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Shahid J, Kashif A, Shahid MK. Enhancing Post-Operative Recovery in Spastic Diplegia through Physical Therapy Rehabilitation following Selective Dorsal Rhizotomy: A Case Report and Thorough Literature Analysis. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050842. [PMID: 37238390 DOI: 10.3390/children10050842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 04/28/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Abstract
Spasticity is a common issue among children, especially those with bilateral spastic cerebral palsy (CP). Selective dorsal rhizotomy (SDR) is a surgical procedure that is often used to decrease lower limb rigidity, alongside other treatment options such as intrathecal medication, peripheral nerve surgery, and deep brain stimulation (DBS). The objective of these therapies is to improve the standard of living for young individuals. This article intends to explain the motor deficits observed in spastic diplegia and a rehabilitation program using physical therapy after SDR. The information can help with counseling parents about the prognosis and developing a clinical treatment plan. The article presents a case study of a 12-year-old girl who recently underwent L3, L4, and L5 nerve root rhizotomy in the physical therapy department. It highlights the importance of long-term physical therapy follow-up and orthotic usage in the management of spastic diplegia.
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Affiliation(s)
- Jawaria Shahid
- Department of Physical Therapy, Ikram Hospital, Gujrat 50700, Pakistan
- Center of Physical Therapy, Rayan Medical Center, Gujrat 50700, Pakistan
| | - Ayesha Kashif
- Department of Senior Health Care, Eulji University, Uijeongbu-si 11759, Republic of Korea
| | - Muhammad Kashif Shahid
- Research Institute of Environment & Biosystem, Chungnam National University, Daejeon 34134, Republic of Korea
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Selective Dorsal Rhizotomy For Treatment of Spasticity After Hemispherectomy In Children: A Case Report. Cureus 2023; 15:e36945. [PMID: 37009349 PMCID: PMC10064527 DOI: 10.7759/cureus.36945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Performing a hemispherotomy or hemispherectomy is known to treat medically intractable epilepsy successfully, yet contralateral hemiparesis and increased muscle tone follow the epilepsy surgery. Spasticity and coexisting dystonia presumably cause the increased muscle tone in the lower extremity on the opposite side of epilepsy surgery. However, the extent of the role of spasticity and dystonia in high muscle tone is unknown. A selective dorsal rhizotomy is performed to reduce spasticity. If a selective dorsal rhizotomy is performed in the affected patient and muscle tone is reduced, the high muscle tone is not due to dystonia. Two children, who previously underwent a hemispherectomy or hemispherotomy, had a selective dorsal rhizotomy (SDR) performed in our clinic. Both children underwent orthopedic surgery to treat heel cord contractures. To study the extent of the role of spasticity and dystonia in high muscle tone, the mobility of the two children was examined pre- and post-SDR. The children had follow-ups 12 months and 56 months after SDR to study long-term effects. Before SDR, both children showed signs of spasticity. The SDR procedure removed spasticity, and muscle tone in the lower extremity became normal. Importantly, dystonia did not surface after SDR. Patients started independent walking less than two weeks after SDR. Sitting, standing, walking, and balance improved. They could walk longer distances while experiencing less fatigue. Running, jumping, and other more vigorous physical activities became possible. Notably, one child showed voluntary foot dorsiflexion that was absent before SDR. The other child showed improvement in voluntary foot dorsiflexion that was present before SDR. Both children maintained the progress at the 12 and 56-month follow-up visits. The SDR procedure normalized muscle tone and improved ambulation by removing spasticity. The high muscle tone following the epilepsy surgery was not due to dystonia.
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Kakodkar P, Girgis H, Nabhan P, Chee SS, Tu A. Efficacy of Selective Dorsal Rhizotomy and Intrathecal Baclofen Pump in the Management of Spasticity. Adv Tech Stand Neurosurg 2022; 45:379-403. [PMID: 35976458 DOI: 10.1007/978-3-030-99166-1_13] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Neurosurgical indications and interventions provided in the management of spasticity have evolved significantly over time. Selective dorsal rhizotomy (SDR) and intrathecal baclofen (ITB) pumps have been used to improve mobility, reduce lower extremity spasticity, and increase quality of life in patients with various diagnoses. METHODS Studies describing ITB and SDR outcomes in adult and pediatric patients were identified from Medline and Embase databases. Only publications between January 1990 to January 2021 were included. Combinations of search terms 'Selective Dorsal Rhizotomy', 'Selective Posterior Rhizotomy', 'functional posterior rhizotomy', 'intrathecal baclofen pump', and 'spasticity' were used. Only studies in English language and those that included parameters for lower extremity outcome (i.e., spasticity, ambulation) were included. Only studies describing follow-up 12 months or greater were included. Case reports, reviews without primary data, or inaccessible publications were excluded. RESULTS Two hundred and ninety publications between January 1990 to January 2021 were identified. Of these, 62 fit inclusion and exclusion criteria for a total of 1291 adult and 2263 patients. Etiologies in adult and pediatric populations varied substantially with multiple sclerosis, cerebral palsy, and trauma comprising the majority of causes for spasticity in adult patients. In pediatric patients, cerebral palsy was the predominant etiology of spasticity. While outcomes after SDR and ITB varied, both are effective for long-term tone reduction. SDR appeared to have a greater effect on function compared to baseline when comparing relatively similar subgroups. The complication rates for either intervention were significant; ITB had a much greater incidence of wound and hardware adverse events, whereas SDR was associated with a not insignificant incidence of new bladder or sensory deficit. CONCLUSION ITB and SDR have demonstrated efficacy and utility for tone reduction in a variety of conditions. The selection of a specific intervention may have a variety of determining features including the etiology of spasticity, age of patient, as well as balancing benefit and complication profiles of each technique. Appropriate patient selection is essential for providing optimal patient outcomes.
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Affiliation(s)
- Pramath Kakodkar
- School of Medicine, National University of Ireland Galway, Galway, Republic of Ireland
| | - Hidy Girgis
- Division of Neurosurgery, University of Ottawa, Ottawa, ON, Canada
| | - Perla Nabhan
- Faculty of Science, University of Ottawa, Ottawa, Canada
| | - Sharini Sam Chee
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Albert Tu
- Division of Pediatric Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
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Ravindra VM, Karas PJ, Hartnett S, Patino I, North R, Tatsui CE, Gonda D, Schwabe A, Curry DJ. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Palliative Rhizotomy: A Novel Technical Application. Oper Neurosurg (Hagerstown) 2021; 20:413-418. [PMID: 33377153 DOI: 10.1093/ons/opaa415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Spastic cerebral palsy is caused by an insult to the developing brain. Various medical and surgical procedures are used to reduce tone. OBJECTIVE To describe a novel method of magnetic resonance-guided laser interstitial thermal ablation for palliative rhizotomy. METHODS Patients treated at a single institution with percutaneous rhizotomy using magnetic resonance-guided laser interstitial thermal therapy were identified. Preoperative and postoperative Modified Ashworth Scale scores were collected as well as procedural information. RESULTS Two male children (7.8 and 19 yr, respectively) with spastic quadriparesis were treated using this technique. Neither patient experienced surgical or perioperative complications, and both were discharged from the hospital within 48 h. Each of them demonstrated improvement in his Modified Ashworth Scale score with no need for retreatment for spasticity at last follow-up. CONCLUSION These 2 cases illustrate a novel technique for treating spasticity in the setting of cerebral palsy. Further study of this technique in additional patients, and comparison with traditional methods of surgical tone reduction, are warranted.
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Affiliation(s)
- Vijay M Ravindra
- Division of Pediatric Neurosurgery, Texas Children's Hospital Baylor College of Medicine, Houston, Texas.,Division of Pediatric Neurosurgery, Rady Children's Hospital, University of California San Diego, San Diego, California
| | - Patrick J Karas
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sara Hartnett
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Ilana Patino
- Division of Pediatric Neurosurgery, Texas Children's Hospital Baylor College of Medicine, Houston, Texas
| | - Robert North
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Claudio E Tatsui
- Department of Neurosurgery, Division of Surgery, MD Anderson Cancer Center, Houston, Texas
| | - David Gonda
- Division of Pediatric Neurosurgery, Rady Children's Hospital, University of California San Diego, San Diego, California
| | - Aloysia Schwabe
- Department of Physical Medicine and Rehabilitation Medicine, Baylor College of Medicine, Section of Pediatric Physical Medicine and Rehabilitation, Texas Children's Hospital, Houston, Texas
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Texas Children's Hospital Baylor College of Medicine, Houston, Texas.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Kakodkar P, Fallah A, Tu A. Systematic review on use and efficacy of selective dorsal rhizotomy (SDR) for the management of spasticity in non-pediatric patients. Childs Nerv Syst 2021; 37:1837-1847. [PMID: 33928427 DOI: 10.1007/s00381-021-05167-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Selective dorsal rhizotomy (SDR) has been used to improve mobility and reduce lower extremity spasticity in patients with a various CNS conditions. Incidentally, literature on SDR has been performed in the pediatric population as such there is a paucity of research on the use in adult patients. METHODS Studies describing SDR in adults were identified from Medline and Embase databases. Combinations of search terms "Selective Dorsal Rhizotomy," "Selective Posterior Rhizotomy," and "Adult" were used. Only literature in English language on patients over the age of 18 years and that included measures for lower extremity outcome (i.e., spasticity, mobility) were included. Case reports, reviews without primary data, or inaccessible publications were excluded. RESULTS One hundred twenty-nine publications between 1970 and 2019 were identified. Twelve of these publications fit the inclusion criteria (n = 141 patients). In series where it was reported, SDR resulted in ambulatory improvement (54%, n = 44 out of 81), reduced spasticity (75.2%, n = 106 out of 141), and minimized muscle and joint pain (74.5%, n = 64 out of 86). SDR also showed improvement in parameters of the activities of daily life. 92.3% (n = 48 out of 52) of patients post-SDR developed new lower limb paresthesia. CONCLUSION The success and efficacy appear durable in the short-term, but further follow-up is necessary to validate these findings. The goal of the intervention dictates the ideal adult patient for SDR. Patients seeking ambulatory improvement, any etiology of spasticity besides MS, seem favorable. Positive locomotive predictors include the ability to isolate lower extremity function, lack of contractures, lower limb strength, and post-SDR physiotherapy.
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Affiliation(s)
- Pramath Kakodkar
- School of Medicine, National University of Ireland Galway, Galway, Republic of Ireland
| | - Aria Fallah
- Divison of Pediatric Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Albert Tu
- Division of Pediatric Neurosurgery, Children's Hospital of Eastern Ontario, Rm 3359 CHEO, 401 Smyth Rd, Ottawa, ON, K1H 8L1, Canada.
