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Neuro-Surgical Interventions for Spasticity

Surgical approaches have been considered as a treatment option for those individuals with severe spasticity which has been refractory to more conservative approaches and for which no useful or potential function exists below the level of the lesion (Livshits et al. 2002). Individuals often shy away from this treatment option because of the irriversability of the procedures. There are few well-controlled neuro-surgical interventional studies that have examined the influence of this approach on spasticity as their main purpose. The primary, and most commonly investigated technique is that of longitudinal myelotomy and this approach has also been applied to pain management and spasticity reduction in other etiologies, although spasticity in individuals with SCI is the most common application (Laitinen & Singounas 1971; Yamada et al. 1976; Fogel et al. 1985; Putty & Shapiro 1991). Other surgical techniques include laminectomy, cordectomy, and adhesolysis (Falci et al. 2009; Ewelt et al. 2010). Gautschi et al. (2009) reported significant improvements in health-related quality of life, in patients undergoing cordotomy for syringomyelia. Spasticity was mentioned as a symptom of syringomyelia. Areas like mobility and daily activities improved; which could be in part due to reduced spasticity, despite spasticity not being specifically measured as an outcome in this study.

Table 10 Neurosurgical Interventions for Reducing Spasticity

Author Year

Country
Research Design

Score
Total Sample Size

MethodsOutcome
Livshits et al. 2002

Israel

RCT

PEDro=5

NInitial=40,

NFinal=32

Population: Pourpre group: Mean age: 27.6 yr; Gender: males=15, females=5; Level of injury: paraplegia=20; Level of severity: complete, incomplete; Mean time with spasticity: 2.8yr; Bischof II group: Mean age: 27.1 yr; Gender: males=14, females=6; Level of injury: paraplegia=20; Level of severity: complete, incomplete; Mean time with spasticity: 2.8 yr.

Intervention: Longitudinal T-myelotomy by Pourpre versus Bischof II technique.

Outcome Measures: Short form of McGill pain questionnaire (SFM), Present Pain Intensity (PPI), Visual analog score for pain (VAS), Ashworth scale (AS), Penn Spasm Frequency (PSF) scale. All collected prior to surgery and 6 mo, 5 yr and 10 yr post-surgery.

1.     Authors states that “good” versus “bad” results with respect to spasticity were obtained with the Pourpre technique in 90% of subjects at 6 mo, 75% at 5 yr and 64.7% at 10 yr. The Bischof II technique was less effective in that “good” effects were seen in 65% of subjects at 6 mo, 45% at 5 yr and 40% at 10 yr. The author did not specify what constituted a “good” versus a “bad” effect other than to say it was a return of spasticity.

2.     AS scores and PSF scale scores were significantly reduced relative to pre-surgery values (p values unreported).

3.     People undergoing the Pourpre technique had significantly reduced AS scores and PSF scores than those undergoing the Bischof II technique (p values unreported).

4.     Pain measures were relieved in all cases although there were successively increasing SFM, PPI and VAS scores at 6 mo versus 5 yr versus 10 yr (p<0.0001 for all).

5.     Pain was relieved better (i.e., lower scores for all measures at all follow-up times) for the Pourpre technique versus Bischof II technique.

Ewelt et al. 2010

Switzerland

Case Series

N=15

Population: Mean age: 50.4 yr; Gender: males=13, females=2; Injury etiology: traumatic syringomyelia and tethered cord=13, spinal ependymoma and surgical cord injury =2; Level of injury: paraplegia, T3-T9.

Intervention: Laminectomy, adhesiolysis, cordectomy.

Outcome Measures: 3-point scale for spasticity.

1.     2 individuals improved in their spasticity.

2.     9 individuals stabilized in spasticity symptoms.

3.     4 individuals reported further spastic deterioration of their lower limbs.

Falci et al. 2009

USA

Case Series

N=362

Population: Mean age: 40.5 yr; Level of injury: C6=163, C6-T1=83, T1=116; Injury severity: AIS A=231, AIS B=36, AIS C=42, AIS D=51, AIS E=2.

Intervention: Surgery to arrest progressive myelopathy.

Outcome Measures: Self-reported change in spasticity.

1.     59% reported improvement of spasticity.

2.     27% reported no change in spasticity.

3.     13% reported worsening of spasticity.

Putty & Shapiro 1991

USA

Case series

NInitial=23,

NFinal=20

Population: Injury etiology: SCI=11, MS=7, other=2; Age range: 22-69 yr; Gender: males=12 females=8; Level of injury: C5-T9; Level of severity: complete, incomplete; Time since injury range: 2–23 yr.

Intervention: Posterior T-myelotomy.

Outcome Measures: Subjective clinical impression.

1.     No statistical results were reported; 9 of 10 individuals with SCI had relief from spasms (1 died, unrelated to surgery).

Discussion

Livshits et al. (2002) conducted a study comparing two approaches of dorsal longitudinal T-myelotomy technique (i.e., Pourpre versus Bischof II) on the effectiveness of reducing pain and spasticity in people with SCI (N=40) with a follow-up period of up to 10 years. For the purpose of this review we have assessed this article as a low-quality RCT (i.e., level 2 evidence, PEDro<6). The authors presented the article as a prospective trial with the two surgical techniques that were “randomly” applied as “it was unknown which of the operations would prove to be more effective” (Livshits et al. 2002). Unfortunately, the method of randomisation was not clearly stated and the explicit designation as a prospective trial was not noted. Regardless, it was demonstrated that good to excellent results were obtained with either of these surgical techniques with Ashworth scale scores and Penn Spasm Frequency scale scores significantly reduced relative to pre-surgery values (p values unreported). More individuals had positive results with the Pourpre technique versus the Bischof II technique in that 64.7% of subjects had maintained benefits at 10 years with the former as compared to 40% with the latter. These results are laudable considering these patients were originally refractory to more conservative treatment.

Putty and Shapiro (1991) in a retrospective review of 20 subjects (n=11 with SCI) employed a modified posterior T-myelotomy technique to reduce spasticity and improve nursing care. Although group results were not reported and no standardized measures of spasticity were employed, these authors concluded that this intervention achieved relief from spasms in almost all patients while the impact on nursing care and patient comfort was less specified.

Two level 4 studies examined the effect of varying surgical techniques on patients of varying etiologies (Falci et al. 2009; Ewelt et al. 2010). Although some patients reported improvement of spasticity, no statistical significant improvements could be determined. There is insufficient evidence to suggest one technique over another for any SCI etiology.

Conclusions

There is level 2 evidence (from one RCT and one case series; Livshits et al. 2002; Putty & Shapiro 1991) that dorsal longitudinal T-myelotomy may result in reduced spasticity in those individuals initially refractory to more conservative approaches. These reductions may not always be maintained over the course of several years.

There is level 2 evidence (from one RCT; Livshits et al. 2002) that Pourpre’s technique for dorsal longitudinal T-myelotomy is more effective in maintaining reduced levels of spasticity than the Bischof II technique.

Dorsal longitudinal T-myelotomy may result in reduced spasticity.