So these procedures do not result in a complete cure that is the hemiplegic limb that has been repaired doesn’t look identical to the way it looked before surgery or to the other limb, but it does usually become much more functional. Functional tasks such as grabbing an object, feeding yourself, using a catheter, manipulating an iPhone. These sorts of things can often be accomplished, but different strategies are often required to accomplish those tasks than were required by the patient prior to the stroke.

In any patient who has suffered a stroke or brain injury resulting Hemiplegia, there are a number of surgical procedures that are available today to augment that function. Patients should be involved in rehabilitation with typical physical and occupational therapy, but once they’ve achieved the best function they can from that program, they should then consult with a reconstructive surgeon who will help them achieve the next level of function. Typically, a patient can gain a significant degree of independence with reconstructive procedures after hemiplegia. Once a patient has been stabilized and achieve their best recovery independently, the goal of the reconstructive neurosurgeon is to bring them to the next level of independence and functionality that is beyond what they could have recovered independently. In most patients, we can achieve significant independence and patients are usually quite happy with what’s accomplished with the reconstructive procedures following hemiplegia.

When a patient is referred for possible reconstructive surgery for their hemiplegic limb, they will come to see us in the clinic and often the surgeons or the surgeons with the therapists together will perform the physical examination. We will then determine which procedures would be the most effective in this case. Sometimes we can determine this based on the physical examination alone and sometimes we need to do additional procedures such as the injections of lidocaine, botox, or the EMG. If those procedures are required, there’s often a second visit involved. We undertake these interventions or these studies, we then see the patient back afterwards to assess the effect of those interventions. If they accomplished what we hope they would accomplish, we will then plan for surgery. Surgery is typically an outpatient procedure, usually lasting less than three hours and the patient would go home the same day. Pain usually is not significant and incisions usually close with absorbable sutures and skin glue so the patient can shower the same day or without any adverse effect of the wound. The patient usually within the same week is referred to physical therapy and began training and learning how to use the limb in its new configuration. The patient usually is referred to physical therapy and they will begin that therapy within a week of surgery. Immediately, the use of the limb will have changed and they will begin to learn how to use the limb in a more functional way.

Reconstructive surgery after stroke is just a small part of the entire recovery process that’s involved in achieving the best results and function. The patient wanted to go immediate stroke care in the hospital setting. They will then undergo therapy and care by rehabilitation specialists after this. They will then achieve their plateau or final spontaneous recovery within about a year, at which point we get involved to do the reconstructive procedures. But after that, they would then return to the care of the rehabilitation specialist who will be caring for them over a number of years.

We usually have to take such procedures in conjunction with a physical medicine and rehabilitation doctor. Somebody who’s undertaken the rehab of the patient may have undergone some trials of Botox, is determined that the patient would benefit from a more significant intervention. We will see the patient assess them. Sometimes EMG or nerve testing studies can be used to help us determine which muscles are the biggest problem and then we can do a very focused intervention. Typically the procedures lasts less than an hour. They are soft tissue incision followed by cutting of the nerve branches and the patient could go home on an outpatient basis. And the recovery of function is almost immediately realized this should be done in conjunction with physical therapy. The patient to after the relaxation of the muscles will need to be trained on how to use the arm and how to get the most function out of what has been performed. So if it’s the upper extremity an occupational therapists will work with us on recovering that function. If it’s a lower extremity, the physical therapist and a gait training program will be involved teaching the patient how to land the foot on the heel and had a swing through more appropriately to get a better date.

So risks of undertaking such procedures are one causing excessive weakness. Sometimes we have to take quite a bit of nerve to reduce the spasticity. And in doing so we may relax the muscles so much that a patient feels a bit unsteady on their feet or like they can’t perform some of the tasks they did previously. Usually this resolves with therapy in a patient is ultimately happy with the outcome. A patient that has had a stroke or brain injury is often under the care of a neurologist who is managing the cause of the prior stroke. This may involve blood thinners. This may involve an entity in the body that can predispose them to another stroke in the future. It is important for your reconstructive neurosurgeon to work together with a neurologist or whoever’s following the care of the stroke to make sure they come up with a plan that will keep the patient safe from any additional strokes or other problems in the future. The patient must be safe to come off their blood thinners for the period of time required to undertake the surgery in the early recovery, and the patient must not be at risk for having further strokes by undergoing anesthesia.

Some patients who would not be a candidate for these procedures would be those with severe, intractable pain, those are the significant medical comorbidities, those in whom it’s unsafe to come off their blood thinning medications for a short period of time, and those patients who are not willing to participate in the significant rehabilitation and physical therapy required to achieve the results of these procedures.