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Intrathecal baclofen, selective dorsal rhizotomy, and extracorporeal shockwave therapy for the treatment of spasticity in cerebral palsy: a systematic review. Neurosurg Rev 2021; 44:3209-3228. [PMID: 33871733 DOI: 10.1007/s10143-021-01550-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/03/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Cerebral palsy (CP) is a chronic congenital disorder as the result of abnormal brain development. Children suffering from CP often battle debilitating chronic spasticity, which has been the focus of recent academic literature. In this systematic review, the authors aim to update the current neuromodulation procedures for the treatment of spasticity associated with CP in all age groups. A systematic review following was conducted using PubMed from inception to 2020. After initial title and abstract screening, 489 articles were identified, and 48 studies met the inclusion criteria for this review. In total, a majority of the published articles of treatments for CP were reporting the use of selective dorsal rhizotomy (SDR) (54%), and the remainder were of intrathecal baclofen (ITB) pumps (29%) and extracorporeal shockwave therapy (ESWT) (17%). Each method was found to have improvement of spasticity at a rate that achieved statistical significance. ITB pump therapy is an all-encompassing method of treating spasticity in children from CP, as it allows for a less invasive treatment that can be titrated to individual patient needs; however, its disadvantages include its long-term maintenance requirements. SDR appears to be an effective method for permanent spasticity relief in young patients. ESWT is a more recent and innovative technique for offering relief of spasticity while being minimally invasiveness. Further studies are needed to establish optimal frequencies and sites of application for ESWT.
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Sun Q, Huang W, Deng B, Ren J, Zhao Y, Mu X, Xu L. The progress in the treatment of spastic cerebral palsy with selective dorsal rhizotomy (SDR). BRAIN SCIENCE ADVANCES 2020. [DOI: 10.26599/bsa.2020.9050007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Spasticity is the main disabling clinical manifestation of children with cerebral palsy (CP). Selective dorsal rhizotomy (SDR) has been performed for the treatment of spastic CP in Asia for quite some time from 1990. The purpose of this review is to discuss the historical origin and development of SDR. Our goal here is to identify the current patient selection criteria for SDR and to point out indications and contraindications based on the patients with CP, age from 2 to 18 years-old, over 6000 cases, who received SDR surgery with spasticity of muscle tension more than 3 degrees in our center. We also discuss evidence-based approaches on how to evaluate postoperative patient outcomes of SDR and how complications can be avoided. Finally, we mention progress made in terms of SDR technical advances and how improvements can be made in the future. In conclusion, SDR surgery is a reliable way to improve outcomes of patients with spastic CP and can be done carefully in patients as long as stringent selection criteria are used. However, more research and technological advancements are needed to help address associated complications.
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Affiliation(s)
- Qi Sun
- Department of Orthopedics, Dongzhimen Hospital, Beijing University
of Chinese Medicine, Beijing 100700, China
| | - Wenling Huang
- Department of Gynaecology, Dongfang Hospital, Beijing University of
Chinese Medicine, Beijing 100078, China
| | - Bowen Deng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University
of Chinese Medicine, Beijing 100700, China
| | - Jingpei Ren
- Department of Orthopedics, Dongzhimen Hospital, Beijing University
of Chinese Medicine, Beijing 100700, China
| | - Yi Zhao
- Department of Orthopedics, Dongzhimen Hospital, Beijing University
of Chinese Medicine, Beijing 100700, China
| | - Xiaohong Mu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University
of Chinese Medicine, Beijing 100700, China
| | - Lin Xu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University
of Chinese Medicine, Beijing 100700, China
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Wheelwright M, Selvey PJ, Steinbok P, Singhal A, Ibrahim G, Fallah A, Weil AG, Halvorson K, Tu A. Systematic review of spinal deformities following multi-level selective dorsal rhizotomy. Childs Nerv Syst 2020; 36:1025-1035. [PMID: 31595313 DOI: 10.1007/s00381-019-04375-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 09/05/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE Cerebral palsy is a common neurological disorder that involves spasticity of the extremities and can lead to lifelong disability. Selective dorsal rhizotomy (SDR) can improve spasticity and quality of life in these patients, but it may be associated with the development of spinal deformity. Risk factors for spinal deformity after SDR have not yet been systematically examined. METHODS Medline, Embase, and Web of Science databases were queried for clinical studies reporting incidence of new or worsening spinal deformity, including scoliosis, after SDR. Variables that represent possible risk factors for deformity were correlated with reported incidence of deformity. RESULTS Twenty-two articles for a total of 1485 patients met the inclusion criteria for this study. Deformity occurs among all patients with a weighted mean incidence of 28.0%. Scoliosis appears to be the most common deformity occurring with a weighted mean incidence of 31.6%. There is substantial heterogeneity between studies, limiting our analysis. Significant positive correlation was found between percent of patients that developed any type of deformity and the ratio of female to male patients, p = 0.02. Significant positive correlation was also found between percent of patients that develop scoliosis and the ratio of female to male patients, p < 0.01, and between scoliosis and the number of years to follow-up, p < 0.01. CONCLUSION Spinal deformity is an important potential complication of SDR with scoliosis being the most common type of deformity. The major risk factor for postoperative deformity is female sex. Deformity was also found to significantly increase with extended follow-up, indicating a slow process that should be carefully monitored.
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Affiliation(s)
| | - Paige J Selvey
- University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Paul Steinbok
- Children's Hospital of British Columbia, Vancouver, BC, V6H 3N1, Canada
| | - Ash Singhal
- Children's Hospital of British Columbia, Vancouver, BC, V6H 3N1, Canada
| | - George Ibrahim
- University of Toronto, Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Aria Fallah
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Alexander G Weil
- Pediatric Neurosurgery Service, Department of Surgery, CHU Sainte-Justine, University of Montreal, Montreal, QC, H3T 1J4, Canada
| | - Kyle Halvorson
- Division of Neurosurgery, Children's Minnesota, Garden View Medical Building, Suite 301, 347 North Smith Ave., St. Paul, MN, 55102, USA
| | - Albert Tu
- Division of Neurosurgery, Children's Hospital of Eastern Ontario, Rm 3359 CHEO, 401 Smyth Ave, Ottawa, ON, K1H 8L1, Canada.
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Barney CC, Merbler AM, Simone DA, Walk D, Symons FJ. Investigating the Feasibility of a Modified Quantitative Sensory Testing Approach to Profile Sensory Function and Predict Pain Outcomes Following Intrathecal Baclofen Implant Surgery in Cerebral Palsy. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:109-117. [PMID: 31268147 PMCID: PMC7999622 DOI: 10.1093/pm/pnz114] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Intrathecal baclofen (ITB) pumps used to manage spasticity in children with cerebral palsy (CP) also improve pain outcomes for some but not all patients. The purpose of this clinical feasibility study was to explore whether a quantitative sensory testing approach could a) be modified and used to subgroup individuals into sensory profiles and b) test whether the profiles were related to postimplant pain outcomes (i.e., pain responsive or pain persistent). SUBJECTS A purposeful clinical sample of nine children with CP (mean age = 12.5 years, male = 56%) and complex communication needs participated. METHODS A prospective within-subject design was used to measure proxy-reported pain before and after ITB implant. Pain response status was determined by proxy-reported pain intensity change (>50% change in maximum rated intensity). A modified quantitative sensory testing (mQST) procedure was used to assess behavioral responsivity to an array of calibrated sensory (tactile/acute nociceptive) stimuli before surgery. RESULTS Seven individuals with presurgical pain had mQST differentiated sensory profiles in relation to ITB pain outcomes and relative to the two individuals with no pain. Presurgically, the ITB pain responsive subgroup (N = 3, maximum rated pain intensity decreased >50% after ITB implant) showed increased behavioral reactivity to an acute nociceptive stimulus and cold stimulus, whereas the ITB pain persistent subgroup (N = 4) showed reduced behavioral reactivity to cold and repeated von Frey stimulation relative to the no pain individuals. CONCLUSION Implications for patient selection criteria and stratification to presurgically identify individuals with CP "at risk" for persistent postprocedure pain are discussed.
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Affiliation(s)
- Chantel C Barney
- Special Education Program, Department of Educational Psychology, University of Minnesota, Minneapolis, Minnesota
- Gillette Children’s Specialty Healthcare, Saint Paul, Minnesota
| | - Alyssa M Merbler
- Special Education Program, Department of Educational Psychology, University of Minnesota, Minneapolis, Minnesota
| | - Donald A Simone
- Department of Diagnostic and Biological Sciences, University of Minnesota, Minneapolis, Minnesota
| | - David Walk
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Frank J Symons
- Special Education Program, Department of Educational Psychology, University of Minnesota, Minneapolis, Minnesota
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Functional outcomes after selective dorsal rhizotomy followed by minimally invasive tendon lengthening procedures in children with spastic cerebral palsy. J Pediatr Orthop B 2020; 29:1-8. [PMID: 31305364 DOI: 10.1097/bpb.0000000000000642] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many surgical options have been proposed to improve the ambulatory status of children with spastic cerebral palsy (CP), but none have focused on addressing both spasticity and lower extremity tendon contractures. The purpose of this study is to evaluate the results of selective dorsal rhizotomy (SDR) followed by minimally invasive tendon lengthening allowing immediate return to ambulation. Two hundred fifty-five spastic CP patients (who received SDR procedure at an average age of 6.9±2.6 years and tendon lengthening procedure at an average age of 7.2±2.5 years) were retrospectively reviewed. Patients were grouped by the gross motor function classification system (GMFCS) 1-3 and 4-5. Kaplan-Meier analysis and Cox proportional hazard model using a requirement for additional tendon lengthening as an end point were conducted. Tendon lengthening followed SDR at an average of 4.3±10.7 months. On an average of 4.9±1.2 years after tendon lengthening, GMFCS was improved in 28 and maintained in 213 patients, respectively. There was no difference of variables and joint angles between the two GMFCS groups. A repeat tendon lengthening was required in 19 patients. The Kaplan-Meier analysis showed 81% success rate. Cox proportional hazard model identified age at tendon lengthening [hazards ratio (HR), 0.53; 95% confidence interval (CI), 0.37-0.76] and duration between SDR and tendon lengthening of more than 6 months (HR, 2.96; 95% CI, 1.05-8.33) associated with need for a repeat tendon lengthening procedure. Our novel approach of SDR/tendon lengthening results in improved joint angles as well as stable or improved GMFCS. Longer follow-up is necessary to determine if this approach could prolong ambulatory ability and reduced need for more invasive orthopedic surgeries.
