Hyperselective Neurectomy for Upper-Limb Spasticity Under General Anesthesia or Wide-Awake Surgery

Background:

Hyperselective neurectomy (HSN) reduces focal upper-limb spasticity while preserving voluntary function. Wide-awake surgery allows intraoperative assessment of tone and movement, but comparative evidence is limited.

Methods:

We retrospectively studied 44 patients undergoing upper-limb HSN under general anesthesia (general anesthesia [GA]; n = 23) or wide-awake local anesthesia without a tourniquet (n = 21). Allocation was nonrandom, and wide-awake surgery was limited to patients able to cooperate with intraoperative testing. Mean follow-up was 23 months after GA and 24 months after wide-awake surgery. The patient was the primary unit of inference; nonindependent joint-level outcomes were summarized descriptively.

Results:

All wide-awake procedures were completed without conversion to GA (0%; exact 95% confidence interval [CI], 0%–16.1%). Intraoperative assessment prompted modification of the neurectomy plan in 5 patients (23.8%; 95% CI, 8.2%–47.2%). Mean House classification improved from 2.0 (SD, 1.0) to 3.8 (SD, 0.9) after GA and from 2.1 (SD, 0.9) to 4.4 (SD, 0.8) after wide-awake surgery; final patient-level distributions differed on rank-based comparison (p = 0.02). Both cohorts showed reduced spasticity and improved motion. Final elbow, forearm, and wrist active arcs were numerically greater after wide-awake surgery, whereas thumb arcs were similar. No major complications or reoperations occurred.

Conclusions:

Wide-awake HSN was feasible in selected cooperative patients and enabled intraoperative modification of the surgical plan. Although some outcomes numerically favored wide-awake surgery, the small, nonrandomized cohorts, selective eligibility, temporal and learning-curve effects, adjunct procedures, and clustered observations preclude causal or superiority conclusions.

Level of Evidence: