1.2.1

Preoperative assessment

The preoperative assessment consisted of:

• •
  

  a detailed examination of the foot, with analysis of motor parameters (evaluation and scoring of the clonic and tonic components of spasticity for the various leg and foot muscles (notably the triceps surae) with the knee extended and flexed), voluntary motor control (notably screening for synkinesis of the tibialis anterior), sensory parameters (screening for cutaneous and deep-tissue sensory disorders) and “orthopaedic” parameters (a forefoot and ankle joint examination and screening for muscle and sheath or ligament retraction);

  
  
• •
  

  a review of the use of walking aids;

  
  
• •
  

  a gait examination (with the patient barefoot and then wearing their usual shoes) and determination of the gait pattern.

Whenever necessary, motor block of the tibial nerve was performed in order to distinguish between spasticity and muscle retraction and, above all, reversibly simulate the outcome of the neurectomy.

The decision to operate and improve gait was made according to the risk-benefit ratio and whenever an adequate level of functional benefit appeared to be sufficiently likely. Of course, one or more preoperative interviews with the patient and his/her family were of major importance in carefully presenting and reviewing the operation’s objectives (the potential for aid-free walking, improved stability and a greater walking distance) and, above all, limitations (so as not to raise false hopes).

With respect to surgery, the chosen procedure consisted of partial or total neurectomy of the terminal nerve branches of the gastrocnemius and soleus muscles (with no intra-trunkal neurotomy) . We defined the triceps surae branches for neurectomy, i.e. those innervating the medial and lateral heads of the gastrocnemius and one or more branches of the soleus. For each of these branches, we specified the extent of neurectomy (usually 100, 75 or 50%). We also decided whether or not to perform other “orthopaedic” interventions (tendon lengthening, arthrolysis, metatarsal/subtalar arthrodesis, treatment of claw toe deformities, etc) during the same operating session. The clinical examination and the surgical procedures were reassessed by the two surgeons at the patient’s bedside on the eve of the operation.

1.2.2

Immediate postoperative assessment

The immediate postoperative assessment enabled us to note:

• •
  

  the presence or absence of residual tonic and/or clonic spasticity. Unfortunately, these parameters were not always scored on the Ashworth’s scale ;

  
  
• •
  

  the presence of persisting varus and/or equinus deformities and their aetiologies (retractions or residual spasticity);

  
  
• •
  

  any surgical complications;

  
  
• •
  

  the immediate functional benefit: improved gait and a reduced need for orthotic devices and/or walking aids, etc;

  
  
• •
  

  patient’s satisfaction.

1.2.3

Long-term assessment

The long-term assessment (performed as long as possible after the operation) included:

• •
  

  identification of postoperative events and ongoing spasticity treatments and/or rehabilitation therapy;

  
  
• •
  

  the patient’s age and the date of the neurectomy;

  
  
• •
  

  the type of neurectomy and any additional orthopaedic operations performed at the same time;

  
  
• •
  

  analysis of interim assessments in the patient’s medical records;

  
  
• •
  

  a detailed examination of the foot, including:

• ∘
  

  angle measurement for passive dorsal foot flexion, with the knee extended and flexed,

  
  
• ∘
  

  voluntary motor control (good/average/poor/null),

  
  
• ∘
  

  screening for synkinetic tibialis anterior activity when standing (via active hip flexion) and synkinesis of use in gait,

  
  
• ∘
  

  a residual spasticity score, with separate assessment of the tonic and clonic components for the heads of the triceps surae. Despite the lack of a reliable measurement device and the risk of low accuracy, this evaluation was performed clinically. In particular, differentiation between gastrocnemius and soleus was performed by direct palpation of the body of the muscle. In fact, the soleus (which lies more deeply and is in contact with bone) can be easily identified in the middle third of the leg, immediately behind the tibia’s medial border. The body of the gastrocnemius muscle is proximal and nearer to the surface; one can easily palpate this muscle over the proximal third of the leg (i.e. the most rounded part of the calf). We consider that this examination method is more reliable that the classic distinction of Silfverskiöld retaining, in the presence of an appearing clonus

  
  
• ∘
  

  flexed knee, the only responsibility of the soleus:

• –
  

  the tonic component was scored on the Ashworth’s scale (from 0 to 4),

  
  
