PMC5682697_01
Presurgical and postsurgical evaluation. Clinical improvement after surgery: the upper pictures (a and b) correspond to the clinical presentation of claw fingers. On the left foot, an arrow shows the claw fingers before and after surgery. The lower pictures (c and d) indicate the clinical presentation before and after spinal neurotomy. On the left image, the patient presents an evident winged scapula, and on the right image (4 years after surgery) it shows a normal symmetry of the scapula
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F1
He also received botulinic toxin injections at following three sites to treat spasticity: (1) lower extremity, a spastic claw foot with plantar pain; (2) upper extremity, a flexed hand; (3) high grade spastic "winged scapula" [Figure 1].
(a) Anterior (A) and posterior (B) neck triangles, crossed by an oblique line corresponding to the spinal nerve location. (b) Skin incision at the posterior triangle. Between the trapezoid (T) muscle fascicles, the spinal nerve (SN) at the beginning of the dissection. (c) The trapezoid muscle with the angular elevator of the scapula (AE) muscle. (d) Stimulation of the spinal nerve (arrow). (e, f) Dissection, traction, and cut-off the SN. (f) The arrow marks the scalpel during the neurotomy. (g) Sectioned by cut branches, to be harmonic with the figures abbreviations (CB). (h) At closure, the SN, T, superficial yugular vein (SYV) and platysma muscle (P)
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F2
Aneurotomy of the angle elevator of the scapula muscle was performed [Figure 2].
Neurotomy of left median nerve. Left image (a) shows the longitudinal skin incision over the arm and forearm on the anterior face at the elbow level (observe the sinusoidal shape of the incision). Right image (b) demonstrates the dissection details of the surgery including the Median Nerve (MN) with its different nerve branches: P (pronator teres), Palmaris Mayor (PM), Palmaris minor (Pm), Fingers Flexor Trunk (FFT)
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F3
Left foot fingers flexors nerves. Left image (a) exemplifies the dissection of the tibial posterior nerve trunk (TN) using a trans-popliteal approach (observe the isolation of its different divisions). Right image (b) illustrates the microscopic approach of the flexor branches dissection that are located deeper to the tibial nerve trunk (TN) and the dissection of them (arrows)
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F4
For the claw foot/toes spasticity, a tibial posterior neurotomy through a trans-popliteal incision [Figure 4a] was utilized. The superficial and profound common nerves were observed [Figure 4b].