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11
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Frequency distribution in intraoperative stimulation-evoked EMG responses during selective dorsal rhizotomy in children with cerebral palsy-part 1: clinical setting and neurophysiological procedure. Childs Nerv Syst 2020; 36:1945-1954. [PMID: 32577878 PMCID: PMC7434802 DOI: 10.1007/s00381-020-04734-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Selective dorsal rhizotomy (SDR) consists of microsurgical partial deafferentation of sensory nerve roots (L1-S2). It is primarily used today in decreasing spasticity in young cerebral palsy (CP) patients. Intraoperative monitoring (IOM) is an essential part of the surgical decision-making process, aimed at improving functional results. The role played by SDR-IOM is examined, while realizing that connections between complex EMG responses to nerve-root stimulation and a patient's individual motor ability remain to be clarified. METHODS We conducted this retrospective study, analyzing EMG responses in 146 patients evoked by dorsal-root and rootlet stimulation, applying an objective response-classification system, and investigating the prevalence and distribution of the assessed grades. Part1 describes the clinical setting and SDR procedure, reintroduced in Germany by the senior author in 2007. RESULTS Stimulation-evoked EMG response patterns revealed significant differences along the segmental levels. More specifically, a comparison of grade 3+4 prevalence showed that higher-graded rootlets were more noticeable at lower nerve root levels (L5, S1), resulting in a typical rostro-caudal anatomical distribution. CONCLUSIONS In view of its prophylactic potential, SDR should be carried out at an early stage in all CP patients suffering from severe spasticity. It is particularly effective when used as an integral part of a coordinated, comprehensive spasticity program in which a team of experts pool their information. The IOM findings pertaining to the anatomical grouping of grades could be of potential importance in adjusting the SDR-IOM intervention to suit the specific individual constellation, pending further validation. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03079362.
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12
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Chen BPJ, Wang KK, Novacheck TF. Selective Dorsal Rhizotomy for the Treatment of Gait Dysfunction in Cerebral Palsy: A Critical Analysis Review. JBJS Rev 2019; 7:e3. [PMID: 31725025 DOI: 10.2106/jbjs.rvw.19.00020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Brian Po-Jung Chen
- Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, St. Paul, Minnesota.,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Kemble K Wang
- Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, St. Paul, Minnesota.,Department of Orthopedic Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Tom F Novacheck
- Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, St. Paul, Minnesota.,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Synergistic Improvement in Children with Cerebral Palsy Who Underwent Double-Course Human Wharton's Jelly Stem Cell Transplantation. Stem Cells Int 2019; 2019:7481069. [PMID: 31636676 PMCID: PMC6766101 DOI: 10.1155/2019/7481069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/30/2019] [Indexed: 01/02/2023] Open
Abstract
Background Our previous studies confirmed that human Wharton's Jelly stem cell (hWJSC) transplantation improved motor function in children with spastic cerebral palsy (CP). This study investigated the dose-effect relationship between the transplanted cell dosage and efficacy in CP children. Methods CP children who received one- or two-course (four or eight times lumbar puncture, 4 or 8 × 107 hWJSCs) cell therapy were recruited into this study. Assessments of motor function were performed according to scales for gross motor function measurement (GMFM) and fine motor function measurement (FMFM). The measurement data obtained in the two different groups were analyzed by t-test. Univariate repeated measures analysis of variance was used to compare the data obtained at baseline and 6 or 12 months posttransplantation and met the conditions for Mauchly's sphericity test. Results The results for fifty-seven pediatric CP patients (including 35 male and 22 female patients) who completed follow-up showed that gross and fine motor functions improved after cell therapy. Interestingly, the GMFM and FMFM scores in patients who received one course of transplantation were significantly increased at 6 months after treatment. Moreover, another course of transplantation further improved gross and fine motor function in children. The scores for GMFM and FMFM were significantly higher at 6 months posttransplantation than at baseline and showed a linear upward trend. There was no gender difference in GMFM. Interestingly, there was a significant difference between male and female patients in the B and C dimensions of FMFM. These results reveal a gender-related susceptibility to stem cell therapy, especially for movement capability of the upper extremity joint and grasping ability. Similarly, in the group aged ≤3 years old, the improvement observed in dimension A (lying and rolling) of GMFM was nearly exponential and showed a quadratic trend. The results for FMFM were similar to those for GMFM. Moreover, the improvement in motor function was not age dependent. Conclusions In this study, our data collectively reveal that CP children display sex- or age-dependent responses to hWJSC therapy; these results shed light on the clinical utility of this approach in specific populations.
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Summers J, Coker B, Eddy S, Elstad M, Bunce C, Bourmpaki E, Pennington M, Aquilina K, Cawker S, Edwards R, Goodden J, Hawes S, McCune K, Pettorini B, Smith J, Sneade C, Vloeberghs M, Patrick H, Powell H, Verity C, Peacock JL. Selective dorsal rhizotomy in ambulant children with cerebral palsy: an observational cohort study. THE LANCET. CHILD & ADOLESCENT HEALTH 2019; 3:455-462. [PMID: 31047843 PMCID: PMC7153769 DOI: 10.1016/s2352-4642(19)30119-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) is an irreversible surgical procedure involving the division of selected sensory nerve roots, followed by intensive physiotherapy. The aim is to improve function and quality of life in children with cerebral palsy and a Gross Motor Function Classification System (GMFCS) level of II or III (walks with or without assistive devices, respectively). We assessed gross motor function before and after SDR and postoperative quality of life in a study commissioned by NHS England. METHODS We did a prospective observational study in five hospitals in England who were commissioned to perform SDR on children aged 3-9 years with spastic diplegic cerebral palsy. The primary outcome was score changes in the 66-item Gross Motor Function Measure (GMFM-66) and seven domains of the Cerebral Palsy Quality of Life Questionnaire ([CP-QoL] social wellbeing and acceptance, feelings about functioning, participation and physical health, emotional wellbeing and self-esteem, access to services, family health, and pain and impact of disability) from before to 24 months after SDR. FINDINGS From Sept 4, 2014, to March 21, 2016, 137 children underwent SDR. The mean age was 6·0 years (SD 1·8). The mean GMFM-66 score increased after SDR with an annual change of 3·2 units (95% CI 2·9 to 3·5, n=137). Of the seven CP-QoL domains, five showed significant improvements over time: feelings about functioning mean annual change 3·0 units (95% CI 2·0 to 4·0, n=133), participation and physical health 3·9 units (2·5 to 5·3, n=133), emotional wellbeing and self-esteem 1·3 units (0·2 to 2·3, n=133), family health 2·0 units (0·7 to 3·3, n=132), and pain and impact of disability -2·5 units (-3·9 to -1·2, n=133). 17 adverse events were reported in 15 children, of which none were severe and 15 (88%) resolved. INTERPRETATION SDR improved function and quality of life in the 24 months after surgery in children with cerebral palsy classified as GMFCS levels II and III. On the basis of these findings, an interim national policy decision was made that SDR would be funded for eligible children in England from 2018. FUNDING National Institute for Health and Care Excellence, National Institute for Health Research Biomedical Research Centre, NHS England.
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Affiliation(s)
- Jennifer Summers
- School of Population Health and Environmental Sciences, King's College London, London, UK.
| | - Bola Coker
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Saskia Eddy
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Maria Elstad
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Catey Bunce
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Elli Bourmpaki
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Mark Pennington
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Kristian Aquilina
- Neurosurgery Department, Great Ormond Street Hospital for Children, London, UK
| | - Stephanie Cawker
- Physiotherapy Department, Great Ormond Street Hospital for Children, London, UK
| | - Richard Edwards
- Paediatric Neurosurgery, Bristol Royal Hospital for Children, Bristol, UK
| | - John Goodden
- Neurosurgery Department, Leeds General Infirmary, Leeds, UK
| | - Sally Hawes
- Paediatric Physiotherapy Department, Nottingham University Hospitals, Nottingham, UK
| | - Kate McCune
- Neuro-Rehabilitation and Spascticity Service, Leeds General Infirmary, Leeds, UK
| | - Benedetta Pettorini
- Department of Paediatric Neurosurgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Jennifer Smith
- Paediatric Physiotherapy, Bristol Royal Hospital for Children, Bristol, UK
| | - Christine Sneade
- Department of Paediatric Neurosurgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Michael Vloeberghs
- Department of Neurosurgery, Nottingham University Hospitals, Nottingham, UK
| | - Hannah Patrick
- National Institute for Health and Care Excellence, Manchester, UK
| | - Helen Powell
- National Institute for Health and Care Excellence, Manchester, UK
| | - Christopher Verity
- Children's and Adolescent Services, Addenbrooke's Hospital, Cambridge, UK
| | - Janet L Peacock
- School of Population Health and Environmental Sciences, King's College London, London, UK
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Velnar T, Spazzapan P, Rodi Z, Kos N, Bosnjak R. Selective dorsal rhizotomy in cerebral palsy spasticity - a newly established operative technique in Slovenia: A case report and review of literature. World J Clin Cases 2019. [DOI: 10.12998/wjge.v7.i10.1133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Velnar T, Spazzapan P, Rodi Z, Kos N, Bosnjak R. Selective dorsal rhizotomy in cerebral palsy spasticity - a newly established operative technique in Slovenia: A case report and review of literature. World J Clin Cases 2019; 7:1133-1141. [PMID: 31183344 PMCID: PMC6547316 DOI: 10.12998/wjcc.v7.i10.1133] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 04/23/2019] [Accepted: 05/01/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Spasticity affects a large number of children, mainly in the setting of cerebral palsy, however, only a few paediatric neurosurgeons deal with this problem. This is mainly due to the fact that until 1979, when Fasano has published the first series of selective dorsal rhizotomy (SDR), neurosurgeons were able to provide such children only a modest help. The therapy of spasticity has made a great progress since then. Today, peroral drugs, intramuscular and intrathecal medicines are available, that may limit the effects of the disease. In addition, surgical treatment is gaining importance, appearing in the form of deep brain stimulation, peripheral nerve procedures and SDR. All these options offer the affected children good opportunities of improving the quality of life. CASE SUMMARY A 15-year old boy is presented that was surgically treated for spasticity as a result of cerebral palsy. Laminotomy at L1 level was performed and L1 to S1 nerve roots were isolated and divided in smaller fascicles. Then, the SDR was made. CONCLUSION We describe a patient report and surgical technique of SDR that was performed in Slovenia for the first time.
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Affiliation(s)
- Tomaz Velnar
- Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
- AMEU-ECM Maribor, Ljubljana 1000, Slovenia
| | - Peter Spazzapan
- Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
| | - Zoran Rodi
- Department of Neurophysiology, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
| | - Natasa Kos
- Medical Rehabilitation Unit, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
| | - Roman Bosnjak
- Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
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Chang CH, Lu KH, Lin WT, Chen SC, Shih WP, Lin CW. Reversible Spasticity Suppression and Locomotion Change After Pulsed Radiofrequency on the Dorsal Root Ganglia of Rats With Spinal Cord Injury. Neuromodulation 2018; 22:53-60. [PMID: 30253013 DOI: 10.1111/ner.12853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/04/2018] [Accepted: 07/15/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Radiofrequency has been used to suppress spasticity affecting motion in patients with cerebral palsy and spinal cord injury. This study tested spasticity suppression and locomotion change after pulsed radiofrequency (PRF) at the dorsal root ganglion of rats with spasticity. MATERIALS AND METHODS Twenty-four rats that survived for 28 days after thoracic spinal cord injury and showed spasticity in the right hind limb were separated randomly to a PRF group or Sham operation group. PRF consisted of 2 Hz biphasic 25 msec trains of PRF (500 kHz, 5 V intensity) applied on the right L5 dorsal root ganglion for 300 sec. Muscle tension of the right triceps surae was measured at 450 deg/sec of passive ankle dorsiflexion on the day before and 3, 7, and 14 days after PRF or sham operation. Locomotive function was evaluated by obtaining Basso, Beattie, and Bresnahan (BBB) scores. RESULTS Muscle tension of the triceps surae decreased significantly three days after PRF, and gradually returned to baseline 14 days later. In the sham operation group, muscle tension increased significantly more than 14 days. The BBB scores declined from 10 to 8 after PRF and returned to pre-PRF levels 14 days later, while scores remained constant after sham operation. CONCLUSIONS PRF produced significant and reversible suppression in spasticity, but this was accompanied by deterioration in locomotive function. Thus, caution should be exercised in considering the benefits and costs in suppressing spasticity in ambulatory patients, and implanted devices that apply titratable doses of PRF may be best to optimize patients' needs.
