Team Approach: Multidisciplinary Perioperative Care in Upper-Extremity Reconstruction for Adults with Spasticity and Contractures

Abstract

» Spasticity is the heightened motor tone that occurs as a result of damage to upper motor neurons in the central nervous system from brain or spinal cord injuries.» Nonoperative interventions for upper-extremity spasticity include chemodenervation or orthotic use, but their efficacy may be limited in correcting severe deformities. In such cases, surgical reconstruction may be necessary.» A single-event multilevel surgery (SEMLS) is a method of addressing deformities involving the entire extremity under 1 anesthetic episode.» It is the responsibility of the surgeon to assemble and communicate with the appropriate health-care team members during the patient’s hospitalization to prevent perioperative complications and to optimize outcomes after surgery. Team entities integral to successful SEMLS for patients with spasticity include respiratory therapy, nutrition, neuropalliative care, internal medicine, occupational therapy, and anesthesiology.» The goal of upper-extremity reconstruction in patients with spasticity is to improve the patient’s quality of life, reduce pain, improve hygiene, restore functionality, and correct disfiguring joint contractures.

Nonoperative Management of Humerus Fractures in Patients With Ispilateral Hemiparesis or Hemiplegia

“…17 The primary aim of fracture management in patients without meaningful function within the injured extremity from a brain injury is to alleviate pain, prevent worsening of deformities, facilitate hygiene, minimize the development of skin breakdown and wounds, and restore quality of life. 7 Typical contractures in patients with UMN injury include shoulder adduction/internal rotation, elbow flexion, forearm pronation, wrist flexion, clenched fist, and thumb-inpalm deformities. 17 These contractures can make it difficult to perform axillary and/or antecubital fossa hygiene and ADLs, such as putting on a shirt.…”

“…Unique factors must be considered in this subset of hemiplegic and hemiparetic patients who often have poor bone quality in whom treatment goals should be aimed at decreasing pain, maintaining function, minimizing skin breakdown and wounds, facilitating hygiene, and preserving quality of life. 7,8 The purpose of this study was to retrospectively review outcomes of nonoperative treatment of acute humerus fractures in patients with severe hemiparesis or hemiplegia due to a brain injury to better guide management of these fractures in this unique patient population. We hypothesized that nonoperative treatment of humerus fractures in patients with upper motor neuron (UMN) injuries would result in union with adequate pain relief, a low rate of HAND 18 (6) conversion to surgery, and low rates of wound development from the use of well-padded splints even in the setting of spasticity and contracture.…”

Assessment of 30-Day Adverse Events in Single-Event, Multilevel Upper Extremity Surgery in Adult Patients with Upper Motor Neuron Syndrome

“…None of the patients in this study experienced any complications that led to hospital readmission or death. 21 Therefore, the single inpatient hospital encounter with a collaborative healthcare team circumvented the potential risks associated with recurrent operations and prolonged inpatient housing.…”

“…None of the patients in this study experienced any complications that led to hospital readmission or death. 21 Therefore, the single inpatient hospital encounter with a collaborative healthcare team circumvented the potential risks associated with recurrent operations and prolonged inpatient housing. Adult patients who undergo SEMLS for the upper extremity are more likely to have skin-related adverse events compared to systemic or orthopedic complications that require hospital readmission within the 30-day postoperative period.…”

“…Patients were admitted preoperatively in order to facilitate transfer from their care facility or living quarters for their convenience or to provide an opportunity for multidisciplinary evaluation, medical clearance for surgery, and stabilization of comorbidities with engagement from services such as internal medicine, respiratory therapy, nutrition, neurology, nephrology, neuropalliative care, cardiology, occupational therapy, and/or social services. 21 Prior to surgery, the patients and their families were extensively counseled on the potential for perioperative complications.…”