SELECTIVE AND CLOSED MYOTENOFASCIOTOMY FOR MYOFASCIAL RELEASE IN PATIENTS WITH BRAIN INJURY SEQUELS
BY DOCTOR IGOR NAZAROV
I can treat:
- Sequels of cerebral palsy, traumatic brain injury, brain hemorrhage and ictus and of brain malformations. Types: hemiparesis, diparesis, paraparesis, tetraparesis, etc…
- Feet deformities (equine feet, club feet, etc), hand deformities (obstetric brachial palsy), neck deformities (congenital torticollis) and other deformities arising from spasticity or from mixed types.
One of the main sequels of those pathologies are myofascial retractions that can be formed in striated muscles of the human body.
For the first 2 years after having received a brain injury, muscles that are excessively contracted by a continued spasticity (muscle hypertonus) suffer metabolic problems (such as the lack of oxygenation, nutrition, excess of lactic acid, etc.) This provokes the development of a degenerative process of dystrophy in the fibres of the fibrous tissue, mainly in fascias, muscles, in the tendinous tissue or other tissues.
Some fibres are shortened and devitalized, showing myofascial retractions that limit muscle extensibility and movements. These retractions, together with spasticity, provoke impaired postures, partially block the normal growth of some parts of the body, and exacerbate the degenerative process of dystrophy, compressing blood vessels and peripheral nerves.
In myofascial retraction areas, the pain symptom usually arises, provoking more spasticity, which in turn favours the development of new retractions. In this way, a vicious circle is reestablished: “pain-spasticity-retraction-pain”.
Retractions can be more or less rigid depending on the seriousness of the modifying factor and of the degenerative process of dystrophy in pathological fibres.
If myofascial retractions are acute and result in a lot of rigidity, they can in time provoke dysplasias, dislocations, bone deformities and dysmetrias. Simultaneously, joint contractures can be formed (joint fusion), as a result of limited movement (usually at the age of 8 – 12).
Doctors’ efforts to recover above all the reversible part of brain injury and to avoid sequels do not always have the desired result with regard to muscles, because myofascial retractions already exist, which have become separate from their cause (brain injury) and, often, patients are only relieved temporarily.
Traumatologists use different corrective techniques for those retractions and their sequels, including from tenotomies to osteotomies and reconstructive surgery in the bone-tendinous apparatus, which can be considerably invasive. The results of these surgeries are not always effective, sometimes they are even counterproductive (limp feet, recurvatum, excessive abduction, etc.).
Selective and closed myotenofasciotomy is a minimally invasive surgery, which enables releasing muscles from myofascial retractions, exclusively sectioning shortened fibres. Surgery is practised with a fine scalpel by percutaneous access and very precisely (with no need to open, and thus avoiding the subsequent suture and formation of scars). Always respecting healthy tissues and their layers.
- During the pre-operative visit, surgery areas are determined, even though they can be modified during the same.
- Surgeries are practised under general inhalation anaesthesia without intubation and approximately last 30 minutes.
- No later immobilisation with plaster or similar is required.
- It is a major outpatient surgery, but taking into account that most patients are outsiders, the optimal term of stay in hospital is 24 hours. Afterwards, dressings are removed, and the patient can move to his address or hotel.
- Post-operative pain is not strong. Painkillers are recommended (ibuprofen or paracetamol) during the first 4 days (2-3 daily doses, the last intake is 1 hour before going to bed).
- Occasionally, haematomas can appear in some operated areas. In that case, you must apply cold (by means of a cold pack) during the first 4 days. Hardened areas can also appear provisionally, notwithstanding the results, which are solved by themselves without needing any treatment.
- By means of this slightly invasive surgery, a successful treatment is possible in a single phase, up to approximately 22 retraction areas in different areas of the body (multilevel surgery). If there are more retractions, it is possible to operate in 2 or more phases with a minimum interval of 8-10 months between surgeries.
- There is a 25% possibility that new myofascial retractions take place after some time due to growth and to the increase in movements. However, most patients do not return to their condition before surgery.
- Surgery frequency is subject to the particularities of each patient, to the development of his disease and to the doctor’s criterion.
This surgical technique is compatible with other treatments or surgery, as in general it does not alter the anatomic structure of the muscle, of the locomotor apparatus, or of other organs or systems of the human body. On the contrary, it brings muscular signs closer to normality as much as possible.
My 25 years of experience in the development of this procedure, have proved to me that we should operate children from 2 years and a half old, and in case of adults, after 2-3 years from the accident (in case of sequels of the traumatic brain injury or cerebral vascular accident). This waiting time period will make us achieve more functionality when the reversible part of the brain injury is completely recovered, and when it can assimilate myofascial release.
