Preoperative evaluation: which assessment and when to propose it? Waiting of the surgeon.
Prof Bertrand COULETa, Dr Flavia COROIANa, Prof Isabelle LAFFONTb, Prof Bernard PARATTEc
a CHU de Montpellier, b MPR CHRU Montpellier, Euromov Université de Montpellier, c MPR CHU Besançon
The preoperative evaluation is fundamental in the establishment of the surgical strategy. Concerning Brain Injured patients, the main difficulty is to appreciate the residual motor capacities generally masked by the tendino-muscular spasticity and retractions. This talk aims to describe the methods of analysis of the residual motor capacities and their implications in the surgical protocol. Clinical scales taking into account the residual functions make it possible to apprehend the potential benefits of a surgical program on the walk and the restitution of grasping capacities. The anaesthetic blocks and especially the hierarchisation of their realization will be exposed, of the standardized protocols will be exposed in order to distinguish retraction and spasticity from flexor of the fingers, to highlight a spasticity of the intrinsic muscles masked by that of extrinsic, and to uncover a function of the bungee cords of the fingers and wrist. The anaesthetic blocks make it possible to simulate the neurectomies and their impact on the pollici-digital grip after neurectomy of the deep branch of the ulnar nerve, like on the inflection of the elbow after that of the musculocutaneous nerve. On the level of the lower extremity, the triceps and its branches will be evaluated by anaesthetic blocks poplities, but also the quadriceps by action on the nerve crural. The interest of botulinic toxin will be presented in the preoperative assessment, from its prolonged effect which, associated with a specific rehabilitation, makes it possible to highlight driving diagrams masked by hypertonicity and the spasticity. The place of the EMG will be in particular defined in evaluation of potentially transferable muscles. Finally, the strategies of evaluation of the principal deformations met with the upper limbs and lower will be exposed with the surgical implications which result from this.