So any patient who is left with Hemiplegia who’s not recovered full function in the arm or leg is probably a candidate for some of these procedures. The risk must be weighed against the benefits. If a patient is very functional with the arm, but yet unhappy with the fact that the increased tone persists, sometimes we recommend they continue with therapy and botox and not undergo surgical procedure. If there is a significant impediment to function, I think that surgical procedures are usually the best way to achieve the increased degree of function that they’re looking for.

So whena patient suffers hemiplegia the body can do some recovering on its own over time. The brain develops what’s called plasticity and it can find other pathways to accomplish some of the tasks that had accomplished formerly. And sometimes patient can recover the ability to grasp and release the hand to reach the mouth to walk better. But usually this plateaus or reaches a final function that still is far less than what they originally had. When this occurs, typically surgical procedures are available to get an additional degree of function. So a patient’s walking after Hemiplegia usually is stiff, spastic, he foot years use turned in, the toes are curled, and the typical answer for this as an AFO brace or an ankle foot orthosis. The patient’s foot of strapped into this to hold the ankle up or at a functional position and then the shoes put on over the top of the brace. This doesn’t correct the underlying problem in this means the patient will be relying on this brace for the rest of their lives. Sometimes function still exists in the muscles that should bring the foot up and bring the foot out and extend the toes, but they’re overpowered by the muscles that push the foot down, turn the foot in, and curl the toes. A simple procedure to correct. This is called the selective peripheral neurotomy. A patient who has this kind of tone should undergo a trial of botox or botulinum toxin. Botox can be injected into those muscles to push the foot down or turn the foot in and sometimes relieve some of that hyperactivity in those muscles to balance the function out. Oftentimes botox is not sufficient because these muscles are quite large muscles and a very large doses required. Instead of botox or even following botox, the procedure, the selective peripheral neurotin me can accomplish the same goals in as long lasting. In our practice. We often use botox to show the patient what we are trying to achieve with surgery. We will inject the muscles, provide a little bit of relaxation, and let them know that surgery would cause even more robust relaxation and be permanent. Once they decide that this is what they would like to have done, a surgical procedure what lasts a little over an hour is performed when this is the foot and walking off, and this is just behind the knee, we open, identify the nerve and the branches that are providing stimulus to the muscles that are overactive are trimmed back. We can usually cut these back by say two thirds or even four fifths, maintaining control of the muscle, but reducing that hyperactive tone substantially. When this is done, that foot will land flat on the floor once again, and many patients can graduate from that brace and walk independently.

A stroke results in an injury to the brain, either from loss of blood flow to a portion of the brain or from bleeding into the brain itself destroying tissue as a result. So our brains control the body through nerve pathways that pass usually from the opposite side of the brain to the opposite side of the body. So the left side of my brain controls the right side of my body. The right side of my brain controls the left side of my body. So when a patient has a stroke, an artery gets blocked, we lose blood flow to a portion of the brain. There’s an area of brain that dies. If that area of brain includes the motor pathways, that control movement in the body, the opposite side of the body will lose significant function. Sometimes strokes can be a small area where there’s just a little bit of increased tone and dysfunction of the movements of the hand or causing walking to be a little less smooth. And sometimes stress can be a very large area of brain resulting in complete loss of function in the opposite side of the body. Where the hand and arm are entirely useless and the patient is limited to living in a wheelchair and not able to walk.

These procedures aren’t limited just to the leg. These procedures are available to the arm and hand. Typically the function of the arm and hand after a stroke is characterized by adduction and internal rotation of the shoulder. That is the arm is pulled into the side and turned in so the forearm is against the abdomen. At the same time the elbow is flexed, the wrist is flexed, protonated that is the hand turned down towards the floor and the fingers are clenched. Sometimes there’s some degree of function, the patient is able to open. The fingers are extended the arm a little bit, but some of the muscles are interfering with that action. We can usually identify which muscles these are and find the branches to them and trim them back and eliminate this dysfunction. Sometimes the patient’s arm and hand can be completely dysfunctional where there is no active motor control at all. When this is the case, often hygiene is a problem or even simple daily tasks such as getting clothes on the arm. When this is the case, we can relax these muscles are these nerves entirely to allow the arm to fall down to the side and a more relaxed position making place in clothes or washing the arm and cleaning the arm much more simple. When we find that the patient has some underlying motor control, they can clench the hand, they can flex at the elbow, yet other muscles are getting in the way, this is using an ideal candidate to find the dysfunctional muscles, trim them back and achieve much more normal function once again. So patient who had no ability to pick up a fork or bring a cup to their mouth, after these procedures, they often can regain that type of control.

