This presentation summarizes the problem of spastic hand and arm problems in patients who have had strokes or traumatic brain injury. Some surgical considerations are reviewed for specific problems.

1. Stroke and Brain Injury Spasticity - Surgical Considerations
www. noelhenley.com

2. STROKE AND
BRAIN INJURY
SURGICAL
CONSIDERATIONS
C. NOEL HENLEY, MD
OZARK ORTHOPAEDICS - HAND AND ARM SURGERY
August 24th, 2010

3. SUMMARY
defining the problem
phases or periods of recovery
surgery as a rehabilitation tool
surgery - timing and expectations
examples of surgical options for the spastic hand
Stroke and Brain Injury Spasticity - Surgical Considerations
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4. STROKE
SCOPE OF THE PROBLEM
cause of 200,000 deaths per year - U.S.
250,000 survivors each year
thrombosis = most common cause
arteriosclerosis = most important risk
factor
Stroke and Brain Injury Spasticity - Surgical Considerations
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5. STROKE
IMPAIRMENT
cognitive
clinically similar to senility/dementia
aphasia - cannot understand instructions
apraxia - cannot perform a previously learned action
Stroke and Brain Injury Spasticity - Surgical Considerations
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6. STROKE
IMPAIRMENT
sensory
loss of touch sensation, vision disturbances; range from
mild to severe
motor
period of flaccid paralysis - followed by increased muscle
tone
voluntary movement returns in proximal muscle groups and
moves distally
Stroke and Brain Injury Spasticity - Surgical Considerations
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7. BRAIN INJURY
SCOPE OF THE PROBLEM
approximately 500k new cases each
year in the US
11% of these will die shortly after
injury
good or moderately good neurologic
recovery for 80% of the survivors
mostly occurs in patients younger than flickr.com - artfulblogger
45
Stroke and Brain Injury Spasticity - Surgical Considerations
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8. BRAIN INJURY
PREDICTORS OF OUTCOME
age
Glasgow Coma Scale
duration of coma
brain stem involvement
duration of post-traumatic confusion
Stroke and Brain Injury Spasticity - Surgical Considerations
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9. BRAIN INJURY
ROLE OF THERAPISTS IN SUSPECTING
FRACTURES/INJURIES
missed fractures
missed peripheral nerve injuries
early fixation/repair may prevent substantial disability
later on
Stroke and Brain Injury Spasticity - Surgical Considerations
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11. PERIODS/PHASES OF
RECOVERY

12. STROKE/BRAIN INJURY
PERIOD OF ACUTE INJURY
goal is medical stabilization
therapists may be involved early for
splinting the hand, wrist or elbow to
prevent deformity
flickr.com - rafahkid
Stroke and Brain Injury Spasticity - Surgical Considerations
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13. STROKE/BRAIN INJURY
PERIOD OF PHYSIOLOGIC RECOVERY
may last for up to 18 months
patient commonly in a rehabilitation facility
maximum motor control usually regained by 6 months
Stroke and Brain Injury Spasticity - Surgical Considerations
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14. STROKE/BRAIN INJURY
PERIOD OF PHYSIOLOGIC RECOVERY
dangers of spasticity
may prevent adequate joint ROM
interferes with joint and limb positioning
force required for PROM may be too painful in the face of
spasticity
peripheral neuropathies may result from pressure or
positioning (CTS, CuTS)
Stroke and Brain Injury Spasticity - Surgical Considerations
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15. STROKE/BRAIN INJURY
PERIOD OF PHYSIOLOGIC RECOVERY
temporary control of spasticity and preventing
complications is a major focus of treatment in this
subacute phase
Stroke and Brain Injury Spasticity - Surgical Considerations
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16. STROKE/BRAIN INJURY
PERIOD OF FUNCTIONAL ADAPTATION TO
RESIDUAL DEFICITS
usually neurologically stable after six months
definitive decisions on surgery or bracing can be
made
time of greatest contribution by the reconstructive
surgeon and post-op therapy
Stroke and Brain Injury Spasticity - Surgical Considerations
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17. STROKE/BRAIN INJURY
PERIOD OF FUNCTIONAL ADAPTATION TO
RESIDUAL DEFICITS
weigh early surgery with risks of waiting on improved
motor control
more contractures
osteopenia
nerve compression
muscle atrophy
immobility/pressure sores
Stroke and Brain Injury Spasticity - Surgical Considerations
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18. GENERAL
THERAPY MEDICATIONS
ORTHOTICS baclofen
casting dantrolene
dynamic splints NEUROSURGICAL
PROCEDURES
NERVE BLOCKS
intrathecal baclofen
neurolytic blocks
phenol rhizotomy
alcohol
Stroke and Brain Injury Spasticity - Surgical Considerations
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20. SURGERY

