Potential Role of Fascia Release Via Percutaneous Needle Fasciotomy in Spasticity Management

The patient is a 46-yr-old left-handed female with a past medical history of grade 3 oligodendroglioma s/p resection 8 years ago with residual left spastic hemiparesis. She has significant spasticity in her left foot and toe that limits her gait, and mild spasticity in her left upper limb muscles that intervenes with her voluntary movements in her arm. However, she has never received medications or injections for upper limb spasticity. In addition to regular injections to her lower limb, percutaneous needle fasciotomy was performed to release fascia overlying biceps brachii muscle. The procedure was performed under ultrasound guidance, and 1% lidocaine was injected to the target area before needling. An 18-gauge needle was used to break down the fascia mechanically for about 1 centimeter horizontally (Fig. 1). The patient tolerated the procedure well. She reported relaxation of elbow flexor muscles immediately after the procedure. As shown in the video, elbow flexor spasticity was decreased from modified Ashworth scale score of 1+ to 0 (Video 1, https://links.lww.com/PHM/C648). Her voluntary elbow extension was smoother and was able to reach to the end of elbow extension easier. This chart review case report received Institutional Review Board approval from our institution.FIGURE 1: Comparison of fascia overlaying the biceps muscles from ultrasound images of spastic biceps muscles (A) and of contralateral nonspastic biceps muscles (B). Panel C illustrates fasciotomy. During the procedure, the needle is inserted under the guidance of ultrasound imaging, and reaches to the thickest part of the fascia overlaying the spastic biceps muscle. The fascia is broken down mechanically about 1 centimeter horizontally at its tightest and thickest part (dash line).Fasciotomy has mostly been utilized in the treatment of Dupytren’s contracture. This is the first case that mechanical breakdown of superficial fascia overlaying the spastic biceps muscles by percutaneous needle fasciotomy can immediately reduce elbow flexor spasticity and improve voluntary movement. In contrast to spasticity interventions such as chemodenervation targeting the neuromuscular complex and neurolysis targeting at nerves, this case suggests the potential role of fascia in the spasticity pathophysiology and thus in spasticity management. The fascial system provides scaffolding structure to the musculoskeletal system and is composed of the epimysium (surrounds the entire muscle), perimysium (bundles groups of muscle fibers), and the endomysium (surrounds the muscle fiber). More importantly, the fascia system is richly innervated with different sensory receptors, and it shares innervation with surrounding tissues, that is, muscle fibers and spindles, to provide a convergence of sensory inputs, thus amplifying pain.1 Comparison of muscle biopsies from spastic cerebral palsy and normal muscle showed thickened fascia primarily involving the perimysium or the endomysium in the spastic muscles.2 It is likely that percutaneous needle fasciotomy breaks down some of sensory inputs from the fascia to the spinal reflex network, thus reducing spasticity. On the other hand, mechanical breakdown of fascia is not likely to reduce spasticity as assessed by modified Ashworth scale but may contribute to the observed increase in the range of motion. This speculation is supported by the observation that manual fascia manipulation and release can effectively reduce spasticity in both upper and lower limbs in stroke subjects.3 This case showcases a proof-of-concept observation that percutaneous needle fasciotomy reduces elbow flexor spasticity immediately after the procedure. This observation stimulates further research questions, such as the potential role of fascia and peripheral sensory contributions in the spasticity pathophysiology, the mechanism underlying this intervention, the duration of the treatment effect, the need of adjunctive therapy, for example, stretching, and patient selection.