The same dysfunction that takes place in the foot can take place further up the leg, so sometimes the patient’s legs, will scissor. That is the adductors where muscles that pull the legs towards one another, can be overactive making it difficult to swing the leg in front. We can do the same procedure on the nerve, supplying those adductor muscles, trimming it back, relaxing that spasticity, and creating a normal swing phase of the gait so they can walk better. These procedures aren’t limited just to the leg. These procedures are available to the arm and hand. Typically, the function of the arm and hand after a stroke is characterized by adduction and internal rotation of the shoulder. That is the arm is pulled into the side and turned in so the forearm is against the abdomen. At the same time the elbow is flexed, the wrist is flexed, pronated, that is the hand turned down towards the floor and the fingers are clenched. Sometimes there is some degree of function. The patient is able to open the fingers or extend the arm a little bit, but some of the muscles are interfering with that action. We can usually identify which muscles these are and find the branches to them and trim them back and eliminate this dysfunction. Sometimes the patient’s arm and hand can be completely dysfunctional where there is no active motor control at all. When this is the case, often hygiene is a problem or even simple daily tasks such as getting clothes on the arm. When this is the case, we can relax these muscles or these nerves entirely to allow the arm to fall down to the side and a more relaxed position making placing clothes or washing the arm, cleaning the arm, much more simple. When we find that the patient has some underlying motor control, they can clench the hand, they can flex the elbow, yet other muscles are getting in the way, this is usually an ideal candidate to find a dysfunctional muscles, trim them back and achieve much more normal function, once again. So patient who had no ability to pick up a fork or bring a cup to their mouth after these procedures, they often can regain that type of control.

There are two primary effects to these procedures. One is the muscle that is being targeted has it’s direct and immediate effect and the other is a more global effect of relaxing the entire limb or even relaxing the entire hemiplegic body to some degree. For example, when we undertake a tibial neurotomy to straighten the foot out and cause that the heel to land on the ground when the patient is walking, they’ll often also experienced some relaxation of the proximal muscles. The leg swings easier, they can stand from a chair easier and they have less difficulty walking than they did previously from the proximal aspect, not just the distal aspect. Because of this, we like to undertake these procedures in a stepwise fashion. We will do the most egregious or the most troublesome muscle group first and then look at the global effect that it’s accomplished over the next three to six months. Once the patient is plateaued in their recovery. Once again, we’ll move on to the second step or the second most problematic muscle group and repeat the same process. Because of this, a patient may undergo four to six procedures before we’ve completed accomplishing everything we can with our functional recovery.

The reconstructive procedures involved in restoring function after a stroke or Hemiplegia are typically covered by insurance, but it will be important for you to check with your particular insurance carrier to be sure that you are a candidate for these.

Unfortunately, there’s little awareness of the procedures available to patients who’ve suffered a stroke. Typically, after a patient has undergone rehabilitation for a year, they’re determined to have achieved the ultimate function that they can achieve. Because of this, most patients are not receiving the surgical care that would help improve their quality of life. It is realistic that in most cases of heavy plegia surgical procedures can increase their functionality substantially. Improving walking, improving independence, improving the use of the hand and leg. The ultimate effect of these procedures is to ease the patient’s day to day life, self care, and ability to get about. Walking should be improved. The ability to use the hands, the ability to take care of yourself, feed yourself, and accomplish tasks of daily living should be eased. Sometimes it requires stepwise procedures, beginning with the leg moving to the arm and back and forth until we achieve the function that we’re after. Typically, a patient should be under the care of a reconstructive surgeon for up to three years from the initiation of these procedures until we achieve the ultimate desired result.

The field of stroke care has advanced dramatically over the last decade. The amount of options for care, the ability to remove a clot, restore blood flow, the type of rehabilitation that’s available to patients after a stroke. But even with all of these advances, we have enormous number of patients across the United States and around the world who are left with a degree of Hemiplegia. Hemiplegia is the result of a stroke or brain injury that causes the opposite side of the body to lose function, to develop hypertonicity or spasticity causing the muscles to be tight, the arm to drop and the fist to clench, the foot and ankle to turn in, impairing a patient’s ability to walk or use their hand for such basic functions as even feeding themselves or writing on paper. Once a patient has done everything that they can do to recover this with physical therapy, with medications to reduce the spasticity, with bracing, they often are left with a sub optimal function of both limbs on that side of the body. And what seems to be not common knowledge is that there are a number of surgical procedures that are available to improve that function.

So when half of the body does not work as a result of this sort of injury to the brain, this is referred to as Hemiplegia. Hemi being half. Plegia being inability to move. So half of the body has a decreased ability to move the way it should have normally because of the opposite side of the brain is no longer providing those functions.