• –
  

  spastic clonus of the ankle was scored on the following scale: 0: absence of clonus; +: rapidly transient clonus; ++: transient clonus; +++: sustained clonus;

• ∘
  

  the presence of spasticity in other muscle groups (notably the tibialis posterior),

  
  
• ∘
  

  cutaneous and deep-tissue sensory disorders (the ability to sense knee joint movement and the segmental positions of the hallux and the knee) and any trophic disorders,

  
  
  
  
  • •
    

    a functional gait analysis, to assess whether the situation had changed after the operation and whether the therapeutic effect had persisted over time in terms of:

  
  
  
  
• ∘
  

  the use of walking aids,

  
  
• ∘
  

  the ability to walk (1) barefoot, (2) outside the home and (3) over uneven ground (in a garden or in woodland, for example) at the time of the consultation,

  
  
• ∘
  

  the new functional ambulation classification (nFAC) before the operation, immediately afterwards and at the time of the last consultation. Student’s t test was used to check for any statistically significant changes over time,

  
  
• ∘
  

  at the end of the consultation, a measure of the comfortable gait velocity on 10 m was performed ;

• 
  

  lastly, we asked the patient about his/her opinion on the operation’s outcome, any changes over time and its efficacy in terms of the changes in the walking distance.

1.2.4

The surgical procedure

Of the many available procedures, surgical treatment of spasticity can draw on neurectomy procedures with resection of the motor fibres involved in the segmental reflexes which cause spasticity and the motoneuron axons; the resulting paralysis of the innervated muscle is proportional to the extent of the fascicular resection. Fascicular neurotomy within the nerve trunk is the most common procedure and has been extensively described in the literature ; it includes an intraneural dissection phase in order to locate the fascicles for resection. This identification is based on the topographic information provided by mapping of the tibial nerve and peroperative electrical stimulation.

Our operating procedure involved selective neurectomy of the terminal motor branches (downstream of their emergence). Neurectomy was performed on the terminal ramifications of the branch going to the gastrocnemius and the branch of the superior nerve of the soleus ( Fig. 1 ).

Neurectomy was performed on the distal branches leading to each head of the gastrocnemius (circled) and the branch of the superior soleus nerve (hatched). The tibial nerve trunk was not resected.

1.3.1

Details of the surgical procedure

Twenty-three patients had undergone neurectomy of the soleus (complete neurectomy in 14 cases, 50% neurectomy in eight cases and 75% neurectomy in one case). The partial neurectomies consisted of an early surgical procedure in which 1 or 2 cm of a group of fascicles were resected and others were left untouched. This procedure was subsequently forsaken in favour of complete resection of the superior branch of the soleus.

Twenty-four patients had undergone partial or complete neurectomy (50, 75 or 100%) of the lateral and medial heads of the gastrocnemius. Complete neurectomy was performed in 12 cases.

Five patients had undergone complete neurectomy of the soleus and the gastrocnemius.

Twenty-one patients had undergone at least one other operation at the same time as the neurectomy:

• •
  

  eight patients had undergone tenotomy of the tibialis posterior;

  
  
• •
  

  11 patients had undergone Bardot’s tenodesis procedure (fixation of the distal end of the peroneus brevis to the tendon of the tibialis anterior, in order to re-enable foot eversion);

  
  
• •
  

  seven patients had undergone tenotomy of the flexor digitorum longus and six others had undergone tenotomy of the flexor hallucis longus;

  
  
• •
  

  one patient had undergone tenodesis of the extensor hallucis longus and the tibialis anterior (Haglund’s procedure);

  
  
• •
  

  one patient had undergone medial mediotarsal (talonavicular) arthrodesis;

  
  
• •
  

  one patient had undergone neurectomy of the tibialis posterior.

1.3.2

Postoperative complications

Only three superficial scarring problems were observed (slow scarring, local wound infection and subcutaneous bruising).

1.3.3

Spasticity

1.3.4

Functional benefits

Twenty of the 23 patients (and not 25, since two patients had been able to walk unaided in flat shoes before the operation) had a long-term lowering of orthotic devices or walking aids (e.g. shoes, a walking stick, a brace, a walking frame, a wheelchair, etc) ( Table 1 ).

Three patients did not enjoy continued benefits:

• •
  

  although the first patient did not experience any functional improvements, the initial situation had not worsened. This patient was one of those with significant residual spasticity of the soleus (after 50% neurectomy of the latter and 100% neurectomy of the gastrocnemius) but did not wish to undergo repeat surgery;

  
  
• •
  

  the second (traumatic head injury) patient’s condition had worsened, with the appearance of non-spastic muscle retraction requiring the use of heavy orthopaedic shoes. The patient suffered from cognitive disorders and was not receiving maintenance physiotherapy. Furthermore, her medical follow-up was very erratic. Achilles’ tendon lengthening would have been possible but the patient did not wish to undergo repeat surgery;

  
  
• •
  

  although the third patient had been less dependent on walking aids immediately after the operation, knee pain appeared after several years and was related to significant recurvatum (but with no recurrence of spasticity). The condition was treated through use of orthopaedic shoes and a brace.

1.3.5

Repeat surgery

Several patients had undergone repeat surgery:

• •
  

  seven patients underwent repeat surgery for complications of their hemiplegia:

• ∘
  

  three patients had persistent, non-spastic foot deformities related to muscle retraction and had undergone an additional “orthopaedic” operation a few months after the neurectomy: Achilles’ tendon lengthening (in two cases) and gastrocnemius lengthening (in one case), combined with Bardot’s procedure. One patient had developed a retracted, non-spastic equinovarus foot due to reflex neurodystrophy and underwent Achilles’ tendon lengthening several years after the neurectomy,

  
  
• ∘
  

  three patients had developed claw toe several years after the operation and thus required tenotomy of the toe flexors;

• •
  

  two patients underwent surgery for problems unrelated to their hemiplegia:

• ∘
  

  one patient underwent several additional operations for deformities resulting from major foot trauma incurred at the same time as the traumatic head injury (again, with no recurrence of spasticity),

  
  
• ∘
  

  one head injury patient had also undergone subtalar arthrodesis for a fracture suffered in a road accident.

Hence, none of the subsequent operations (except the case of spontaneous neurotization) were related to recurrence of spasticity.

1.3.6

Patient’s satisfaction

Twenty-four patients answered this question. Eighty-three percent of the patients (i.e. 20 out of 24) stated that they were satisfied with the operation’s outcome (both immediately afterwards and long afterwards).

1.3.7

Patient’s satisfaction with their walking distance

During the last interview, patients were asked to compare their postoperative and preoperative situations:

• •
  

  immediately after surgery, the walking distance had increased in 20 out of 25 cases (80%);

  
  
• •
  

  long after surgery, the walking distance had increased (relative to the preoperative situation) in 20 out of 25 cases;

  
  
• •
  

  in five cases, the walking distance had decreased between the immediate postoperative assessment and the last assessment but was still greater than the preoperative distance. This decrease was related to intercurrent events: a fall (in one case), a fall with hip pain (in one case), a subtalar fracture following an accident (in one case), neuropathic pain at the back of the foot (in one case) and knee pain (in one case).

1.4.1

Bias and limitations

In order to evaluate the study results as objectively as possible and thus avoid bias potentially related to worsening of the condition (degenerative conditions, for example), we decided to only include patients presenting with acquired, non-degenerative hemiplegia (i.e. with traumatic and vascular aetiologies).

The study limitations were as follows:

• •
  

  the partially retrospective nature of the study design, with a number of missing data items (preoperative and immediately postoperative gait speed, for example);

  
  
• •
  

  the low number of patients;

  
  
• •
  

  the subjective nature of certain data items, such as patient satisfaction and walking distance (since the latter was difficult to determine otherwise).

However, we also based our analysis on valid, objective data, such as spasticity measurements and functional benefits.

One key strength of the present study is its long post-neurectomy follow-up period (mean period: 11 years and 3 months; range: 4 years and 1 month to 19 years); to the best of our knowledge, this is the longest follow-up to be published. In fact, few studies have evaluated the long-term efficacy of tibial nerve neurectomy . In 1988, Sindou and Mertens reported on a series of 53 patients with an average follow-up period of 3 years (range: 15 months to 10 years). In 2000, Decq et al. described a series of 46 patients with an average follow-up period of 15 months (range: 8 to 28 months). In 2003, Roujeau et al. published the results for six patients with an average follow-up period of 29 months (range: 10 to 48 months) and Deltombe’s et al. 2006 publication reported on three cases monitored over 2 years. In 1998, Berard et al. published results for 13 paediatric patients with an average follow-up period of 3.2 years (range: 1.5 to 5.3 years).

1.4.2

The surgical procedure

Fascicular intra-trunkal neurotomy enables controlled, partial neurectomy but runs the risk of:

• •
  

  postoperative pain syndrome, due to the trauma and ischaemia induced by intraneural dissection. This neuropathic-type pain can be particularly refractory to treatment;

  
  
• •
  

  unintentional damage to sensory components: this is likely to be particularly harmful in patients with poor foot control and thus high-pressure zones.

We believe that these risks are too high and so we adopted a partial neurectomy technique, which does not require intraneural dissection and directly targets the tibial nerve’s terminal motor branches. This peripheral neurectomy procedure is not new but fell into disuse because of the supposedly high rate of nerve regrowth. In order to circumvent this disadvantage, we worked on the following aspects:

• •
  

  the procedure does not result in neurotomy per se ; it corresponds to neurectomy with 1 or 2 cm of nerve resection, in order to avoid any risk of complete nerve regrowth;

  
  
• •
  

  the branches are located with respect to the local anatomy and are unambiguously confirmed by peroperative electoral stimulation;

  
  
• •
  

  great attention is paid to the proximal end of the neurectomy zone by checking that it remains well clear of the adjacent muscle body. We try to keep a gap of at least 1 cm between these two structures, in order to avoid any risk of direct muscle neurotization by secondary nerve regrowth;

  
  
• •
  

  the partial neurectomy only affects the gastrocnemius and the soleus. In fact, the efferents to the tibialis posterior and (above all) to the flexor digitorum longus and the flexor hallucis longus are usually too distal for use of this method. Any weakening of the latter muscles is implemented peripherally via direct action on the end tendons.

This procedure has a certain number of advantages ( Fig. 2 ):

• •
  

  it is technically simple and does not require significant optical magnification or the use of a surgical microscope. Simple magnifying glasses (with a magnification of 2.5 to 3) are sufficient;

  
  
• •
  

  it enables selective neurectomy of the gastrocnemius. The fact that there are three terminal ramifications of the afferent branch enables selective, partial neurectomy (100, 75 and 25% or even 50%, due to the frequent presence of one ramification, which is larger than the others) and can be used optionally on one or more of gastrocnemius’ heads. In terms of the soleus, the superior nerve is easily identified and the literature data suggest that neurectomy of the latter is sufficient ;

  
  
• •
  

  the procedure is compatible with a lateral decubitus position, since the leg is held by a support on each side of the popliteal region. This position is also compatible with subnormal hip mobility: internal rotation enables good exposure of the popliteal fossa and external rotation provides access to the anterior part of the neck of the foot and the foot’s dorsal aspect. Under these conditions, it is possible of perform other “orthopaedic” operations (such as peripheral tenotomies or tendon transfer) during the same anaesthetic session without changing the patient’s position.

A peroperative view of our neurectomy procedure.

1.4.3

Long-term spasticity

Long-term spasticity had almost completely disappeared in 22 of our 25 patients (including one after repeat neurectomy), i.e. 88% of the study population. These results confirmed the efficacy of our neurectomy procedure in relieving spasticity; the proportion of good outcomes is comparable to that reported in the literature for fascicular neurotomy procedures. Feve et al. reported that spasticity has disappeared in 91% of patients (11 out of 12, evaluated on the Held’s scale ). Caillet et al. observed the disappearance of the spasticity in all nine patients (rated on the modified Ashworth’s scale) , whereas Decq et al. noted the disappearance of spasticity in 95% of patients (44 out of 46, evaluated on the modified Ashworth’s scale and the Tardieu’s scale ). Lastly, in two publications by Sindou et al., spasticity (as evaluated on the Ashworth’s scale) disappeared in 89% (33 out of 37) and 92% (57 out of 62) of patients, respectively ).

