I. Overview
Upper motor neuron injury is defined as nerve damage above the motor neurons in the anterior horn of the spinal cord and includes all causes of brain and spinal cord injury, including trauma, infection, degeneration, tumors, congenital cranial and spinal malformations, and other causes. As a result of lesions in the cortical motor projection areas and upper motor neuron pathways, patients often present with paralysis with limb spasticity, hence the term upper motor neuron paresis. Different lesion sites and different pathogenesis can lead to various types of clinical symptoms, classified as hemiplegia, monoplegia, paraplegia, tetraplegia, etc. The main clinical manifestations are loss of superficial reflexes, hyperactive deep reflexes, increased muscle tone, presence of joint movements, and positive pathological reflexes. Cerebral palsy also belongs to upper motor neuron palsy.
Lower limb dysfunction after upper motor neuron injury
After upper motor neuron injury, unilateral or bilateral lower limbs will have spastic paralysis and lower limb standing and walking dysfunction.
Standing dysfunction often occurs in patients with severe upper motor neuron injury, manifesting as poor muscle strength and severe spasticity in the bilateral lower extremities, accompanied by hip flexion and knee flexion horseshoe foot deformity, due to long-term inability to stand, patients are often accompanied by severe osteoporosis, joint contracture, tendon shortening, hip and knee dysplasia, and spinal deformity.
The most common abnormal gait for walking dysfunction is hemiplegic gait and scissor gait.
The upper limbs are flexed, the lower limbs are straightened, the waist is tilted to the healthy side, the paralyzed lower limbs are straightened and externally rotated, swinging forward and outward, and walking in a half circle is called spastic hemiplegic gait, which is commonly caused by corticospinal tract lesions, such as post-stroke.
This gait is called “scissor” gait, which is common in patients with cerebral palsy and spinal cord injury.
The spasm and contracture of bilateral thigh adductor muscles and the limitation of thigh abduction reduce the weight-bearing area of both feet when the patient stands and walks, which is the intrinsic cause of unstable walking and easy falling of the patient. Hip and knee flexion contracture deformity makes it difficult for patients to walk with normal weight bearing and retards trunk development with complications such as osteoporosis. Horseshoe clubfoot deformity is a common limb deformity in upper motor neuron palsy diseases. Due to the presence of clubfoot, patients have difficulty standing and walking normally and need to flex the hip and knee to obtain the biomechanical balance of the lower limbs; therefore, long-term clubfoot deformity is often followed by hip and knee flexion deformity.
Third, the reconstruction of lower limb standing and walking function after upper motor neuron injury
(A) Selective intrapelvic foraminal nerve and tibial nerve dissection
Selective intrapelvic foramen ovale neurectomy is the most common surgical procedure adopted by the Department of Spinal Cord Neurological Reconstruction of the Chinese Rehabilitation Research Center for the effective treatment of thigh adductor spasticity after upper motor neuron paresis. It is suitable for all patients who have no contraindications to surgery. A transverse incision is made across the pubic symphysis, the rectus abdominis sheath is incised longitudinally, the peritoneum is bluntly separated, protected by a large cotton pad outside the peritoneum, a sigmoid pulling hook is applied to retract, the foramen ovale nerve is found on the foramen ovale, stimulated with an electrical stimulator to confirm, the foramen ovale nerve is divided into bundles, and the part with a lower threshold is identified by electrical stimulation and cut. The incision was routinely rinsed and sutured. The patient retains a degree of thigh adductor strength after surgery while effectively removing the spasm of the thigh adductor muscle. Some patients with severe adductor contracture require release of the adductor muscle.
Selective tibial neurectomy is a commonly used surgical method for the treatment of triceps calf hypertonia and ankle clonus with good clinical efficacy. The Department of Spinal Cord Neurological Reconstruction of the Chinese Rehabilitation Research Center uses a minimally invasive surgical approach to cut the skin and subcutaneous tissue in a small transverse incision at the N fossa, reveal the tibial nerve trunk and its dermatomal nerve branch, the medial and lateral head branches of the gastrocnemius muscle and the floundering muscle branch according to anatomy, further divide these muscle branches into several small bundles under the microscope, apply instrumentation to stimulate identification, select the branches with low threshold and cut them, and preserve the high threshold The branches with low threshold were selected and cut, while the branches with high threshold were retained. In this way, the triceps spasm can be removed and the muscle strength can be preserved to the maximum extent possible. Of course, this operation requires a high degree of surgical skill.
Anatomy of the obturator nerve and anatomy of the tibial nerve
Severe spasm of bilateral thigh adductors after thoracic spinal cord injury, making it difficult for the examiner to separate the thighs
The spasticity of both lower limbs after thoracic spinal cord injury was so severe that the patient needed support to stand and walk with a scissor gait before surgery.
