Surgical Approaches to Upper Limb Spasticity in Adult Patients: A Literature Review

Abstract

Introduction: Spasticity is the main complication of many upper motor neuron disorders. Many studies describe neuro-orthopedic surgeries for the correction of joint and limb deformities due to spasticity, though less in the upper extremity. The bulk of care provided to patients with spasticity is provided by rehabilitation clinicians, however, few of the surgical outcomes have been summarized or appraised in the rehabilitation literature.Objective: To review the literature for neuro-orthopedic surgical techniques in the upper limb and evaluate the level of evidence for their efficacy in adult patients with spasticity.Method: Electronic databases of MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched for English, French as well as Farsi languages human studies from 1980 to July 2, 2020. After removing duplicated articles, 2,855 studies were screened and 80 were found to be included based on the criteria. The studies were then divided into two groups, with 40 in each trial and non-trial. The results of the 40 trial articles were summarized in three groups: shoulder, elbow and forearm, and wrist and finger, and each group was subdivided based on the types of intervention.Results: The level of evidence was evaluated by Sackett's approach. There were no randomized control trial studies found. About, 4 studies for shoulder, 8 studies for elbow and forearm, 26 studies for wrist and finger (including 4 for the thumb in palm deformity), and 2 systematic reviews were found. Around, two out of 40 trial articles were published in the rehabilitation journals, one systematic review in Cochrane, and the remaining 38 were published in the surgical journals.Conclusion: Most surgical procedures are complex, consisting of several techniques based on the problems and goals of the patient. This complexity interferes with the evaluation of every single procedure. Heterogenicity of the participants and the absence of clinical trial studies are other factors of not having a single conclusion. This review reveals that almost all the studies suggested good results after the surgery in carefully selected cases with goals of reducing spasticity and improvement in function, pain, hygiene, and appearance. A more unified approach and criteria are needed to facilitate a collaborative, evidence-based, patient referral, and surgical selection pathway.

Wrist arthrodesis and soft tissue rebalancing in the spastic hand

“…These limitations are similar to those in other publications on wrist spasticity surgery (Hashemi et al., 2021). However, it is hoped that this study provides insight into expected outcomes, especially with the emphasis on digital rebalancing.…”

Surgical management of the spastic elbow

“…Whilst the underlying principle of elbow flexor release is agreed in the literature, different methods of achieving this have been described. 16 We recommend a sequential release of structures to reduce FFD, preserving where possible 7 and those that do not (spastic hemiplegia), 8 although we did not find these factors influenced our decision making or outcomes.…”

“…Whilst the underlying principle of elbow flexor release is agreed in the literature, different methods of achieving this have been described . 16 We recommend a sequential release of structures to reduce FFD, preserving where possible biceps’ supination power in milder cases and anticipating more extended releases in severe cases. In very severe and long-standing cases of elbow contracture full correction is unlikely, and this is likely to be due to underlying bony dysplastic changes.…”

A Case Report Illustrating the Combined Use of Cryoneurolysis and Percutaneous Needle Tenotomy in the Treatment of Longstanding Spastic Shoulder Contractures After Stroke

“… 4 , 8 Additionally, because tenotomy and cryoneurolysis are minimally-invasive treatments which do not require the use of general anesthesia, they can be applied to treat medically frail upper limb spasticity patients with contractures, a population which often lacks effective treatments. 10 …”