Highly Selective Neurectomy
Highly selective neurectomy is a technique that has been used for many years. However, it has been more widely used in recent years due to significant advances in nerve surgery and microsurgical techniques.
This surgery involves finding the small motor nerves that supply the problematic spastic muscles. The stretch reflex and co-ordination of muscle contraction is complex but these small nerves play a role transmitting the hyperactive signals from stretching that cause the muscles to become spastic and stiff. Not all spastic muscles are suitable for this procedure. The suitability of a muscle depends on its location and the branching pattern of nerves that supply it.
If a muscle is suitable, experienced surgeons will carefully find all of the tiny nerve branches to the affected spastic muscle. Once the nerves are found they double check with a special needle that stimulates the nerve and causes the muscle to contract - the is to check they have definitely found the nerves to the correct muscle.
Between 60-80% of nerves to a spastic muscle can be cut just before they disappear into the muscle itself. Sometimes there is mild and temporary weakness within the affected muscle. The cut nerve ends over time can grow back into the muscle. This means that the child's ability to control the muscle and the muscle strength are not lost. However when the nerve regrows the fibres that cause the hyper active signals in spasticity cannot regrow. This means that the there can be long lasting relief of spasticity without causing muscle weakness.
In the immediate post operative period no immobilisation is required, unless other procedures on the tendons or bones have been performed at the same time. The effect of the operation will be immediate and the child will be able to start participating with rehabilitation as soon as comfort and wound healing allow.
New Concepts in development
Cryoneurotomy
Peripheral nerve transfers
Peripheral nerve transfers
Internationally there is upcoming research about the use of ultrasound for guided cryoneurotomy. This is the process of freezing the nerve branches to the spastic muscles with a special needle inserted through the skin. It is designed to have a similar effect to highly selective neurectomy.
It is considered a novel or new technique and currently there isn't any long term information as to how good it is. Most of the research is in adults with strokes but it may become available in the future, most likely initially as part of research studies.
Peripheral nerve transfers
Peripheral nerve transfers
Peripheral nerve transfers
There has been some early research into the role of peripheral nerve transfer for weak or paralysed muscles in upper limb cerebral palsy.
Some surgeons when performing a highly selective neurectomy will also consider taking the cut nerve from the overactive spastic muscles and moving it to the weak non-spastic muscles.
A number of studies have proven it is technically possible to combine selective neurectomy with transfer of the motor nerves to the weak muscles. In theory this could be used to improve wrist and fingers motion while decreasing spasticity. However there is currently no clinical information as to whether this beneficial to patients.
Contralateral C7 transfer
Peripheral nerve transfers
Contralateral C7 transfer
Contralateral C7 transfer is an operation on the spine that involves cutting a spinal nerve (C7) from the good arm and transferring it to the C7 nerve on the other side of the neck that supplies the bad arm. It does involve a major surgery and requires a nerve to be sacrificed from the good arm and also an extra nerve needs to be taken usually from the leg to bridge the gap between the two nerve ends. Currently it is not a recognised or established treatment for upper limb CP but is an area of ongoing development.
In itself is not a new treatment, it has been in use for many decades for the management of brachial plexus injuries.
Recently there has been some positive research in China as a potential future treatment in UL spasticity.