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Affiliation(s)
- Chia-Hsieh Chang
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan.,Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kuo-Hsiang Lu
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wei-Tso Lin
- Institute of Bioelectronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Shih-Ching Chen
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan
| | - Wen-Pin Shih
- Department of Mechanical Engineering, National Taiwan University, Taipei, Taiwan
| | - Chii-Wann Lin
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan.,Institute of Bioelectronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
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Georgoulis G, Brînzeu A, Sindou M. Dorsal rhizotomy for children with spastic diplegia of cerebral palsy origin: usefulness of intraoperative monitoring. J Neurosurg Pediatr 2018; 22:89-101. [PMID: 29652243 DOI: 10.3171/2018.1.peds17577] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The utility of intraoperative neuromonitoring (ION), namely the study of muscle responses to radicular stimulation, remains controversial. The authors performed a prospective study combining ventral root (VR) stimulation for mapping anatomical levels and dorsal root (DR) stimulation as physiological testing of metameric excitability. The purpose was to evaluate to what extent the intraoperative data led to modifications in the initial decisions for surgical sectioning established by the pediatric multidisciplinary team (i.e., preoperative chart), and thus estimate its practical usefulness. METHODS Thirteen children with spastic diplegia underwent the following surgical protocol. First, a bilateral intradural approach was made to the L2-S2 VRs and DRs at the exit from or entry to their respective dural sheaths, through multilevel interlaminar enlarged openings. Second, stimulation-just above the threshold-of the VR at 2 Hz to establish topography of radicular myotome distribution, and then of the DR at 50 Hz as an excitability test of root circuitry, with independent identification of muscle responses by the physiotherapist and by electromyographic recordings. The study aimed to compare the final amounts of root sectioning-per radicular level, established after intraoperative neuromonitoring guidance-with those determined by the multidisciplinary team in the presurgical chart. RESULTS The use of ION resulted in differences in the final percentage of root sectioning for all root levels. The root levels corresponding to the upper lumbar segments were modestly excitable under DR stimulation, whereas progressively lower root levels displayed higher excitability. The difference between root levels was highly significant, as evaluated by electromyography (p = 0.00004) as well as by the physiotherapist (p = 0.00001). Modifications were decided in 11 of the 13 patients (84%), and the mean absolute difference in the percentage of sectioning quantity per radicular level was 8.4% for L-2 (p = 0.004), 6.4% for L-3 (p = 0.0004), 19.6% for L-4 (p = 0.00003), 16.5% for L-5 (p = 0.00006), and 3.2% for S-1 roots (p = 0.016). Decreases were most frequently decided for roots L-2 and L-3, whereas increases most frequently involved roots L-4 and L-5, with the largest changes in terms of percentage of sectioning. CONCLUSIONS The use of ION during dorsal rhizotomy led to modifications regarding which DRs to section and to what extent. This was especially true for L-4 and L-5 roots, which are known to be involved in antigravity and pelvic stability functions. In this series, ION contributed significantly to further adjust the patient-tailored dorsal rhizotomy procedure to the clinical presentation and the therapeutic goals of each patient.
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Affiliation(s)
- George Georgoulis
- 1University of Lyon, France.,3Medical School, University of Athens, Greece
| | - Andrei Brînzeu
- 1University of Lyon, France.,4University of Medicine and Pharmacy "Victor Babeș" Timișoara, Romania; and
| | - Marc Sindou
- 1University of Lyon, France.,5Clinique Bretéché, Groupe ELSAN, Nantes, France
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Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children. Acta Neurochir (Wien) 2018; 160:811-821. [PMID: 29116382 DOI: 10.1007/s00701-017-3349-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/29/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) has been established as an effective surgical treatment for spastic diplegia. The applicability of SDR to the full spectrum of spastic cerebral palsy and the durability of its therapeutic effects remain under investigation. There are currently limited data in the literature regarding efficacy and outcomes following SDR in Gross Motor Function Classification System (GMFCS) IV and V patients. Intrathecal baclofen has traditionally been the surgical treatment of choice for these patients. When utilised primarily as a treatment for the relief of spasticity, it is proposed that SDR represents a rational and effective treatment option for this patient group. We report our outcomes of SDR performed on children with severe cerebral palsy (GMFCS grade IV and V). The commensurate improvement in upper as well as lower limb spasticity is highlighted. Apparent benefit to urological function following SDR in this patient group is also discussed. METHOD A retrospective review of prospectively collected data for 54 paediatric patients with severe cerebral palsy (GMFCS IV-V) who received SDR plus specialised physiotherapy. Mean age was 10.2 years (range, 3.0-19.5). SDR guided by electrophysiological monitoring was performed by a single experienced neurosurgeon. All subjects received equivalent physiotherapy. The primary outcome measure was change to the degree of spasticity following SDR. Spasticity of upper and lower limb muscle groups were quantified and standardised using the Ashworth score. Measures were collected at baseline and at 2-, 8- and 14-month postoperative intervals. In addition, baseline and 6-month postoperative urological function was also evaluated as a secondary outcome measure. RESULTS The mean lower limb Ashworth score at baseline was 3.2 (range, 0-4). Following SDR, significant reduction in lower limb spasticity scores was observed at 2 months and maintained at 8 and 14 months postoperatively (Wilcoxon rank, p < 0.001). The mean reduction at 2, 8 and 14 months was 3.0, 3.2 and 3.2 points respectively (range, 1-4), confirming a sustained improvement of spasticity over a 1-year period of follow-up. Significant reduction in upper limb spasticity scores following SDR was also observed (mean, 2.9; Wilcoxon rank, p < 0.001). Overall, the improvement to upper and lower limb tone following SDR-generally to post-treatment Ashworth scores of 0-was clinically and statistically significant in GMFCS IV and V patients. Urological assessment identified pre-existing bladder dysfunction in 70% and 90% of GMFCS IV and V patients respectively. Following SDR, improvement in urinary continence was observed in 71% of affected GMFCS IV and 42.8% of GMFCS V patients. No serious postoperative complications were identified. CONCLUSIONS We conclude that SDR is safe and-in combination with physiotherapy-effectively reduces spasticity in GMFCS grade IV and V patients. Our series suggests that spastic quadriplegia is effectively managed with significant improvements in upper limb spasticity that are commensurate with those observed in lower limb muscle groups. These gains are furthermore sustained more than a year postoperatively. In light of these findings, we propose that SDR constitutes an effective treatment option for GMFCS IV and V patients and a rational alternative to intrathecal baclofen.
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20
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Graham D, Aquilina K, Mankad K, Wimalasundera N. Selective dorsal rhizotomy: current state of practice and the role of imaging. Quant Imaging Med Surg 2018; 8:209-218. [PMID: 29675362 DOI: 10.21037/qims.2018.01.08] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Spastic diplegic cerebral palsy (CP) is the most common form of CP. A specific goal-oriented approach, tailored to the child, is essential to management in all forms of CP. Selective dorsal rhizotomy (SDR) is a neurosurgical procedure that permanently reduces lower limb spasticity in children with spastic diplegic CP. The current technique is performed through a single level laminectomy at the level of the conus and, with the aid of intraoperative electromyography (EMG), allows selective division of the afferent lumbosacral nerve roots. In carefully selected children, reduction in spasticity has positive effects on the growing child. SDR is associated with minimal complications and good long-term outcomes. This article describes the surgical technique and patient selection, including the importance of medical imaging, and discusses the long-term outcomes of SDR.
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Affiliation(s)
- David Graham
- Faculty of Medicine, the University of Sydney, Sydney, Australia.,Institute of Neuroscience and Muscle Research, Kids Research Institute, Children's Hospital at Westmead, Sydney, Australia
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
| | - Neil Wimalasundera
- Victorian Paediatric Rehabilitation Service, Royal Children's Hospital, Melbourne, Australia
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Park TS, Liu JL, Edwards C, Walter DM, Dobbs MB. Functional Outcomes of Childhood Selective Dorsal Rhizotomy 20 to 28 Years Later. Cureus 2017. [PMID: 28649479 PMCID: PMC5473717 DOI: 10.7759/cureus.1256] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) is a surgical method used to treat childhood spastic cerebral palsy (CP). However, the effects of early SDR on functional outcomes and quality of life decades later in adulthood remains to be elucidated. OBJECTIVES To evaluate the long-term outcomes in terms of satisfaction and mobility of adult patients who received childhood SDR. METHODS Adult patients who received SDR in childhood were surveyed. The survey questionnaire asked about demographic information, quality of life, health outcomes, SDR surgical outcomes, ambulation, manual ability, pain, braces/orthotics, post-SDR treatment, living situation, education level, and work status. RESULTS Our study included 95 patients. The age that patients received SDR was between two and 18 years. The age at the time of survey was between 23 and 37 years (mean ± S.D., 30.2 ± 3.6 years). Post-SDR follow-up ranged from 20 to 28 years (mean ± S.D., 24.3 ± 2.2 years). Seventy-nine percent of patients had spastic diplegia, 20% had spastic quadriplegia, and one percent had spastic triplegia. Ninety-one percent of patients felt that SDR impacted positively the quality of life and two percent felt that the surgery impacted negatively the quality of life after SDR. Compared to pre-operative ambulatory function, 42% reported higher level of ambulation and 42% ambulated in the same level. Eighty-eight percent of patients would recommend the procedure to others and two percent would not. Thirty-eight percent reported pain, mostly in the back and lower limbs, with mean pain level 4.2 ± 2.3 on the Numeric Pain Rating Scale (NPRS). Decreased sensation in patchy areas of the lower limbs that did not affect daily life was reported by eight percent of patients. Scoliosis was diagnosed in 31%. The severity of scoliosis is unknown. Only three percent of them underwent spinal fusion. Fifty-seven percent of patients required some orthopedic surgery after SDR. The soft-tissue tendon lengthening procedures included lengthening on hamstrings, Achilles tendons or adductors. Out of all bone procedures, 24% of patients had hip surgery, five percent had knee surgery, and 10% had derotational osteotomies. No late side effects of SDR surgery were reported in this survey. CONCLUSIONS In our 95 adult patients who received SDR in childhood, the surgery had positive effects on the quality of life and ambulation 20-28 years later. There were no late complications of SDR surgery.