21. MUSCULOSKELETAL
RECONSTRUCTIVE SURGERY AS A
REHABILITATION TOOL
extremities, musculoskeletal system, and brain
musculoskeletal system gives mobility to the brain
the brain and mind interact with the world, positioned by the
extremities and musculoskeletal system
independent mobility and function are foundational to
human life and well-being
Stroke and Brain Injury Spasticity - Surgical Considerations
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22. MUSCULOSKELETAL
RECONSTRUCTIVE SURGERY AS
A REHABILITATION TOOL
balance of cognitive, behavioral, and
physical well-being after brain
injury/stroke
musculoskeletal limitations can be
devastating for patients
improvement in physical mobility and
function is therapeutic in emotional,
cognitive, and behavioral spheres
Stroke and Brain Injury Spasticity - Surgical Considerations
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23. MUSCULOSKELETAL
RECONSTRUCTIVE SURGERY AS A
REHABILITATION TOOL
wellness promotion among the physically disabled
maximizing function and mobility to avoid complications of
chronic incapacity
infection
pain
social isolation
physical/emotional dependence
these benefits also accrue to the patient’s family in a real
sense
Stroke and Brain Injury Spasticity - Surgical Considerations
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24. MUSCULOSKELETAL
SURGERY TIMING AND EXPECTATIONS
should be performed early, before deformities are
severe and fixed
effects of therapy, injections, and systemic
medications may be beneficial, but are temporary
surgery is a powerful rehabilitation tool that creates
permanent change in muscle tone and force direction
Stroke and Brain Injury Spasticity - Surgical Considerations
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25. MUSCULOSKELETAL
SURGERY TIMING AND EXPECTATIONS
results of surgery are improved when deformities are
corrected early
maximum muscle strength is preserved
less muscle lengthening is needed when deformity is mild
scar-producing joint releases are rarely needed
ligament flexibility and cartilage integrity is preserved
patients may be in better physiologic and nutritional
condition early in their rehabilitation process
Stroke and Brain Injury Spasticity - Surgical Considerations
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26. MUSCULOSKELETAL
SURGERY TIMING AND EXPECTATIONS
assessing volitional control is critical pre-operatively
amount of improvement correlates with residual motor
control, not with severity of deformity
extremity function versus patient function/quality of
life
surgical release of a contracted arm in a hemiplegic patient
may allow her to dress independently, though the arm
remains “nonfunctional”
Stroke and Brain Injury Spasticity - Surgical Considerations
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27. MUSCULOSKELETAL
INDICATIONS
voluntary use
will the patient use the hand in ADLs, even as a functional
assistant?
Stroke and Brain Injury Spasticity - Surgical Considerations
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28. MUSCULOSKELETAL
INDICATIONS
cognitive ability
patient and family must understand goals
follow commands
cooperate with postoperative therapy
able to incorporate the improved motor function into hand
use
adequate memory to retain knowledge taught in therapy
Stroke and Brain Injury Spasticity - Surgical Considerations
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29. MUSCULOSKELETAL
INDICATIONS
sensibility
pain, light touch, temperature
two point discrimination is a good screening test
age
hand placement
test in hemiplegic patients
Stroke and Brain Injury Spasticity - Surgical Considerations
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30. MUSCULOSKELETAL
PRE-REQUISITES FOR ACTIVE FUNCTION
PROCEDURES
obey simple commands
cooperate with therapy after surgery
retain what is taught from session to session
assimilate newly learned activities into daily activities
Stroke and Brain Injury Spasticity - Surgical Considerations
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31. MUSCULOSKELETAL
PRE-REQUISITES FOR ACTIVE FUNCTION
PROCEDURES
intact pain, light touch, temperature sensation; 2PD
<10 mm; kinesthetic awareness (reproduces body
positions)
+spontaneous extremity use
+volitional motor control of affected extremity
Stroke and Brain Injury Spasticity - Surgical Considerations
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33. DEFORMITIES

