The Victoria Combined Peripheral Nerve and Spasticity Clinic

Issue: BCMJ, vol. 61, No. 4, May 2019, Pages 158,182 News

The Victoria General Hospital Clinic is offering novel, ground-breaking collaborative innovations. After witnessing impressive neuro-orthopedic outcomes in Europe, physiatrist Dr Paul Winston (medical director of Rehabilitation for Island Health) accessed a team of experts to test, trial, and improve the latest standard of care.

Dr Winston was already providing a complex peripheral nerve clinic with plastics and hand surgeon Dr Emily Krauss, who specializes in nerve transfers for people with spinal cord injury. He approached Dr Daniel Vincent, interventional anesthesiologist, on how they could best reproduce an individual lidocaine selective nerve motor block to spastic muscles to choose the most responsible muscle causing spastic deformity and determine if the patient had underlying contracture.

From a 1-day session with physiatrists from Victoria, Vancouver, and Nanaimo, they learned the technique by adding ultrasound guidance to what was previously an EMG guided technique. The change in range of motion in the spastic limbs was sufficiently profound that Dr Vincent, who had decades of experience using cryoneurotomy for sensory nerve pain relief, suggested adapting the protocol to motor nerves. This decades-old technique of freezing nerves involves a percutaneous ice ball at −60 °C. After 6 months of researching the technique, and finding only one published case of motor cryoneurotomies, the team began to offer cryoneurotomy, resulting in impressive change in function. At the same time, Dr Krauss began to offer selective microsfascicular neurotomies by stimulating the tiny nerve branches of selective nerves and cutting the branches to the most spastic muscle group found after the ultrasound-guided nerve blocks. By cutting nerves, she has been restoring active hand opening to patients with no hand function, or opening nonfunctional clenched fists with skin breakdown. Dr Krauss specialized in this microfascicular arrangement of nerves in her fellowship in St. Louis.

The Victoria physicians have partnered with Vancouver-based physiatrists, led by Dr Rajiv Reebye, along with Dr Patricia Mills and Dr Heather Finlayson and orthopaedic surgeons Drs Kishore Mulpuri, Lise Leveille, and Tom Goetz to create a new organization, the Canadian Advances in Neuro-Orthopedics for Spasticity Congress. An inaugural congress in April ( brought international experts together in Vancouver. Together they plan to advocate for collaborative care with physical therapies, botulinum toxin, and bracing.

The project was supported by a grant from the Specialist Services Committee, a joint collaborative committee of Doctors of BC and the Ministry of Health.

. The Victoria Combined Peripheral Nerve and Spasticity Clinic. BCMJ, Vol. 61, No. 4, May, 2019, Page(s) 158,182 - News.

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