The spasm of thigh adductor muscle disappeared after selective closed-hole neurectomy; the spasm of calf triceps muscle disappeared after selective tibial nerve myotomy, and one week after surgery, the patient could walk on crutches, and the scissor gait disappeared.
(B) Hip and knee joint release surgery
For patients with upper motor neuron injury, hip flexion contracture, knee flexion contracture and horseshoe and horseshoe inversion deformity are very common. In cases where conservative and rehabilitation treatment is not effective, surgery should be performed as early as possible. This is because a normal negative gravity line of the lower limbs is crucial for the growth and development of the patient’s bones and joints. Most of the older cerebral palsy patients have dysplasia and subluxation of hip and knee joints, and very rarely dislocation will occur, and incorrect biomechanical stimulation is a trigger for further osteoarthritis. Short stature and psychological disorders are also more common. Therefore, it is very important to actively operate to restore normal lower extremity negative gravity lines and create conditions for patients to stand and walk.
The order of lower limb deformity correction generally follows the order of hip, knee and ankle joints. The hip flexion contracture deformity is treated by hip release, which generally adopts Smith’s incision, and the iliopsoas and gluteus muscles can be released by subperiosteal stripping at the internal and external plates of the ilium; the lateral femoral cutaneous nerve must be protected; the suture descending muscle and rectus femoris can be released to further straighten the hip joint, and sometimes the anterior part of the joint capsule needs to be incised.
The knee joint is generally released by a long S-shaped incision, revealing the biceps femoris, semitendinosus and semimembranosus muscles and extending the Z. If necessary, the posterior joint capsule is incised and part of the medial and lateral gastrocnemius head stop is removed. Pay attention to protect the important vascular nerves in the N fossa.
Pre-operative hip and knee flexion contracture deformity, flatfoot, adductor contracture and other deformities after thoracic spinal cord injury
The deformity basically disappeared after intrapelvic foramen ovale neurectomy and bilateral hip and knee arthrolysis
Significant improvement in standing and walking function with lower limb aids after bilateral hip and knee arthrolysis and pelvic foramen ovale neurectomy
(C) Lower limb orthopedic external fixation bracket fixation
Many patients with upper motor neuron injury have deformities of the hip, knee, ankle and foot, such as flexion of the hip and knee deformity, horseshoe foot deformity, etc. Especially in older patients, these deformities can become serious, complex and irreversible, and simple functional exercise and rehabilitation therapy have little effect. Advanced lower limb orthopedics are required, and those with severe deformities need to gradually correct the deformity after applying external fixation brace fixation to avoid vascular-neural complications. In some patients, due to the long-term squatting gait, the pulling of the quadriceps muscle relaxes the patellar ligament and the patella is displaced and dislocated to form a high patella, so that the quadriceps muscle pulls the patella and the whole biomechanical mechanism with the patellofemoral condylar joint as the fulcrum and the tibial tuberosity as the force doing point becomes disordered and inefficient, so surgery is needed to reset the patella and shorten and suture the patellar ligament. In the case of clubfoot deformity, a selective tibial nerve branch severance is required to relieve the spasm of the triceps calf, followed by Achilles tendon lengthening, tibialis anterior transposition, and, depending on the circumstances, triple joint fusion in some patients. On the basis of the above orthopedic surgery, external fixation brace fixation of the lower extremity is required to maintain the orthopedic shape or further limb correction and to create a good repair environment for tendons and bones. The Department of Spinal Cord Neurological Function Reconstruction of China Rehabilitation Research Center has applied a combination of the above methods and obtained satisfactory results in the treatment of older cerebral palsy, spinal cord injury sequelae and hemiplegic sequelae.
1. Reconstruction of lower limb standing function in a patient with severe cerebral palsy
A male patient, 19 years old, with cerebral palsy (quadriplegia type), had a contracture deformity of both lower limbs with inward hip flexion and knee flexion, unable to stand, and bilateral upper limb flexion spasm, unable to take food and eat by himself.
After the systematic treatment of intrapelvic foramen ovale neurotomy, bilateral lower limb hip release, bilateral knee release, bilateral selective tibial nerve myotomy, selective sciatic nerve cut, and external fixation brace fixation, the patient’s lower limb spasticity was relieved, the deformity disappeared, and the standing negative gravity line was restored. This figure shows the patient’s condition after hip and knee arthroplasty.
The left lower extremity orthopedic brace fixation was removed 2 months later, and the lower extremity knee flexion contracture deformity was completely corrected after the right lower extremity orthopedic brace fixation.
The patient was able to stand and walk therapeutically with the aid of braces after the removal of the bilateral external fixation braces.
