Short-term Outcomes of Combined Fractional Lengthening and Hyperselective Neurectomy for Triceps Spasticity in Upper Motor Neuron Injury
Lainey Grey Bukowiec, MD1, Kitty Y Wu, MD1 and Peter C Rhee, DO2, (1)Mayo Clinic, Rochester, MN, (2)Orthopaedic Surgery, Mayo Clinic, Rochester, MN
Introduction: Triceps spasticity secondary to upper motor injuries can be functionally limiting and is often missed or only unmasked when the spastic elbow flexors are first addressed. We hypothesized that a novel combined approach, with fractional lengthening (FL) of the long and lateral heads and hyperselective neurectomy (HSN) of the medial head, would decrease triceps spasticity and improve elbow active and passive range of motion without decreasing triceps strength.
Materials & Methods: Patients undergoing combined FL and HSN for triceps spasticity from a single tertiary referral center were retrospectively reviewed. Patient demographics, pre-operative Modified Ashworth Score (MAS) for spasticity, range of motion, concomitant procedures, and complications were recorded. The primary outcomes were post-operative MAS score and elbow range of motion.
Results: 10 patients (six male, four female, mean age of 48.5 years) with varying underlying diagnoses (two spinal cord injuries, four cerebrovascular accidents, two vascular malformations, one anoxic brain injury, one brain tumor) underwent combined FL and HSN procedure for triceps spasticity. The mean time of surgery from diagnosis was eight years (range one to 24 years) and mean follow-up was 10.2 months (range: six to 16 months). Nine of 10 patients also had concurrent surgery to address the spastic elbow flexors. The mean total active elbow arc of motion improved from 78° pre-operatively to 111° post-operatively (p = 0.006). There was a mean gain of 17.5° of active elbow flexion, from 103° pre-operatively to 120.5° post-operatively (p = 0.01). Nine of 10 patients had no residual triceps spasticity (MAS 0) post-operatively compared to a mean pre-operative triceps MAS of 2.75. There was one major complication in a patient with a wound dehiscence from a concurrent procedure in the forearm that required subsequent surgical intervention and one minor complication of forearm cellulitis from a concurrent procedure treated with antibiotics. Importantly, no patients lost elbow extension function post-operatively.
Conclusions: This procedure effectively reduces triceps spasticity in short-term follow-up, with improved post-operative MAS scores, elbow arc of motion and active flexion. This procedure should be examined in a larger population to more definitively determine risks and benefits associated with combined FL and HSN.
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