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Affiliation(s)
- T S Park
- Neurological Surgery, Washington University School of Medicine, St. Louis Children's Hospital
| | - Jenny L Liu
- Pediatric Neurosurgery, Washington University School of Medicine, St. Louis Children's Hospital
| | - Caleb Edwards
- Pediatric Neurosurgery, Washington University School of Medicine, St. Louis Children's Hospital
| | - Deanna M Walter
- Pediatric Neurosurgery, Washington University School of Medicine, St. Louis Children's Hospital
| | - Matthew B Dobbs
- Pediatric Orthopedic Surgery, Washington University School of Medicine, St. Louis Children's Hospital
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Naro A, Leo A, Russo M, Casella C, Buda A, Crespantini A, Porcari B, Carioti L, Billeri L, Bramanti A, Bramanti P, Calabrò RS. Breakthroughs in the spasticity management: Are non-pharmacological treatments the future? J Clin Neurosci 2017; 39:16-27. [DOI: 10.1016/j.jocn.2017.02.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/12/2017] [Indexed: 12/16/2022]
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Park TS, Edwards C, Liu JL, Walter DM, Dobbs MB. Beneficial Effects of Childhood Selective Dorsal Rhizotomy in Adulthood. Cureus 2017; 9:e1077. [PMID: 28401027 PMCID: PMC5382010 DOI: 10.7759/cureus.1077] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Selective dorsal rhizotomy (SDR) has been used to treat children with spastic cerebral palsy (CP) for over three decades. However, little is known about the outcomes of childhood SDR in adults. Objectives: 1) To study the effects of childhood SDR on the quality of life and ambulatory function in adult life. 2) To determine late side effects of SDR in adults. Methods: Adults (> 17.9 years) who underwent SDR in childhood (2 - 17.9 years) between 1987 and 2013 were surveyed in 2015. Patients completed a survey, including questions on demographic information, quality of life, health, surgical outcomes, motor function, manual ability, pain, braces/orthotics, post-SDR treatment, living situation, education level, work status, and side effects of SDR. Results: In our study population of 294 patients (18.0 - 37.4 years), patients received SDR during the ages of 2.0 - 17.9 years and were followed up 2.2 to 28.3 years after surgery. Eighty-four percent had spastic diplegia, 12% had spastic quadriplegia, and 4% had spastic triplegia. The majority (88%) of patients reported improved post-SDR quality of life and 1% considered the surgery detrimental. Most (83%) would recommend the procedure to others and 3% would not. However, patients who would not recommend SDR to others ambulated with a walker or were not ambulatory at all prior to SDR. The majority (83%) of patients improved (30%) or remained stable (53%) in ambulation. Twenty-nine percent of patients reported pain, mostly in the back and lower limbs, with a mean pain level of 4.4 ± 2.4 on the Numeric Pain Rating Scale (NPRS). Decreased sensation in small areas of the lower limbs was reported by 8% of patients, though this did not affect daily life. Scoliosis was diagnosed in 28%, with 40% of these patients pursuing treatment. Whether scoliosis was related to SDR is not clear, though scoliosis is known to occur in patients with CP and also in the general population. Only 4% of patients underwent spinal fusion. Orthopedic surgeries were pursued by 59% of patients. The most common orthopedic surgeries were hamstring lengthenings (31%), Achilles tendon lengthenings (18%), adductor lengthenings (16%), and derotational osteotomies (16%). Twenty-four percent of all patients later underwent hip surgery and 8% had surgeries on their knees. Conclusion: Results of this study indicate that the beneficial effects of childhood SDR extend to adulthood quality of life and ambulatory function without late side effects of surgery.
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Affiliation(s)
- T S Park
- Neurological Surgery, Washington University School of Medicine, St. Louis Children's Hospital
| | - Caleb Edwards
- Pediatric Neurosurgery, Washington University School of Medicine, St. Louis Children's Hospital
| | - Jenny L Liu
- Pediatric Neurosurgery, Washington University School of Medicine, St. Louis Children's Hospital
| | - Deanna M Walter
- Pediatric Neurosurgery, Washington University School of Medicine, St. Louis Children's Hospital
| | - Matthew B Dobbs
- Pediatric Orthopedic Surgery, Washington University School of Medicine, St. Louis Children's Hospital
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Abou Al-Shaar H, Imtiaz MT, Alhalabi H, Alsubaie SM, Sabbagh AJ. Selective dorsal rhizotomy: A multidisciplinary approach to treating spastic diplegia. Asian J Neurosurg 2017; 12:454-465. [PMID: 28761524 PMCID: PMC5532931 DOI: 10.4103/1793-5482.175625] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Spasticity is a motor disorder that interferes with mobility and affects the quality of life. Different approaches have been utilized to address patients with spastic diplegia, among which is selective dorsal rhizotomy (SDR). Although SDR has been shown to be efficacious in treating spastic patients, many neurologists and neurosurgeons are not well aware of the procedure, its indications, and expected outcomes due to the limited number of centers performing this procedure. Objectives: The aim of this study is to describe the collaborative multidisciplinary approach between neurosurgeons, neurophysiologists, and physiotherapists in performing SDR. In addition, we delineate three illustrative cases in which SDR was performed in our patients. Materials and Methods: A retrospective review and analysis of the clinical records of our three patients who underwent SDR was conducted and reported. Patients’ outcomes were evaluated and compared to preoperative measurements based on clinical examination of power, tone (Ashworth scale), gait, and range of motion, as well as subjective functional assessment, gross motor function classification system, and gross motor function measure with follow-up at 6, 12, and 24 months postoperatively. A detailed description of our neurosurgical technique in performing SDR in collaboration with neurophysiology and physiotherapy monitoring is provided. Results: The three patients who underwent SDR using our multidisciplinary approach improved both functionally and objectively after the procedure. No intraoperative or postoperative complications were encountered. All patients were doing well over a long postoperative follow-up period. Conclusion: A multidisciplinary approach to treating spastic diplegia with SDR can provide good short-term and long-term outcomes in select patients suffering from spastic diplegia.
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Affiliation(s)
- Hussam Abou Al-Shaar
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Department of Pediatric Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Muhammad Tariq Imtiaz
- Department of Neurophysiology, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hazem Alhalabi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Shara M Alsubaie
- Department of Physiotherapy, Rehabilitation Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman J Sabbagh
- Department of Pediatric Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia.,Faculty of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Neurosciences, Division of Neurological Surgery, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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PABLO MANZONE PATRICIO, VALLEJOS ARCE MARÍASELVA, ORSINI EDITH, DORTIGNAC MARIANO, MARIÑO AVALOS EDUARDO, CARDOZO IÑIGUEZ MARIALORENA, GEMETRO JOSÉ. SPINAL DEFORMITIES AFTER SELECTIVE DORSAL RHIZOTOMY. COLUNA/COLUMNA 2016. [DOI: 10.1590/s1808-185120161503149860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: Selective dorsal rhizotomy (SDR) used for spasticity treatment could worsen or develop spinal deformities. Our goal is to describe spinal deformities seen in patients with cerebral palsy (CP) after being treated by SDR. Methods: Retrospective study of patients operated on (SDR) between January/1999 and June/2012. Inclusion criteria: spinal Rx before SDR surgery, spinography, and assessment at follow-up. We evaluated several factors emphasizing level and type of SDR approach, spinal deformity and its treatment, final Risser, and follow-up duration. Results: We found 7 patients (6 males): mean age at SDR 7.56 years (4.08-11.16). Mean follow-up: 6.64 years (2.16-13), final age: 14.32 years (7.5-19). No patient had previous deformity. GMFCS: 2 patients level IV, 2 level III, 3 level II. Initial walking status: 2 community walkers, 2 household walkers, 2 functional walkers, 1 not ambulant, at the follow-up, 3 patients improved, and 4 kept their status. We found 4 TL/L laminotomies, 2 L/LS laminectomies, and 1 thoracic laminectomy. Six spinal deformities were observed: 2 sagittal, 3 mixed, and 1 scoliosis. There was no association among the type of deformity, final gait status, topographic type, GMFCS, age, or SDR approach. Three patients had surgery indication for spinal deformity at skeletal maturity, while those patients with smaller deformities were still immature (Risser 0 to 2/3) although with progressive curves. Conclusions: After SDR, patients should be periodically evaluated until they reach Risser 5. The development of a deformity does not compromise functional results but adds morbidity because it may require surgical treatment.
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Affiliation(s)
| | | | - EDITH ORSINI
- Hospital General de Agudos "Dr. Julio C. Perrando", Argentina
| | | | | | | | - JOSÉ GEMETRO
- Hospital 4 de Junio "Dr. Ramón Carrillo", Argentina
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Sharma J, Bonfield C, Steinbok P. Selective dorsal rhizotomy for hereditary spastic paraparesis in children. Childs Nerv Syst 2016; 32:1489-94. [PMID: 27312078 DOI: 10.1007/s00381-016-3122-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/16/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of this study was to determine the outcomes for children who underwent selective dorsal rhizotomy (SDR) for the treatment of spasticity related to spinal pathology. METHODS We performed a retrospective review of all cases of SDR at our institution over the last 30 years and identified patients in whom spasticity was attributed to spinal rather than cerebral pathology. We gathered demographic information and recorded functional status and spasticity scores pre-operatively and over long-term follow-up. RESULTS We identified four patients who underwent SDR for spinal-related spasticity. All four had hereditary spastic paraparesis (HSP). All patients had reduced spasticity in the lower limbs after SDR, which was maintained over long-term follow-up. Two patients had a more severe and progressive subtype of HSP, and both these patients exhibited functional decline despite improvement in tone. CONCLUSIONS Our findings suggest SDR is a reasonable option to consider for relief of spinal-related spasticity in uncomplicated hereditary spastic paraparesis. However, SDR for the treatment of complicated HSP seems to carry more risks and have a less predictable outcome. Overall, SDR is probably best reserved for pathologies that are relatively stable in their disease course.
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Affiliation(s)
- Julia Sharma
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | | | - Paul Steinbok
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada. .,Division of Pediatric Neurosurgery, British Columbia Children's Hospital (BCC), 4480 Oak Street, Rm K3-216, Vancouver, BC, V6H 3V4, Canada.