34. DEFORMITIES
BIRD’S EYE VIEW
shoulder adduction + internal rotation spasticity
elbow flexion spasticity
wrist and finger flexion spasticity
intrinsic spasticity
Stroke and Brain Injury Spasticity - Surgical Considerations
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35. DEFORMITIES
BIRD’S EYE VIEW
shoulder adduction + internal rotation spasticity
elbow flexion spasticity
wrist and finger flexion spasticity
intrinsic spasticity
Stroke and Brain Injury Spasticity - Surgical Considerations
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36. DEFORMITIES
SPASTIC CLENCHED FIST
unmasking of primitive grasp reflex
fingernails may dig into the palm
good hygiene may be difficult
pain with manipulation
Stroke and Brain Injury Spasticity - Surgical Considerations
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37. DEFORMITIES
SPASTIC CLENCHED FIST
FDS/FDP contribute to deformity
Intrinsic contracture may be masked by extrinsic
spasticity
chemodenervation may be useful early
surgery
fractional lengthening (if volitional motor control is present)
superficialis to profundus transfer if not
Stroke and Brain Injury Spasticity - Surgical Considerations
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38. DEFORMITIES
SPASTIC CLENCHED FIST - SURGERY
fractional lengthening
division of the palmaris longus
incising tendon fibers at the musculotendinous juntion
(FDS/P) tendons
FPL
allows tendons to lengthen with minimal scarring from
incision or sutures
pronator or wrist flexor lengthening may also be performed
Stroke and Brain Injury Spasticity - Surgical Considerations
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39. FRACTIONAL LENGTHENING

40. DEFORMITIES
SPASTIC CLENCHED FIST - SURGERY
fractional lengthening
post-operatively
prevent hyperextension of wrist with a volar wrist splint
active/active assist finger ROM on first post-op day
release
passive surgical procedure
risk of hyperextension/overpull of extensors
Stroke and Brain Injury Spasticity - Surgical Considerations
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41. DEFORMITIES
SPASTIC CLENCHED FIST - SURGERY
superficialis to profundus tendon transfer
advantages over release
more pleasing hand position
at best: mass action grasp pattern
at least: restraint to extension
Stroke and Brain Injury Spasticity - Surgical Considerations
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42. DEFORMITIES
SPASTIC CLENCHED FIST - SURGERY
superficialis to profundus tendon transfer
volar approach
palmaris transected
four FDS tendons sutured together distally then cut
four FDP tendons sutured together proximally, then cut
with the fingers extended, the distal ends of FDS are sutured to the proximal
ends of FDP (FDP tendons motored by the FDS)
Stroke and Brain Injury Spasticity - Surgical Considerations
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43. SUPERFICIALIS TO PROFUNDUS TRANSFER