- Acute infectious disease.
- Acute somatic disease in a decompensation status.
- Very delicate general medical condition (severe breathing problems, extreme epileptic condition, etc.).
- Severe blood coagulation problems.
- Allergy to all anaesthesia preparations.
Desired results of myofascial release are:
- Maximum possible reduction of rigidity.
- Extensibility of the fibrous tissue is close to normality (fascia, muscle, tendinous tissue or other tissues).
- Improvement of blood flow and tissue metabolism of operated areas.
- Reduction of the degenerative process of dystrophy and recovery of the vitality of the fibrous tissue.
- Reduction of spasticity.
- Increase of muscle mass and strength.
- Improvement in muscle control.
- Removal or decrease of muscle pain (if it shows up), breaking the vicious circle: “pain-spasticity-retraction-pain”.
- Possibility of reduction or cancellation of the use of the botulinum toxin and of muscle relaxant drugs (baclofen, lioresal). Always under medical control.
- Development of new connections in the central nervous system (especially at a proprioceptive level) due to improvements achieved with “bottom-up” influence.
Those results are possible provided the problem is due to myofascial retractions.
Considering that most patients show an acquired brain injury (which could have taken place during the intrauterine period, during labour, postpartum, or during life), the healthy nature of the body of the patient can benefit from the release of myofascial retractions, showing this functional results:
- Increase and improvement of movements (active and/or passive) in the affected segments of the locomotor apparatus.
- Improvement of motor skills/mobility of hands, arms, legs and other areas.
- Stabilisation or correction of pathological positions and postures.
- Improvement of balance, sitting and verticalisation, and possibility of improvement of the type of displacement or walk.
- Biomechanical parameters of patients are completely close to normality (symmetry, linings, etc.).
- In children: release of growth and of the formation of the body in general.
- Improvement in chewing, swallowing, pronunciation, speech, breathing and sputum.
- Prevention or stabilisation of orthopaedic problems such as subluxations, joint contractures, bone deformities, recurvatum and dysmetria if they are not severe (simultaneously, they require attention from orthopaedic technicians).
- Improvement of temperature in limbs.
- Reduction or removal of constipation.
- Reduction or removal of strabismus and improvement of sight.
- Reduction or removal of headaches and improvement of psychoemotional balance and personal well-being.
- Improvement of conditions for general development, giving opportunities to patient neuroplasticity, and making access to physiological patterns easier.
- Making care relatives should give the patient easier.
Post-operative recovery is simple and requires fulfillment of recommendations prescribed by the doctor.
Lower limbs, because they bear a considerable load, need a short period of recovery and adaptation to new postures, even though they are good. Patients need 2 weeks to stand again, and those who moved by themselves before surgery, 3 weeks to begin displacements.
Results begin to show, depending on the operated areas and according to the particular characteristics of the patient. In some muscles, they can be appreciated on the following day, while in others this can be after weeks or months (up to 6 months).
Taking into account that this group of patients has multifunctional problems, in some cases the excessive spasticity or other modifying factors (dystonia, limpness of some joints, etc.) do not allow enjoying positive results of the treatment. In that case, patients may require the attention of other professionals.
From 1 month after the surgery, patients must go back to their therapists, rehabilitation specialists or other specialists to be evaluated according to their new situation. The evaluation of the changes and the rethinking of the physiotherapeutic tactic are fundamental for the treatment of current problems and to maximise the rehabilitation of each patient.
To achieve the best results, we recommend beginning joint mobilisations after three weeks, and beginning strengthening and re-education of muscles after one month from the operation, gradually.
Also, joint problems must be treated: contractures or limpness (if any) performing stretchings, using orthopaedic procedures such as insoles, orthosis, standing frames, walkers, and applying at the same time from physiotherapeutic techniques to intensive techniques (the last ones from 3 months).
The intensity and type of exercise will depend on the characteristics of each patient, and on the professional criterion of the physiotherapist treating him, always trying to achieve the maximum development of autonomy.
The main objectives are the following:
- Optimising the rehabilitation process of disabled patients, and offering them the opportunity to undergo this treatment in Spain.
- Studying the results of the treatment itself, and looking for new possibilities to improve life standard of this group of patients. All of this together with specialists (neurologists, paediatricians, physiotherapists, orthopaedic technicians and other interested specialists).
- Continue researching on these diseases in other areas, such as the functional diagnostic or other advanced diagnostic methods.
Everything mentioned in this informative text is general and for guidance. Each patient requires individualised attention by the specialist in this treatment.
It is impossible to practise this technique without any risk for the patient’s health if you haven’t had the possibility of training with a doctor with experience in this field.