In the three (out of 25) patients with incomplete outcomes, spasticity persisted immediately after and long after the operation. It is noteworthy that the spasticity mainly affected the soleus, for which the neurectomy had been incomplete (50%) or not performed. Neurectomy (75 or 100%) was chiefly performed on the gastrocnemius. These results are in agreement with the literature: indeed, by performing selective motor blocks of the soleus and the gastrocnemius in a series of 16 patients, Decq et al. demonstrated the predominant role of the soleus, which was fully responsible for the spasticity in 75% of cases. The gastrocnemius alone was responsible for 12.5% of cases, whereas both muscles were involved in the remaining 12.5%. Three other more recently published studies also confirm these results . It is noteworthy that we inconsistently observed a lower branch of the soleus nerve; when present, it emerged over a distance of between 25 and 156 mm (82 mm, on average) across the popliteal fold . This location can thus be very distal and it may be impossible to resect this branch when using the initial approach. Some researchers suggest that this branch has only a slight effect on spasticity because selective block of the superior branch of the soleus nerve inhibits the patients’ spasticity. However, these studies deal with small series of patients . In our study, the three cases of persistent spasticity and the one case of early re-innervation can be explained without the action of this branch. Studies with larger series are nevertheless required to establish whether or not the lower branch has a role in spasticity. Of these three patients, only one failed to gain functional benefit and did not wish to undergo repeat surgery. In the second case, the residual spasticity was not unduly troublesome and patient was able to walk freely in flat town shoes. The third patient improved immediately after the operation but then lost some of the benefits due to heminegligence and the resulting functional fluctuations.

We observed one case of re-innervation at the lateral head of the gastrocnemius (after complete neurectomy of the soleus and the gastrocnemius). Decq et al. reported just 1% of spasticity recurrence in the leg (regardless of the type of neurectomy), whereas Buffenoir et al. did not observe any recurrence of spasticity 10 months after the operation (in 55 patients). In contrast, the results of tibial nerve neurectomies in children are less good; Berard et al. reported that spasticity recurred in eight out of 13 children (61%) between 5 and 17 months after the operation (using the same intrafascicular surgical procedure). The biopsies performed in four cases evidenced re-innervation of the surgically denervated muscle fibres. However, the reason for these relapses was not unambiguously demonstrated. In an electrophysiological follow-up study, Roujeau et al. confirmed that fascicular neurectomy did not induce permanent denervation. There is a re-innervation by sprouting of residual alpha motoneurons, but interruption of myotatic reflex is still abolished in the long-term, which means a permanent damage on reflex afferences. For them, motor re-innervation is therefore probably not responsible for recurrence of spasticity because the myotatic reflex was still abolished. The question of other central and peripheral mechanisms (including the muscles themselves) behind this residual hypertonia (particularly in the child) arises and thus remains to be investigated.

1.4.4

The new functional ambulation classification score

The nFAC score revealed a significant improvement. Nevertheless, this scale did not appear to be very pertinent for our assessments because it took account of items for which improved foot stability does not necessarily result in functional gain (notably the ability to climb stairs for scores of five or more). The nFAC scale has very rarely been used in the various published studies evaluating the efficacy of tibial nerve neurectomy: only one recent study recent by Rousseaux et al. compared the respective effects of botulinum toxin and tibial nerve neurectomy on spasticity and functional parameters. The results showed an improvement in the nFAC score (0 to 5) but only when walking barefoot. The improvement was greater after neurectomy.

1.4.5

The mean comfortable gait speed

The mean comfortable gait speed over 10 m was 0.52 m/s but, unfortunately, this parameter had not been measured before the operation. Hence, the effect of tibial nerve neurectomy on gait could not be evidenced. In an initial study, Caillet et al. noted a significant improvement in gait speed but this outcome was not confirmed in a subsequent study of a more homogeneous population with a high degree of personal independence in terms of gait : the mean gait speed was 0.51 m/s before neurectomy and 0.54 m/s 6 months afterwards. Decq et al. and Feve et al. did not see any improvement. Only Buffenoir et al. noted a gain in the comfortable gait speed while barefoot and when wearing shoes (increasing from 0.18 to 0.29 m/s and from 0.24 to 0.33 m/s, respectively) on a series of 55 patients.

1.4.6

Additional surgery

For the four patients who underwent orthopaedic surgery (lengthening, plus Bardot’s procedure in some cases), it is clear that the functional benefit was related, at least in part, to this additional operation. Given the population of patients studied here, the existence of additional operations was inevitable . However, it should be noted that none of these cases presented a recurrence of spasticity and that only retractions were involved.

We wish to emphasize the importance of regular, long-term medical follow-up for preventing secondary complications – notably retraction of the triceps but also claw toe (the three cases in our series underwent tenotomy of the toe flexors) – which are frequent after the profile of the sole of the foot has been significantly modified.

