Orthopedic and neurosurgical operations in neuroorthopedics: one-step or two-step procedure?
Prof Christian FONTAINEa, Dr Michel-Yves GRAUWINa, Dr Etienne ALLARTb, Prof André THÉVENONb, Prof Patrick MERTENSc
a Pôle des neurosciences et de l'appareil locomoteur, b Pôle des rééducation et réadaptation fonctionnelle, c Service de Neurochirurgie
Surgery of hemiplegic patients was historically and remains often scheduled in two steps: neurotomies (hyponeurotization) at first, to reduce hypertonia; orthopedic procedures then, to handle tendinous shortenings, rebalance the altered musculotendinous balances and, more rarely, correct unstable or fixed deformities by arthrodesis.
Keeping such a strategy in two steps seems still justified:
- In border cases, where we can believe a priori that the only neurosurgical procedure will be enough for the patient;
- In difficult cases, where all of the operating schedule can be only decided with difficulty in a certain way and where we can prefer to analyze the situation after the neurosurgical procedure.
In all other cases, a one-step combined neurosurgical and orthopedic procedure should be discussed, with the following advantages:
- A single operating procedure, a single anesthesia, a single period of immobilization and a single period of post-operative rehabilitation;
- A quickly acquired outcome, not requiring a second multidisciplinary consultation, a second delayed operation.
By comparison, the inconveniences are minor:
- Of organizational order: if the two teams are different, one of the two surgeons has to move at the other’s operating theater, and both surgeons have to grant their diary. It also asks the question of the overtaking of the cleavages of specialties; the neurosurgeon could be trained for performing simple orthopedic procedures and the orthopedist for neurotomies
- Of financial order (impossibility to invoice more than 2 procedures while that such an association can require 4, 5 or 6 different procedures).
The authors present the experience of the team in which they work in the light of the evolution of attitudes over these last 10 years. In conclusion, one can wonder if the neurosurgeon or the orthopedist interested in the neuroorthopedics should not know the simple procedures on tendons or on nerves, which would allow making mixed procedures in one step without obliging the appeal to two teams?