards one another, can be overactive making it difficult to swing the leg in front. We can do the same procedure on the nerve, supplying those adductor muscles, trimming it back, relaxing that spasticity, and creating a normal swing phase of the gait so they can walk better. These procedures aren't limited just to the leg. These procedures are available to the arm and hand. Typically, the function of the arm and hand after a stroke is characterized by adduction and internal rotation of the shoulder. That is the arm is pulled into the side and turned in so the forearm is against the abdomen. At the same time the elbow is flexed, the wrist is flexed, pronated, that is the hand turned down towards the floor and the fingers are clenched. Sometimes there is some degree of function. The patient is able to open the fingers or extend the arm a little bit, but some of the muscles are interfering with that action. We can usually identify which muscles these are and find the branches to them and trim them back and eliminate this dysfunction. Sometimes the patient's arm and hand can be completely dysfunctional where there is no active motor control at all. When this is the case, often hygiene is a problem or even simple daily tasks such as getting clothes on the arm. When this is the case, we can relax these muscles or these nerves entirely to allow the arm to fall down to the side and a more relaxed position making placing clothes or washing the arm, cleaning the arm, much more simple. When we find that the patient has some underlying motor control, they can clench the hand, they can flex the elbow, yet other muscles are getting in the way, this is usually an ideal candidate to find a dysfunctional muscles, trim them back and achieve much more normal function, once again. So patient who had no ability to pick up a fork or bring a cup to their mouth after these procedures, they often can regain that type of control.
These procedures aren't limited just to the leg. These procedures are available to the arm and hand. Typically the function of the arm and hand after a stroke is characterized by adduction and internal rotation of the shoulder. That is the arm is pulled into the side and turned in so the forearm is against the abdomen. At the same time the elbow is flexed, the wrist is flexed, protonated that is the hand turned down towards the floor and the fingers are clenched. Sometimes there's some degree of function, the patient is able to open. The fingers are extended the arm a little bit, but some of the muscles are interfering with that action. We can usually identify which muscles these are and find the branches to them and trim them back and eliminate this dysfunction. Sometimes the patient's arm and hand can be completely dysfunctional where there is no active motor control at all. When this is the case, often hygiene is a problem or even simple daily tasks such as getting clothes on the arm. When this is the case, we can relax these muscles are these nerves entirely to allow the arm to fall down to the side and a more relaxed position making place in clothes or washing the arm and cleaning the arm much more simple. When we find that the patient has some underlying motor control, they can clench the hand, they can flex at the elbow, yet other muscles are getting in the way, this is using an ideal candidate to find the dysfunctional muscles, trim them back and achieve much more normal function once again. So patient who had no ability to pick up a fork or bring a cup to their mouth, after these procedures, they often can regain that type of control.
When a patient suffers hemiplegia the body can do some recovering on its own over time. The brain develops what's called plasticity and it can find other pathways to accomplish some of the tasks that had accomplished formerly. And sometimes patient can recover the ability to grasp and release the hand to reach the mouth to walk better. But usually this plateaus or reaches a final function that still is far less than what they originally had. When this occurs, typically surgical procedures are available to get an additional degree of function. So a patient's walking after Hemiplegia usually is stiff, spastic, he foot years use turned in, the toes are curled, and the typical answer for this as an AFO brace or an ankle foot orthosis. The patient's foot of strapped into this to hold the ankle up or at a functional position and then the shoes put on over the top of the brace. This doesn't correct the underlying problem in this means the patient will be relying on this brace for the rest of their lives. Sometimes function still exists in the muscles that should bring the foot up and bring the foot out and extend the toes, but they're overpowered by the muscles that push the foot down, turn the foot in, and curl the toes. A simple procedure to correct. This is called the selective peripheral neurotomy. A patient who has this kind of tone should undergo a trial of botox or botulinum toxin. Botox can be injected into those muscles to push the foot down or turn the foot in and sometimes relieve some of that hyperactivity in those muscles to balance the function out. Oftentimes botox is not sufficient because these muscles are quite large muscles and a very large doses required. Instead of botox or even following botox, the procedure, the selective peripheral neurotin can accomplish the same goals in as long lasting. In our practice. We often use botox to show the patient what we are trying to achieve with surgery. We will inject the muscles, provide a little bit of relaxation, and let them know that surgery would cause even more robust relaxation and be permanent. Once they decide that this is what they would like to have done, a surgical procedure what lasts a little over an hour is performed when this is the foot and walking off, and this is just behind the knee, we open, identify the nerve and the branches that are providing stimulus to the muscles that are overactive are trimmed back. We can usually cut these back by say two thirds or even four fifths, maintaining control of the muscle, but reducing that hyperactive tone substantially. When this is done, that foot will land flat on the floor once again, and many patients can graduate from that brace and walk independently.
Any patient who is left with Hemiplegia who's not recovered full function in the arm or leg is probably a candidate for some of these procedures. The risk must be weighed against the benefits. If a patient is very functional with the arm, but yet unhappy with the fact that the increased tone persists, sometimes we recommend they continue with therapy and botox and not undergo surgical procedure. If there is a significant impediment to function, I think that surgical procedures are usually the best way to achieve the increased degree of function that they're looking for.
Some patients who would not be a candidate for these procedures would be those with severe, intractable pain, those are the significant medical co-morbidities, those in whom it's unsafe to come off their blood thinning medications for a short period of time, and those patients who are not willing to participate in the significant rehabilitation and physical therapy required to achieve the results of these procedures.
Risks of undertaking such procedures are one causing excessive weakness. Sometimes we have to take quite a bit of nerve to reduce the spasticity. And in doing so we may relax the muscles so much that a patient feels a bit unsteady on their feet or like they can't perform some of the tasks they did previously. Usually this resolves with therapy in a patient is ultimately happy with the outcome. A patient that has had a stroke or brain injury is often under the care of a neurologist who is managing the cause of the prior stroke. This may involve blood thinners. This may involve an entity in the body that can predispose them to another stroke in the future. It is important for your reconstructive neurosurgeon to work together with a neurologist or whoever's following the care of the stroke to make sure they come up with a plan that will keep the patient safe from any additional strokes or other problems in the future. The patient must be safe to come off their blood thinners for the period of time required to undertake the surgery in the early recovery, and the patient must not be at risk for having further strokes by undergoing anesthesia.
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