The long-term efficacy of tibial nerve neurectomy was objectively evidenced by the lasting functional benefit in terms of gait (an increased walking distance (20 of the 25 patients concerned), reduced need for walking aids (20 of the 23 patients concerned) and the ability to walk barefoot (11 of the 18 patients concerned), on uneven ground (seven of the 12 patients concerned) and outside (four of the five patients concerned) and improved comfort for orthopaedic shoe wearers (all three patients concerned).

The patients were generally satisfied with the outcome of the operation (83%).

2.2.1

L’évaluation préopératoire

L’évaluation préopératoire lors de cette consultation comprenait :

• •
  

  un examen analytique du pied. Sur le plan moteur, pour la spasticité : une évaluation et une cotation de la composante clonique et tonique des différents muscles de la jambe et du pied et notamment pour le triceps surae, genou étendu et fléchi ;

  
  
• •
  

  une appréciation de la commande motrice volontaire, la recherche de syncinésies du tibialis anterior notamment. Sur le plan sensitif : la recherche de troubles de la sensibilité superficielle et profonde. Et sur le plan « orthopédique » : un examen articulaire (cheville, couple de torsion et avant-pied), la recherche de rétractions musculaires et capsuloligamentaires ;

  
  
• •
  

  une analyse des aides techniques de marche ;

  
  
• •
  

  un examen de la marche pieds-nus (si possible) et avec les chaussures habituelles, et une détermination du schème de marche.

Chaque fois que nécessaire, un bloc moteur du nerf tibial était réalisé pour faire la part respective de la spasticité et des rétractions musculaires, et surtout simuler, de façon réversible, le résultat de la neurectomie.

La décision chirurgicale, motivée par un objectif d’amélioration des possibilités de marche, était retenue, à la lumière du rapport avantages/risques, à chaque fois que le bénéfice fonctionnel apparaissait suffisamment fondé en termes de probabilité et de qualité. Bien entendu, l’entretien préopératoire, avec le patient et sa famille avait une importance de tout premier plan, pour préciser les objectifs de l’intervention et surtout ses limites, afin d’éviter de susciter des espoirs hors de proportion avec la réalité thérapeutique. Lors de ces entretiens, volontiers répétés, les objectifs de l’intervention (allègement des aides de marche, amélioration de la stabilité, du périmètre de marche) étaient soigneusement et clairement passés en revue.

Sur le plan chirurgical, la technique était celle d’une hyponeurotisation des rameaux terminaux des nerfs du gastrocnemius et des nerfs du soleus sans aucun temps de neurotomie intratronculaire . Pour le triceps surae étaient définies les branches sur lesquelles devaient porter les différentes neurectomies, à savoir rameaux destinés aux chefs médial et latéral du gastrocnemius et branches(s) du soleus. Pour chacune de ces branches était précisé le pourcentage d’hyponeurotisation (le plus souvent 100 ou 50 %, voire 75 %). De même était décidée l’indication d’éventuels temps « orthopédiques » associés (allongements tendineux, arthrolyse, arthrodèse du couple de torsion, cure de griffes d’orteils). L’examen clinique et les modalités de l’intervention étaient réévalués la veille de l’intervention, au lit du malade par les deux opérateurs.

2.2.2

L’évaluation postopératoire immédiate

L’évaluation postopératoire immédiate avait permis de noter :

• •
  

  l’existence ou non d’une spasticité tonique et/ou clonique résiduelle. Elle n’avait malheureusement pas toujours été évaluée précisément par l’échelle d’Ashworth ;

  
  
• •
  

  l’existence de déformations persistantes (varus et/ou équin) et leur étiologie (rétractions ou spasticité résiduelle) ;

  
  
• •
  

  les complications liées à la chirurgie ;

  
  
• •
  

  le bénéfice fonctionnel immédiat : amélioration de la marche, allègements de l’appareillage et/ou des aides techniques ;

  
  
• •
  

  la satisfaction du patient.