44. DEFORMITIES
SPASTIC THUMB-IN-PALM DEFORMITY
heterogeneous appearance
spastic muscles = FPL, adductor pollicis, thenar
muscles (FPB)
Stroke and Brain Injury Spasticity - Surgical Considerations
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45. DEFORMITIES
SPASTIC THUMB-IN-PALM DEFORMITY
- SURGERY
FPL fractional lengthening
thenar muscle slide
thumb IP joint stabilization
Stroke and Brain Injury Spasticity - Surgical Considerations
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46. DEFORMITIES
SPASTIC THUMB-IN-PALM DEFORMITY
- SURGERY
Stroke and Brain Injury Spasticity - Surgical Considerations
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47. DEFORMITIES
SPASTIC THUMB-IN-PALM
DEFORMITY - SURGERY
first dorsal interosseous may be
contracted and require release
first web contracture may require z-
plasty of the web space
therapy post-op
active therapy started after three weeks of
immobilization
Stroke and Brain Injury Spasticity - Surgical Considerations
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48. DEFORMITIES
INTRINSIC SPASTICITY
look for swan neck or boutonniere
deformities
may be painful and disfiguring
intrinsic tightness test
positive when PIP flexion is decreased (tighter)
with the MCPs extended (with the intrinsic
tendons on stretch)
Stroke and Brain Injury Spasticity - Surgical Considerations
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49. DEFORMITIES
INTRINSIC SPASTICITY
overpull of extrinsic extensors combined
with spastic intrinsic muscles
Stroke and Brain Injury Spasticity - Surgical Considerations
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50. DEFORMITIES
INTRINSIC SPASTICITY
dynamic EMG and diagnostic nerve
blocks may be helpful in these patients
spasticity versus contracture
Ex: spastic intrinsics will relax with ulnar
motor nerve denervation; contracted
muscle-tendon units will not relax unless
cut/released/lengthened
Stroke and Brain Injury Spasticity - Surgical Considerations
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51. DEFORMITIES
INTRINSIC SPASTICITY - SURGERY
intrinsic release
done if intrinsic contracture present after extrinsic flexor
release/STP transfer complete intraoperatively
done at level of MCP joints
fingers held in safe position after this release for two weeks
with gentle ROM of MCPs after splint removal
recurrent intrinsic-plus deformity (safe position) is common,
so ulnar motor neurectomy is usually performed at the same
time
Stroke and Brain Injury Spasticity - Surgical Considerations
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52. INTRINSIC RELEASE, NEURECTOMY

53. DEFORMITIES
INTRINSIC SPASTICITY - SURGERY
neurectomy - ulnar nerve motor branch
to prevent intrinsic spasticity (intrinsic plus hand)
now that extrinsic flexors are not spastic, intrinsic spasticity
may be unmasked
Stroke and Brain Injury Spasticity - Surgical Considerations
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54. CONCLUSION
Stroke and Brain Injury Spasticity - Surgical Considerations
www. noelhenley.com

55. CONCLUSION
phases of recovery are critical
Stroke and Brain Injury Spasticity - Surgical Considerations
www. noelhenley.com

56. CONCLUSION
phases of recovery are critical
surgery may be more successful early in the course of
recovery and rehabilitation
Stroke and Brain Injury Spasticity - Surgical Considerations
www. noelhenley.com

57. CONCLUSION
phases of recovery are critical
surgery may be more successful early in the course of
recovery and rehabilitation
accurate assessment of pre-operative function is
mandatory for success
Stroke and Brain Injury Spasticity - Surgical Considerations
www. noelhenley.com

58. CONCLUSION
phases of recovery are critical
surgery may be more successful early in the course of
recovery and rehabilitation
accurate assessment of pre-operative function is
mandatory for success
therapists are intimately involved during all stages!
Stroke and Brain Injury Spasticity - Surgical Considerations
www. noelhenley.com

59. ACTION STEPS
Stroke and Brain Injury Spasticity - Surgical Considerations
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60. ACTION STEPS
Stroke and Brain Injury Spasticity - Surgical Considerations
www. noelhenley.com

61. ACTION STEPS
join my Hand and Arm Therapy Digest e-
mail list - drhenley@gmail.com
THANKS!
Stroke and Brain Injury Spasticity - Surgical Considerations
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