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Funk JF, Haberl H. Monosegmental laminoplasty for selective dorsal rhizotomy--operative technique and influence on the development of scoliosis in ambulatory children with cerebral palsy. Childs Nerv Syst 2016; 32:819-25. [PMID: 26759019 DOI: 10.1007/s00381-016-3016-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 01/05/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE Selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy (CP) and is performed either through a lumbosacral multilevel laminectomy or a single-level laminectomy at the medullary conus. Spinal interventions generally involve the risk of subsequent instability depending on the extent of structural weakening. Destabilizing spasticity in CP might further increase this risk for both options. Laminoplasty is frequently applied to reduce instability through anatomical restoration, although the unavoidable interruption of interspinous ligaments might be a reason for inconsistent results. We report on a novel technique of laminoplasty, achieving complete restoration of the dorsal column. METHODS One hundred sixteen ambulatory children with gross motor function classification scale (GMFCS) level I to III were submitted to SDR through a single-level approach. The lamina was reinserted with a previously unreported technique of laminoplasty. Osseous reintegration of the excised lamina was supposed, if its spinous process was located in place on late follow-up radiographs. Scoliosis was described via Cobb's angle. RESULTS At a mean follow-up of 33 months, radiographs were available from 72 children with a mean age at surgery of 7.2 years. Sixty-two out of the 72 reinserted laminae were supposed to be vital and reintegrated. Seven children developed a predominantly mild scoliosis. No association was found between development of scoliosis and GMFCS level or age. CONCLUSIONS This novel laminoplasty technique provides the least invasive approach for SDR. The incidence of scoliosis after this single-level approach is comparable to the natural history of ambulatory CP children.
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Affiliation(s)
- Julia Franziska Funk
- Department of Pediatric Orthopedic Surgery and Neuroorthopedics, Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Hannes Haberl
- Section of Pediatric Neurosurgery, Department of Neurosurgery, University of Ulm, Eythstrasse 24, 89075, Ulm, Germany
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Sindou M, Georgoulis G. Keyhole interlaminar dorsal rhizotomy for spastic diplegia in cerebral palsy. Acta Neurochir (Wien) 2015; 157:1187-96. [PMID: 26002713 DOI: 10.1007/s00701-015-2453-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/12/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND The efficiency and safety of dorsal rhizotomies for cerebral palsy lie in the accuracy of radicular identification together with selectivity of root sectioning. Two different exposures are currently in use. The first is extended laminotomy/laminectomy from the upper lumbar level to the sacrum, which allows accurate identification of all L2-S2 roots/rootlets. The second is limited laminotomy exposing the conus/cauda equina at the thoracolumbar junction; this less invasive method limits accessibility to the roots. To optimize the accuracy and selectivity while minimizing invasiveness, the authors developed a tailored interlaminar procedure targeting the radicular levels involved in the harmful components of spasticity directly and individually. METHODS Six patients with spastic diplegia at different levels of the Gross Motor Functional Classification System were selected. In each patient, two to three interlaminar spaces, preselected according to planning, were enlarged in the "keyhole" fashion, respecting the spinous processes and interspinous ligaments. Ventral root stimulation identified the radicular level. Dorsal root stimulation evaluated its implication in the hyperactive segmental circuits, helping quantify the percentage of rootlets to be cut. RESULTS There were neither wound-related nor general complications. At 1 year of follow-up, X-ray examination did not reveal kyphosis or instability. In all children, the excess of spasticity was reduced. The Ashworth score decreased from 3.2 on average to 0.6 postoperatively (range: 2-4 to 0-2). Regarding the functional status at 1 year of follow-up for the three ambulatory children, the Gillette ability-to-walk score increased from 3/10 on average to 7.3/10 postoperatively (range: 2-4 to 7-8). For the three non-ambulatory children, abnormal postures, painful contractures and ease of care were much improved. CONCLUSION Keyhole interlaminar dorsal rhizotomy (KIDr) offers direct intradural access to each of the ventral/dorsal roots, thus maximizing the reliability of anatomical mapping and allowing individual physiological testing of all targeted roots. The interlaminar approach minimizes invasiveness by respecting the posterior spine structures.
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Affiliation(s)
- Marc Sindou
- 1st Department of Neurosurgery, Hôpital Neurologique "Pierre Wertheimer", University of Lyon 1, Lyon, France,
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Abstract
Cerebral palsy (CP) is the leading cause of childhood disability affecting function and development. CP is defined as a nonprogressive neuromotor disorder of cerebral origin. It cannot be correlated with any single disease or condition in Ayurveda, as it is a multi-factorial disease with clinical features of a wide variation. According to Vāgbhaṭa, it is classified in the disease categories of sahaja (hereditary) and garbhaja (congenital) and jātaja (psychosomatic) type of diseases. Of the many types and subtypes of CP, none has any known “cure.” Here, an effort was made to treat a 3-year-old male child with spastic type of CP using multiple Ayurveda treatment modalities. At the end of 94 days of treatment, Pañcakarma procedures along with internal medication resulted in 10–15% improvement in the overall effect of therapy.
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Affiliation(s)
- Sagar Mahendrabhai Bhinde
- Department of Kaumarbhritya, G. J. Patel Institute of Ayurvedic Studies and Research Centre, New V V Nagar, Anand, Gujarat, India
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Eppinger MA, Berman CM, Mazzola CA. Selective dorsal rhizotomy for spastic diplegia secondary to stroke in an adult patient. Surg Neurol Int 2015; 6:111. [PMID: 26167363 PMCID: PMC4496840 DOI: 10.4103/2152-7806.159382] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 04/24/2015] [Indexed: 11/17/2022] Open
Abstract
Background: Selective dorsal rhizotomy (SDR) is often recommended for children with spastic paraparesis and cerebral palsy. SDR reduces spasticity in the lower extremities for these children with spastic paraplegia. However, SDR is infrequently recommended for adults with spasticity. Spastic diplegia in adult patients can be due to stroke, brain or spinal cord injury from trauma, infection, toxic-metabolic disorders, and other causes. Although rarely considered, SDR is an option for adult patients with spastic diplegia as well. Case Description: The authors describe a patient who underwent a SDR with a successful postoperative outcome. This man suffered a hypertensive and hemorrhagic stroke secondary to intravenous drug abuse at age 46. A SDR was performed after two failed intrathecal baclofen pump placements due to recurrent infections, likely resulting from his immunocompromised status. The patient underwent lumbar laminectomies and dorsal rhizotomies at levels L1-S1 bilaterally. Postoperatively, the patient's spasticity was significantly reduced. His Ashworth spasticity score decreased from 4/5 to 1/5, and the reduction in tone has been durable over 3 years. Conclusion: SDR in older patients with spastic paraparesis may be considered as a treatment option.
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Affiliation(s)
- Melissa Ann Eppinger
- Department of Neurosciences, Morristown Medical Center, Goryeb Children's Hospital, Morristown, New Jersey, USA
| | - Casey Melissa Berman
- Department of Neurosciences, Morristown Medical Center, Goryeb Children's Hospital, Morristown, New Jersey, USA
| | - Catherine Anne Mazzola
- Department of Neurosciences, Morristown Medical Center, Goryeb Children's Hospital, Morristown, New Jersey, USA
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Cervical selective dorsal rhizotomy for treating spasticity in upper limb neurosurgical way to neurosurgical technique. INTERDISCIPLINARY NEUROSURGERY 2015. [DOI: 10.1016/j.inat.2014.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Carraro E, Zeme S, Ticcinelli V, Massaroni C, Santin M, Peretta P, Martinuzzi A, Trevisi E. Multidimensional outcome measure of selective dorsal rhizotomy in spastic cerebral palsy. Eur J Paediatr Neurol 2014; 18:704-13. [PMID: 24954890 DOI: 10.1016/j.ejpn.2014.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 05/28/2014] [Accepted: 06/01/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND One of the treatment option to reduce spasticity in cerebral palsy children is selective dorsal rhizotomy. Several studies have demonstrated short and long term improvements in gait and other activities after rhizotomy but this surgery still remains a controversial procedure and patient outcome indicators measures are not uniform. AIMS To describe our assessment and outcome evaluation protocol and to verify by this protocol short term results of rhizotomy. METHODS We recruited 9 cerebral palsy children (mean age 7.9 years ± 3.2) affected by mild to moderate spastic diplegia and operated by rhizotomy. Patients were studied preoperatively and at 12 months after surgery by the following clinical and instrumental measures correlated to the International Classification of Functioning: modified Ashworth Scale, passive Range of Motion, Medical Research Council Scale, Selective Motor Control Scale, 3D-motion analysis and energy cost of locomotion measurements (indicators of "body functions"); Gross Motor Functional Measure and Motor Functional Independence Measure (indicators of "activities and participation"). RESULTS Our data showed, after rhizotomy, reduction of spasticity specially in plantarflexors muscles (p < 0.01), increase of strength of knee flexors/extensors and foot plantar/dorsiflexion muscles (p < 0.01), improvement of selective motor control (p < 0.05), more similar spatio-temporal parameters of gait analysis to healthy subjects, reduced equinus foot and knees hyperflexion as energy cost. CONCLUSION The complementary use of multiple indicators may improve the evaluation of the results of dorsal rhizotomy. A beneficial outcome measured by these indicators has been found in our spastic diplegic children one year after rhizotomy.
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Affiliation(s)
- Elena Carraro
- "E. Medea" Scientific Institute, Conegliano Research Centre, Conegliano, TV, Italy.
| | - Sergio Zeme
- Functional Neurosurgery Unit, Neuroscience Department, University of Torino, Torino, Italy
| | - Valentina Ticcinelli
- "E. Medea" Scientific Institute, Conegliano Research Centre, Conegliano, TV, Italy
| | - Carlo Massaroni
- "E. Medea" Scientific Institute, Conegliano Research Centre, Conegliano, TV, Italy
| | - Michela Santin
- "E. Medea" Scientific Institute, Conegliano Research Centre, Conegliano, TV, Italy
| | - Paola Peretta
- Department of Pediatric Neurosurgery, Regina Margherita Children's Hospital, Torino, Italy
| | - Andrea Martinuzzi
- "E. Medea" Scientific Institute, Conegliano Research Centre, Conegliano, TV, Italy
| | - Enrico Trevisi
- "E. Medea" Scientific Institute, Conegliano Research Centre, Conegliano, TV, Italy
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Gump WC, Mutchnick IS, Moriarty TM. Selective dorsal rhizotomy for spasticity not associated with cerebral palsy: reconsideration of surgical inclusion criteria. Neurosurg Focus 2014; 35:E6. [PMID: 24175866 DOI: 10.3171/2013.8.focus13294] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Children with spastic diplegia from cerebral palsy (CP) experience measurable improvement in their spasticity and motor function following selective dorsal rhizotomy (SDR). The role of this operation in the treatment of other spasticity causes is less well defined. A literature review was undertaken to survey outcomes from SDRs performed outside the CP population. Multiple sclerosis was the most common diagnosis found, accounting for 74 of 145 patients described. Selective dorsal rhizotomies have also been reported in patients with traumatic brain and spinal cord injuries, ischemic and hemorrhagic stroke, neurodegenerative disease, hypoxic encephalopathy, and other causes of spasticity. Outcomes from surgery are generally described as favorable, although postoperative assessments and follow-up times are not standardized across reports. Long-term outcomes are sparsely reported. Larger numbers of patients and more detailed outcomes data have the potential to form a basis for expanding the inclusion criteria for SDR.