Selective sciatic nerve myotomy can be performed in order to release bilateral N cord spasm.
2. Reconstruction of lower limb walking function in an older cerebral palsy patient
A male patient with cerebral palsy, 21 years old, walked with crouching gait, flexed hip and knee contracture deformity, and high patella.
The joint deformity was corrected after bilateral hip and knee joint release, patellar repositioning and external fixation brace fixation.
The patient walked with the assistance of an aid after the external fixation frame was removed
Bilateral knee mobility is normal, exercise quadriceps
3.Horseshoe clubfoot deformity correction with external fixation bracket fixation
Cerebral palsy, hemiplegia, spinal cord injury, etc. can lead to upper motor neuron injury, so that the loss of muscle balance around the ankle joint and foot, and then contracture of muscle ligaments and joint capsule in the state of long-term imbalance, resulting in a relatively fixed clubfoot deformity. Of course, other types of foot deformities can also occur, but clinically, clubfoot deformity is the most common. For deformities of short duration and easy to correct, the muscle balance of the foot and ankle can be reestablished by applying the tendon transposition balance reconstruction technique to improve the walking function of the lower extremity. For patients with longer duration and more severe deformity, it is difficult to correct the deformity and maintain the healing effect by using tendon transposition alone, then the bony fusion external fixation frame fixation surgery is suitable.
Preoperative right limb hemiparesis after traumatic brain injury, right foot horseshoe inversion toe flexion spastic deformity for 13 years.
The deformity was satisfactorily corrected after fusion of the 1-3 interphalangeal joints of the right foot, metatarsal head suspension by transfer of the long extensor tendon of the first toe, fusion of the talonavicular and heel dice joints, and fixation with an external fixator.
The walking function improved significantly 3 months after the correction of clubfoot and toe deformity
(IV) Discussion
1, break through the traditional concept, not simply stuck in rehabilitation and conservative treatment
Various diseases have their inherent laws of development, and the treatment of disease, must first fully understand this law, and follow the law of disease development, the development of the correct treatment plan. Conservative treatment and surgical treatment are a contradiction that has existed almost since the beginning of medicine. Is it conservative or surgical for the same condition? There can be a great deal of controversy between patients and families, and doctors and physicians. In general, both conservative and surgical treatment are scientifically sound; however, there is only one treatment option that is best for a particular individual, at a certain point in time, and for the patient’s condition: either conservative treatment or surgical treatment. When the wrong option is chosen, the outcome is further and further away from the health goal.
For upper motor neuron injuries, early scientific and reasonable rehabilitation treatment can prevent deformity and improve function. When a patient has no limb deformity, rehabilitation can be effective in prevention; when a patient has mild reversible limb deformity, rehabilitation can be chosen to correct the deformity and maintain the function of the limb. However, when the patient is already in a state of long-term severe irreversible limb deformity, conservative rehabilitation can neither correct the deformity nor improve the function of the limb. If conservative treatment continues to be applied at this time, it will not only fail to achieve the purpose of rehabilitation, but also, as the amount of limb deformity and incorrect weight-bearing pattern increases, the patient’s joint deformity will gradually deteriorate, function will be gradually lost, and both physical and psychological development will be affected.
When the limb spasm seriously affects the function, and oral medication has not helped, Botox injection is not effective, spasm repeatedly aggravated, the patient’s liver and kidney function by the toxic side effects of drugs, conservative treatment is no longer suitable; only surgery, only according to the specific condition under the guidance of the correct surgical plan, in order to obtain a more satisfactory treatment effect, of course, the removal of limb spasm of many surgical methods Only a scientific and reasonable surgical method can obtain satisfactory results.
When the limb deformity seriously affects the function of the limb, conservative treatment can not improve the function of the limb, then only the surgical method can achieve the purpose of correcting the deformity and improving the function of the limb, of course, the rehabilitation treatment after surgery is an essential key link.
2.The correct surgical plan is the key to successful treatment
Only by carefully examining the patient before surgery and considering from multiple perspectives such as biology, mechanics, medicine, sociology and psychology can a scientific and reasonable surgical plan be formulated. In some patients, the spasticity of the limb can be removed to achieve a stable gait during weight-bearing and walking, thus improving the function of the limb; in some patients, the spasticity of some useful limb muscles needs to be preserved, while the spasticity of another part of the limb needs to be released; in some patients, tendon transposition needs to be performed while the spasticity is released; in some patients, spasticity release, joint release, deformity correction, and external fixation brace need to be performed simultaneously or in stages. Some patients require simultaneous or staggered implementation of spasticity release, joint release, deformity correction, and external fixation. In short, a detailed plan should be made according to the patient’s specific situation, with the aim of limb function reconstruction, while taking into account the patient’s economic and humanistic factors.