What is Selective Percutaneous Myofascial Lengthening/PERCS/Percutaneous Fascial Lengthening?

It is not not recommend walking up to your local surgeon and asking if he/she performs SPMLs.  Most likely they have never heard of a procedure by that name.   If they say they have, they typically are thinking ‘yes, I have done percutaneous tendon or aponeurotic lengthening”.

Some know of the name “SPML” but refuse to acknowledge that it exists or that it is more beneficial functionally over short and long term in our cerebral palsy kids. This is basically a “hide your head in the sand” and “don’t confuse me with facts” mentality.  It is strange that we learn a surgical technique from traditional teaching.  The surgery is not wrong.  It is how I was taught.   However one would think that over the past 50 years or so, other techniques evolved from our earlier, simplistic and not entirely correct understanding of the problem at hand.  Well techniques did evolve as technology marched on so that functional success rates have increased and rehab times have decreased.   Yes it is just easier to bury one’s head in the sand rather than to add surgical techniques to my repertoire.

The basis of the procedure was developed by Roy M. Nuzzo MD [pediatric orthopedics].  Much information about SPML and other aspects of pediatric orthopedics can be found at Dr. Roy Nuzzo’s website.   

Since I met Dr. Nuzzo over 35 years ago, some of the specifics of the procedure have changed a bit and the post operative immobilization time decreased or eliminated while the basic fundamental technique and rationale remain the same.

I learned, then performed and later offered minimal modification to  this surgical technique.  Phenol and lateral ethanol perineural injection was later offered for those children who might benefit from combined, selective relieve spasticity.   The procedures were taught by me at Cornell’s NY Hospital and shortly afterward at NY Hospital for Special Surgery by me.   Dr. Nuzzo taught visiting practitioners in New Jersy including orthopedic fellows and residents.

The actual technique is easy to learn.  What is most difficult is the ‘selective’ part; selecting the offending, problematic neuromuscular anatomical regions that are interfering with the child’s abilities.  What is it that limits the child’s movement against gravity and constrains the joints of the hips, knees, ankles and feet?   THAT is the most difficult aspect to learn; not just of SPML but all surgeries for all children with neuromuscular disorders.   Release or elongate the wrong ‘tight’ muscle/tendon and the child becomes more disabled; not surprising in cerebral palsy since the issue is neurological rather than a muscle disorder.

Other surgeons have taught by myself or Dr. Nuzzo reside in the U.S. and other countries. Ssome of the earliest surgeons are now retired yet had performed numerous SPML surgeries for children with cerebral palsy.

Surgeons write about SPML in the literature, describing the technique and rationale for it being better than traditional tendon lengthening outcomes.  So, they give it their own name.   What’s in a name if it offers the same benefit for the right child.  They key is Selective  evaluation a child’s abilities to determine if they would or would not benefit from such a procedure and at what levels – the hip, knees, ankles, or feet.  Most are performed at multiple levels for reasons of need and functional gain.

There are published studies around if we look for them such as this one one study of SPML outcomes  with a good number of subjects and the  surgeons trained with Dr. Roy Nuzzo.

Does that mean they cannot do an SPML/Pecutaneous Myofascial Lengthening?  Not at all.  Frankly, it is much more difficult to select the targets and restrain from surgically releasing all that appears too tight.  Do less, not more and be selective since whatever is cut will affect adjacent neuromotor function.   The surgeon must be have excellent skills in surface anatomy and be able to ‘see’ with their fingertips.  Through the finger tips, tone is can be felt (not seen by eye) and constraint of motion seen through the finger tips rather than by simply joint range measured by eye.

There are a number of surgeons performing selective percutaneous fascial lengthening but do not refer to the surgery as SPML.  Still, they are quite successful in doing the procedure – despite what they wish to call it.  However, those who state that they can and do “percutaneous” surgery is most often referring to common superficial, small incision tendon lengthening rather than fascial or myofascial lengthening; a big difference in outcome between the two.

Insurance coding remains the same, regardless of ‘how’ a ‘lengthening’ is performed.  A fractional tendon lengthening with fascial lengthening will have the same procedure code as spml/spl, etc.  Everyone keeps looking to get their insurance company to cover SPMLs.  It is hard enough to get an insurer to pay for much at all these days.  If soft tissue surgery that results in measurable lengthening is necessary, by indirect or direct means, it is a ‘covered’ item.

 

Using only a limited number of “portals”  (they are not incisions) and if selectively performed, a significant change in the child’s lower limb can immediately be observed while in the operating room.

As seen in these images taken in the operating room, what was diagnosed as a bone deformity of tibial “torsion’ is instead a constraint from thickened, superficial fascial bands or “cord”.  Surgery is not performed upon the muscle or tendons.

 

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Is This a Short Term “Fix” or Will the Benefits Remain?

There is no simple black and white answer here since all kids are different and all ‘cerebral palsy’ is different; even those that have the same anatomical distribution or name.  For example, not all hemiplegic kids react or move the same.  Same with diplegic kids and even more variation exists with dystonic cerebral palsy.  This variation of neurosensory-motor dyscoordination makes the crystal ball of prediction a bit cloudy or fuzzy.

However with complete assessment of a child and observations of their abilities permits some degree of  functional outcome following soft tissue surgeries.  It is what the children are ABLE to do and is up to the surgeon to fully understand the primary problem(s) are so that they can be addressed.  It is considerably easier to slow bone and joint deformity than to manage by ‘watchful waiting’ until there is no choice but to do extensive bone surgery.

Parents must have some idea of their intermediate and long term goals following any surgical procedure.  The surgeon needs to discuss, not just the surgery, but the anticipated functional benefit for the child.  These surgeries are not magic.  They can be excellent tools to use when I child becomes stuck or gets in trouble with joint and bone deformities.

So how long can benefits be seen?  If the child has abilities that are limited by fascial / soft tissue constraint then selective relief can be gained using SPML/SPL lengthening with good predictability and without weakening muscle but leaving the muscles  intact.

The following youngster is a child provided with an anatomical diagnosis of CP spastic hemiplegia.  At age 7 years the soft tissue fascial tethering or constraint would not allow permit energy efficient and reduced compensatory standing and walking.

I performed full assessment followed by minimal hamstring and medial gastrocnemius myofascial lengthening without cutting muscle or tendon.  He was placed in walking casts on both lower legs where he gained a heel to toe walk and improved weight shifting to the right.  He was lost to follow up after moving out of state until age 22 years when he visited my office for ‘follow up photo’ and no complaints.