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Affiliation(s)
- William C Gump
- Division of Pediatric Neurosurgery, Norton Neuroscience Institute and Kosair Children's Hospital; and
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Dudley RWR, Parolin M, Gagnon B, Saluja R, Yap R, Montpetit K, Ruck J, Poulin C, Cantin MA, Benaroch TE, Farmer JP. Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy. J Neurosurg Pediatr 2013; 12:142-50. [PMID: 23713680 DOI: 10.3171/2013.4.peds12539] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECT Large-scale natural history studies of gross motor development have shown that children with spastic cerebral palsy (CP) plateau during childhood and actually decline through adolescence. Selective dorsal rhizotomy (SDR) is a well-recognized treatment for spastic CP, but little is known about long-term outcomes of this treatment. The purpose of this study was to assess the durability of functional outcomes in a large number of patients through adolescence and into early adulthood using standardized assessment tools. METHODS The authors analyzed long-term follow-up data in children who had been evaluated by a multidisciplinary team preoperatively and at 1, 5, 10, and 15 years after SDR. These evaluations included quantitative, standardized assessments of lower-limb tone (Ashworth Scale), Gross Motor Function Measure (GMFM), and performance of activities of daily living (ADLs) by the Pediatric Evaluation of Disability Inventory in children who had been stratified by motor severity using the Gross Motor Function Classification System (GMFCS). In addition, group-based trajectory modeling (GBTM) was used to identify any heterogeneity of response to SDR among these treated children, and to find which pretreatment variables might be associated with this heterogeneity. Finally, a chart review of adjunct orthopedic procedures required by these children following SDR was performed. RESULTS Of 102 patients who underwent preoperative evaluations, 97, 62, 57, and 14 patients completed postoperative assessments at 1, 5, 10, and 15 years, respectively. After SDR, through adolescence and into early adulthood, statistically significant durable improvements in lower-limb muscle tone, gross motor function, and performance of ADLs were found. When stratified by the GMFCS, long-lasting improvements for GMFCS Groups I, II, and III were found. The GBTM revealed 4 groups of patients who responded differently to SDR. This group assignment was associated with distribution of spasticity (diplegia was associated with better outcomes than triplegia or quadriplegia) and degree of hip adductor spasticity (Ashworth score < 3 was associated with better outcomes than a score of 3), but not with age, sex, degree of ankle plantar flexion spasticity, or degree of hamstring spasticity. In a sample of 88 patients who had complete records of orthopedic procedures and botulinum toxin (Botox) injections, 52 (59.1%) underwent SDR alone, 11 (12.5%) received only Botox injections in addition to SDR, while 25 patients (28.4%) needed further lower-extremity orthopedic surgery after SDR. CONCLUSIONS In the majority of patients, the benefits of SDR are durable through adolescence and into early adulthood. These benefits include improved muscle tone, gross motor function, and performance of ADLs, as well as a decreased need for adjunct orthopedic procedures or Botox injections. The children most likely to display these long-term benefits are those in GMFCS Groups I, II, and III, with spastic diplegia, less hip adductor spasticity, and preoperative GMFM scores greater than 60.
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Affiliation(s)
- Roy W R Dudley
- Division of Neurosurgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
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Bakir MS, Gruschke F, Taylor WR, Haberl EJ, Sharankou I, Perka C, Funk JF. Temporal but not spatial variability during gait is reduced after selective dorsal rhizotomy in children with cerebral palsy. PLoS One 2013; 8:e69500. [PMID: 23922724 PMCID: PMC3724918 DOI: 10.1371/journal.pone.0069500] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 06/09/2013] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Variability in task output is a ubiquitous characteristic that results from non-continuous motor neuron firing during muscular force generation. However, variability can also be attributed to errors in control and coordination of the motor neurons themselves in diseases such as cerebral palsy (CP). Selective dorsal rhizotomy (SDR), a neurosurgical approach to sever sensory nerve roots, is thought to decrease redundant or excessive afferent signalling to intramedullary neurons. In addition to its demonstrated ability to reduce muscular spasticity, we hypothesised that SDR is able to decrease variability during gait, the most frequent functional motor activity of daily living. METHODS Twelve CP children (aged 6.1 ± 1.3 yrs), who underwent SDR and performed gait analysis pre- and 12 months postoperatively, were compared to a control group of eleven typically developing (TD) children. Coefficients of variability as well as mean values were analysed for: temporal variables of gait, spatial parameters and velocity. RESULTS Gait parameters of cadence (p = 0.006) and foot progression angle at mid-stance (p = 0.041) changed significantly from pre- to post-SDR. The variability of every temporal parameter was significantly reduced after SDR (p = 0.003-0.049), while it remained generally unchanged for the spatial parameters. Only a small change in gait velocity was observed, but variability in cadence was significantly reduced after SDR (p = 0.015). Almost all parameters changed with a tendency towards normal, but differences between TD and CP children remained in all parameters. DISCUSSION The results confirm that SDR improves functional gait performance in children with CP. However, almost exclusively, parameters of temporal variability were significantly improved, leading to the conjecture that temporal variability and spatial variability may be governed independently by the motor cortex. As a result, temporal parameters of task performance may be more vulnerable to disruption, but also more responsive to treatment success of interventions such as SDR.
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Affiliation(s)
- Mustafa Sinan Bakir
- Center for Musculoskeletal Surgery, Department of Orthopaedics, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Center for Musculoskeletal Surgery, Julius Wolff Institute, Center for Sports Science and Sports Medicine Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Franziska Gruschke
- Center for Musculoskeletal Surgery, Department of Orthopaedics, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Center for Musculoskeletal Surgery, Julius Wolff Institute, Center for Sports Science and Sports Medicine Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - William R. Taylor
- Center for Musculoskeletal Surgery, Julius Wolff Institute, Center for Sports Science and Sports Medicine Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
| | - Ernst Johannes Haberl
- Department of Paediatric Neurosurgery, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Ilya Sharankou
- Center for Musculoskeletal Surgery, Julius Wolff Institute, Center for Sports Science and Sports Medicine Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Department of Orthopaedics, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Julia F. Funk
- Center for Musculoskeletal Surgery, Department of Orthopaedics, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Center for Musculoskeletal Surgery, Julius Wolff Institute, Center for Sports Science and Sports Medicine Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Social Paediatric Center, Charité–Universitätsmedizin Berlin, Berlin, Germany
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Thibaut A, Chatelle C, Ziegler E, Bruno MA, Laureys S, Gosseries O. Spasticity after stroke: Physiology, assessment and treatment. Brain Inj 2013; 27:1093-105. [PMID: 23885710 DOI: 10.3109/02699052.2013.804202] [Citation(s) in RCA: 252] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Aurore Thibaut
- Coma Science Group, Cyclotron Research Centre, University and University Hospital of Liège
LiègeBelgium
| | - Camille Chatelle
- Coma Science Group, Cyclotron Research Centre, University and University Hospital of Liège
LiègeBelgium
| | - Erik Ziegler
- Cyclotron Research Centre, University of Liège
LiègeBelgium
| | - Marie-Aurélie Bruno
- Coma Science Group, Cyclotron Research Centre, University and University Hospital of Liège
LiègeBelgium
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Centre, University and University Hospital of Liège
LiègeBelgium
| | - Olivia Gosseries
- Coma Science Group, Cyclotron Research Centre, University and University Hospital of Liège
LiègeBelgium
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Hurvitz EA, Marciniak CM, Daunter AK, Haapala HJ, Stibb SM, McCormick SF, Muraszko KM, Gaebler-Spira D. Functional outcomes of childhood dorsal rhizotomy in adults and adolescents with cerebral palsy. J Neurosurg Pediatr 2013; 11:380-8. [PMID: 23394352 DOI: 10.3171/2013.1.peds12311] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this descriptive study the authors evaluated medical outcomes, interventions, satisfaction with life, and subjective impressions about selective dorsal rhizotomy (SDR) in older adolescents and adults who had undergone the procedure as children. METHODS A survey was administered to older adolescents (16-20 years old) and adults with CP who had undergone SDR between 1986 and 2000 at two academic centers. The patients or their caregivers participated in telephone or clinic interviews. Subjective impressions about the SDR and a history of post-SDR medical interventions were obtained. Current functional status, history and ratings of pain, educational achievement, living situation, and subjective health status were also recorded. The Diener Satisfaction with Life Scale (SWLS) was administered. RESULTS Eighty-eight participants, mean age 25.6 ± 4.8 years (mean ± standard deviation), were interviewed at a mean of 19.6 ± 3.0 years after surgery. The distribution of current reported Gross Motor Function Classification System levels was as follows: I, 7%; II, 18%; III, 23%; IV, 36%; and V, 16%. Moreover, 56% of respondents were living with parents and 25% were living alone. Thirty-five percent were employed, and 39% were still in school. The mean overall SWLS score was 26.0 ± 7.3, indicating a high level of satisfaction with life. According to 65% of the patients, the SDR was helpful; 31% were uncertain about the procedure's efficacy. Sixty-five percent would recommend the procedure to others. Fifty-eight percent reported excellent to very good health. Forty-four percent reported pain in the past week. Fifty-one percent reported chronic back pain in general. Logistic regression analysis suggested that an increased satisfaction with life was a predictor (p = 0.01) of an affirmative response to the question about recommending the procedure to others and that better overall health showed a trend toward being such a predictor (p = 0.08). Additional interventions were frequently performed after the SDR. Seventy-four percent of participants underwent orthopedic surgery. Thirty-eight percent were currently taking oral medications for tone, and 53% had received botulinum toxin injections for spasticity treatment. Thirteen patients (15%) had an intrathecal baclofen pump placed. CONCLUSIONS The majority of adults who had undergone SDR as children would recommend the procedure to others. Very few reported negative impressions of the procedure. Levels of satisfaction with life were generally high. Pain prevalence was similar to what has been reported in the literature for adults with cerebral palsy. Despite the SDR, further interventions, both surgical and nonsurgical, were used in the majority of patients.
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Affiliation(s)
- Edward A Hurvitz
- Departments of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan 48108, USA.
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A comparison of hip dislocation rates and hip containment procedures after selective dorsal rhizotomy versus intrathecal baclofen pump insertion in nonambulatory cerebral palsy patients. J Pediatr Orthop 2012; 32:853-6. [PMID: 23147631 DOI: 10.1097/bpo.0b013e31826ba7b2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Spasticity is the major etiology for hip dislocation in nonambulatory cerebral palsy patients. Selective dorsal rhizotomy (SDR) was used to control lower extremity spasticity, but is now done infrequently in nonambulatory cerebral palsy. Current surgical treatment is usually intrathecal baclofen pump (ITBP) placement. A major theoretical difference between SDR and ITBP is the effect on the iliopsoas through the L1 nerve root. This study compares the rate of hip dislocation and the need for further hip surgeries in SDR and ITBP patients. METHODS All nonambulatory cerebral palsy patients who had either an SDR or ITBP and had minimum follow-up of 2 years were retrospectively reviewed for demographic data and timing, total number, and type of hip procedures (soft tissue vs. bony), and occurrence of hip dislocation. χ (2)test was used to assess for statistical significance. RESULTS Sixty-nine patients who underwent SDR (40 males) and 50 patients who underwent ITBP (27 males) were included in the study. Average age at spasticity intervention was 6 years 11 months for SDR and 9 years 8 months for ITBP. In the SDR group, 25% of hips underwent reconstruction versus 32% of hips in the ITBP group. There were a total of 19 hip procedures in the SDR group and 20 in the ITBP group (P = 0.15). Seventeen soft-tissue procedures were performed in both SDR and ITBP groups (P = 0.265). Six bony procedures (0 salvage) were performed in the SDR group and 10 in the ITBP group (4 salvage; P = 0.075). At final follow-up the hip dislocation rate was 10.6% in the SDR group and 7.4% in the ITBP group. CONCLUSIONS There was no significant difference in the rate of secondary hip reconstructive surgery or dislocation between nonambulatory cerebral palsy patients who underwent SDR versus ITBP. Reconstruction was required for 25% to 32% of hips despite spasticity intervention with either procedure. This suggests that the L1 nerve root alone does not play a major role in the progression of hip dislocation. LEVEL OF EVIDENCE Level 3--therapeutic study.