2.2.3

L’évaluation à distance

L’évaluation à distance, au recul maximum, comprenait :

• •
  

  la recherche d’évènements intercurrents depuis l’intervention, les traitements antispastiques actuels et la poursuite de la rééducation ;

  
  
• •
  

  l’âge du patient et la date de la neurectomie ;

  
  
• •
  

  le type de neurectomie et les temps orthopédiques éventuels ;

  
  
• •
  

  une analyse des évaluations intermédiaires dans le dossier médical ;

  
  
• •
  

  un examen analytique du pied avec :

• ∘
  

  la mesure angulaire de la dorsiflexion passive du pied, genou étendu et fléchi,

  
  
• ∘
  

  la cotation de la commande motrice volontaire (bonne/moyenne/faible/nulle),

  
  
• ∘
  

  la recherche d’une activité syncinétique du tibialis anterior lors de l’examen debout (par flexion active de hanche) et d’une syncinésie utile à la marche,

  
  
• ∘
  

  la cotation de la spasticité résiduelle avait cherché à évaluer séparément les composantes tonique et clonique sur les différents chefs du triceps surae. En dépit du risque d’inexactitude et faute de moyen instrumental de mesure fiable, cette évaluation avait été effectuée cliniquement. En particulier, la différentiation entre gastrocnemius et soleus s’était effectuée par palpation directe des corps musculaires. En effet, le soleus, qui est plus profond et au contact du squelette osseux, est facilement identifiable au tiers moyen de jambe, immédiatement en arrière du bord médial du tibia. Les corps musculaires du gastrocnemius sont superficiels et proximaux. On les palpe facilement au tiers proximal de jambe (sur le galbe du mollet). Cette méthode d’examen nous avait semblé plus sûre que la classique distinction de Silfverskiöld retenant, en présence d’un clonus apparaissant genou fléchi, la seule responsabilité du soleus :

• –
  

  l’évaluation de la composante tonique s’était effectuée selon l’échelle d’Ashworth (de 0 à 4),

  
  
• –
  

  l’évaluation de la spasticité clonique par la recherche d’un clonus de cheville, avec la cotation suivante : 0 = absente ; + = clonus vite épuisable ; ++ = clonus épuisable ; +++ = clonus inépuisable ;

• ∘
  

  l’existence de spasticité sur d’autres groupes musculaires (tibialis posterior, notamment),

  
  
• ∘
  

  les troubles de sensibilité superficielle et profonde (sens de position segmentaire de l’hallux et du genou et sens arthrokinétique du genou), ainsi que les troubles trophiques éventuels ;

• •
  

  une analyse de la marche avec un bilan fonctionnel permettant de noter si la situation avait évolué après l’intervention et si l’effet thérapeutique s’était maintenu au cours du temps, notamment en termes :

• ∘
  

  d’aides techniques à la marche,

  
  
• ∘
  

  de possibilités de marcher pieds-nus, en extérieur (à l’interrogatoire) et sur terrain accidenté (à l’interrogatoire : jardin, forêt…),

  
  
• ∘
  

  une mesure de la functional ambulation classification (FAC) modifiée avant l’intervention, en postopératoire immédiat et à distance était réalisée. La comparaison des résultats a été effectuée par un test de Student pour rechercher une différence significative,

  
  
• ∘
  

  au décours de la consultation avait été effectuée la mesure d’une vitesse confortable de marche sur 10 m ;

• 
  

  enfin, une appréciation par le patient du bénéfice de son intervention et du profil évolutif avait été demandée, ainsi que l’efficacité sur son périmètre de marche.

2.2.4

Technique chirurgicale

Au sein de très nombreux procédés, la chirurgie de la spasticité peut faire appel à des techniques d’hyponeurotisation obtenue par section des fibres motrices participant aux différents réflexes segmentaires responsables de la spasticité et des axones des motoneurones entraînant de ce fait une paralysie du muscle tributaire proportionnelle à l’importance des sections fasciculaires. Les procédés habituellement utilisés réalisent des neurotomies fasciculaires intratronculaire. Ce sont ces dernières qui font l’objet des publications de la littérature . Ces techniques comportent un temps de dissection intraneural pour repérage des fascicules dont on souhaite interrompre la continuité. Ce repérage se fonde sur les renseignements topographiques apportés par les données de la cartographie du nerf tibial et sur celles de la stimulation électrique peropératoire.

Notre technique opératoire réalise une neurectomie effectuée à la demande sur les branches motrices terminales en aval de leur émergence. La neurectomie porte sur les rameaux terminaux (ramuscules) de la branche destinée au gastrocnemius et sur la branche du nerf supérieur du soleus ( Fig. 1 ).

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