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The Spastic Upper Extremity in Children: Multilevel Surgical Decision-making
Sonia Chaudhry1, Praveen Bhardwaj, Hari Venkatramani
1From the Department of Orthopaedic Surgery (Chaudhry), University of Connecticut, Connecticut Children's Medical Center, Hartford, CT, and the Department of Hand and Microsurgery (Bhardwaj, Venkatramani, and Sabapathy), Ganga Hospital, Coimbatore, India.
Insights
Multilevel surgery for upper extremity spasticity requires careful surgical planning to optimize outcomes. Comprehensive assessment is crucial to balance contracture release with functional goals, avoiding worsened function or new deformities.
Area of Science:
- Orthopedic Surgery
- Neurology
- Rehabilitation Medicine
Background:
- Multilevel surgery is the standard for upper extremity spasticity.
- Existing literature lacks comprehensive surgical planning guidance.
- Patient presentations involve complex posturing patterns.
Purpose of the Study:
- To provide a comprehensive guide for surgical planning in upper extremity spasticity.
- To detail considerations for optimizing surgical outcomes.
- To address common challenges in surgical decision-making.
Main Methods:
- Detailed examination for contracture, laxity, and aberrant muscle activity.
- Balancing contracture release and tendon transfers against functional weakening.
- Considering joint fusion for stability when necessary.
Main Results:
- Recognizing dynamic posturing and intrinsic hand spasticity is vital.
- Surgical indications must be tailored to individual deformity patterns and goals.
- Preexisting voluntary control is a key prognostic indicator for functional improvement.
Conclusions:
- Careful surgical planning is essential for successful multilevel surgery in upper extremity spasticity.
- Balancing interventions and managing expectations optimizes limb function and appearance.
- Failure to plan adequately can lead to worsened function and new deformities.
Abstract:
Multilevel surgery for upper extremity spasticity is the current surgical standard. While the literature details surgical techniques and outcomes, a comprehensive guide to surgical planning is lacking. Patients commonly present with posturing into shoulder internal rotation, elbow flexion, forearm pronation, wrist flexion with ulnar deviation, finger flexion, and thumb adduction, although variations exist. Multiple surgical options exist for each segment; therefore, repeated examinations for contracture, pathologic laxity, and out of phase activity are necessary to optimize the surgical plan. To avoid decreasing function, one must carefully balance the benefits of contracture release and tendon transfers with their weakening effects. In certain cases, stability from joint fusion outweighs the loss of motion. Failure to recognize dynamic posturing, grasp and release requirements, or hand intrinsic spasticity can worsen function and cause new deformities. Surgical indications are formulated for individual deformity patterns and severity along with personal/family goals. General comprehension, voluntary control, and sensation, although not modifiable, influence decision making and are prognostic indicators. Functional improvement is unlikely without preexisting voluntary control, but appearance and visual feedback may be improved by repositioning nonetheless. Appropriate interventions and management of expectations will optimize limb appearance and function while avoiding unexpected sequelae.
