Hyperselective neurectomy: current status and future perspectives

Surgery has a limited place in the treatment of spasticity of the upper limb. It is only one element of the rehabilitative care, together with physiotherapy, splinting, occupational therapy and pharmacological treatment as needed. Surgical decisions are best made with the patient and family by a multidisciplinary team including all the involved specialists. Upper limb deformity and impairment in spasticity is a complex association of spasticity itself, and of resulting muscle/ joint contracture and weakness / paralysis. Each component must be treated simultaneously for a durable result. Therefore, nerve procedures, including hyperselective neurectomy, are rarely performed in isolation. Selective (or partial) neurectomy, which consists in resecting only part of the motor rami for each of the involved muscles, was introduced in the early 1900 but was not widely spread until popularized by Brunelli (1980, 1983). The technique of hyperselective neurectomy, by which the motor rami are interrupted at their point of entry into the muscle, allows durable reduction of hypertonia without loss of muscle strength, and thus improvement of balance, with a low morbidity rate. Precise knowledge of the anatomy of motor nerve branches and their variations is critical in order to plan these procedures properly.