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Shilt JS, Seibert PS, Kadyan V. Optimal management for people with severe spasticity. Degener Neurol Neuromuscul Dis 2012; 2:133-140. [PMID: 30890884 DOI: 10.2147/dnnd.s16630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Spasticity is characterized by velocity-dependent increase in tonic stretch reflexes and tendon jerks. Many people affected by spasticity receive late treatment, or no treatment, which greatly reduces the potential to regain full motor control and restore function. There is much to consider before determining treatment for people with spasticity. Treatment of pediatric patients increases the complexity, because of the substantial difference between adult and pediatric spasticity. Proper patient evaluation, utilization of scales and measures, and obtaining patient and caregiver history is vital in determining optimal spasticity treatment. Further, taking into consideration the limitations and desires of individuals serve as a guide to best management. We have grouped contributing factors into the IDAHO Criteria to elucidate a multidisciplinary approach, which considers a person's complete field of experience. This model is applied to goal setting, and recognizes the importance of a spasticity management team, comprising the treatment subject, his/her family, the environment, and a supportive, well-informed medical staff. The criteria take into account the complexity associated with diagnosing and treating spasticity, with the ultimate goal of improved function.
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Affiliation(s)
- Jeffrey S Shilt
- Idaho Spasticity Program, Saint Alphonsus Health Systems, Boise, ID
| | - Pennie S Seibert
- Department of Psychology, Boise State University, Boise, ID, USA,
| | - Vivek Kadyan
- Idaho Spasticity Program, Saint Alphonsus Health Systems, Boise, ID
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Nomura S, Kagawa Y, Kida H, Maruta Y, Imoto H, Fujii M, Suzuki M. Effects of intrathecal baclofen therapy on motor and cognitive functions in a rat model of cerebral palsy. J Neurosurg Pediatr 2012; 9:209-15. [PMID: 22295929 DOI: 10.3171/2011.10.peds11209] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebral palsy (CP) arises in the early stages of brain development and manifests as spastic paresis that is often associated with cognitive dysfunction. Available CP treatments are aimed at the management of spasticity and include botulinum toxin administration, selective dorsal rhizotomy, and intrathecal baclofen (ITB). In this study, the authors investigated whether the management of spasticity with ITB therapy affected motor function and whether the release of spasticity was associated with an improvement in intellectual function. METHODS Newborn Sprague-Dawley rats were divided into the following groups: control, CP model, and CP model with ITB therapy. For the CP model, postnatal Day 7 (P7) rats were exposed to hypoxic conditions (8% O(2)) for 150 minutes after ligation of the right common carotid artery. In the groups receiving ITB therapy, a spinal catheter was connected to an osmotic pump filled with baclofen and placed in the spinal subarachnoid space on P21 in the early group and on P35 in the late group. A daily dose of 12 μg of baclofen was continuously administered until P49, resulting in 28 days of therapy in the early group and 14 days in the late group. Changes in spasticity in the CP and CP with ITB treatment groups were confirmed by assessing the motor evoked potential in the plantar muscle. RESULTS In the CP group, the time required to complete a beam-walking test on P49 was significantly longer than that in the control and ITB treatment groups (4.15 ± 0.60 vs 2.10 ± 0.18 and 2.22 ± 0.22 seconds, respectively). Results of the beam-walking test are expressed as the mean ± SD. Radial arm maze performance on P49 indicated that spatial reference memory had significantly deteriorated in the CP group compared with controls (2.33 ± 0.87 vs 0.86 ± 0.90 points); moreover, working memory was also negatively affected by CP (0.78 ± 1.09 vs 0.14 ± 0.38 points). Results of the memory tests are expressed as the mean ± SE. These memory functions did not recover after ITB treatment. CONCLUSIONS Management of spasticity with ITB therapy improved the walking ability in the rat CP model. Intrathecal baclofen therapy-which reduces harmful sensory and motor stimulations caused by spasticity to more optimal levels-contributed to motor function recovery; however, it had no effect on intellectual recovery as assessed by memory performance in the rat CP model.
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Affiliation(s)
- Sadahiro Nomura
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan.
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Gait status 17-26 years after selective dorsal rhizotomy. Gait Posture 2012; 35:244-9. [PMID: 22050972 DOI: 10.1016/j.gaitpost.2011.09.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 09/07/2011] [Accepted: 09/14/2011] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to use three-dimensional gait analysis to describe the gait status of adults with spastic diplegia who underwent selective dorsal rhizotomy (SDR) in childhood. Outcome measures were the gait deviation index (GDI), non-dimensional temporal-distance parameters, and kinematics of the lower limbs. A total of 31 adults with spastic diplegia who had previously undergone SDR were eligible and participated in current study (SDR group). These participants had a median age of 26.8 years (range 21-44 years) with a mean time between surgery and assessment of 21.2±2.9 years (range 17-26 years). For comparison purposes, 43 typically developed adults also participated (CONTROL group), with a median age of 28.3 years (range 21-45 years). More than 17 years after SDR 58% of the SDR group showed improved GMFCS levels, while none of them deteriorated. The participants in the SDR group walked with a mild crouch gait, although there was a loading response, adequate swing-phase knee flexion, adequate swing-phase plantarflexion, reasonable speed and cadence. The gait status of the SDR group more than 17 years after SDR was similar to what has been reported in short-term follow-up studies, as well as our earlier 20 year follow-up study that did not include 3D gait analysis. Appropriate orthopaedic intervention was required in 61% of the study cohort. Whether the types and numbers of orthopaedic interventions are positively affected by SDR remains an open question. Further studies examining this question are warranted. In addition, long-term follow-up studies focused on other interventions would also be of clinical relevance.
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Reynolds MR, Ray WZ, Strom RG, Blackburn SL, Lee A, Park TS. Clinical outcomes after selective dorsal rhizotomy in an adult population. World Neurosurg 2011; 75:138-44. [PMID: 21492678 DOI: 10.1016/j.wneu.2010.09.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2009] [Accepted: 09/13/2010] [Indexed: 12/11/2022]
Abstract
OBJECT Selective dorsal rhizotomy (SDR) is a highly effective and well-established surgical tool for correction of lower-extremity spasticity in children with spastic diplegia caused by cerebral palsy (CP). Although the literature demonstrates considerable immediate and long-term functional benefits in children treated with SDR, the effects of SDR on adults with spastic diplegia have not been thoroughly investigated. The purpose of this retrospective study was to examine the objective and subjective clinical outcomes of SDR on an adult population. METHODS We reviewed the charts of 21 consecutive adult patients who underwent SDR for treatment of CP-related spastic diplegia between the years of 1989 and 2007. All patients were treated by a single surgeon (T.S.P.) and underwent formal pre- and postoperative physical therapy assessments to examine joint range of motion (ROM), gross motor function measure (GMFM), and muscle tone. The majority of patients (15/21) exhibited preoperative ambulatory independence without an assistive device. Postoperative assessments were performed at 4 months, but most patients (11/21) had longer follow-up periods (mean, 17.6 ± 30.2 months). All patients were assessed with a telephone survey to estimate pre- and postoperative function with the Katz and Lawton Activities of Daily Living (ADL) Scale. RESULTS After SDR surgery, patients experienced significant improvements in lower-extremity passive joint ROM (namely, decreases in hamstring and gastrocnemius tightness) as well as in GMFM crawling and kneeling scores. In addition, spasticity in all measured lower-extremity muscle groups was decreased as compared with preoperative levels. On the basis of our patient self-assessments conducted via telephone, each patient demonstrated subjective improvements in ambulatory ability, spasticity, coordination, joint ROM, pain, overall quality of life, and independence. Also, the Lawton total instrumental ADL scale scores were subjectively improved from preoperative levels. We documented no complications, including postoperative sensory deficits, in any of our patients. CONCLUSIONS Our experience suggests that SDR can be an effective treatment for CP-related spastic diplegia in ambulatory adults who are unresponsive to medical therapy and should be considered as a therapeutic option in carefully selected patients. Although our study represents the largest series of adult patients with spastic diplegia to date treated with SDR, the data collected will need to be validated in a larger, prospective clinical trial.
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Affiliation(s)
- Matthew R Reynolds
- Department of Neurological Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.
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Vles GF, Vles JS, van Kleef M, van Zundert J, Staal HM, Weber WE, van Rhijn LW, Soudant D, Graham HK, de Louw AJ. Percutaneous radiofrequency lesions adjacent to the dorsal root ganglion alleviate spasticity and pain in children with cerebral palsy: pilot study in 17 patients. BMC Neurol 2010; 10:52. [PMID: 20569438 PMCID: PMC2909941 DOI: 10.1186/1471-2377-10-52] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 06/22/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebral palsy (CP) may cause severe spasticity, requiring neurosurgical procedures. The most common neurosurgical procedures are continuous infusion of intrathecal baclofen and selective dorsal rhizotomy. Both are invasive and complex procedures. We hypothesized that a percutaneous radiofrequency lesion of the dorsal root ganglion (RF-DRG) could be a simple and safe alternative treatment. We undertook a pilot study to test this hypothesis. METHODS We performed an RF-DRG procedure in 17 consecutive CP patients with severe hip flexor/adductor spasms accompanied by pain or care-giving difficulties. Six children were systematically evaluated at baseline, and 1 month and 6 months after treatment by means of the Modified Ashworth Scale (MAS), Gross Motor Function Measure (GMFM) and a self-made caregiver's questionnaire. Eleven subsequent children were evaluated using a Visual Analogue Scale (VAS) for spasticity, pain and ease of care. RESULTS A total of 19 RF-DRG treatments were performed in 17 patients. We found a small improvement in muscle tone measured by MAS, but no effect on the GMFM scale. Despite this, the caregivers of these six treated children unanimously stated that the quality of life of their children had indeed improved after the RF-DRG. In the subsequent 11 children we found improvements in all VAS scores, in a range comparable to the conventional treatment options. CONCLUSION RF-DRG is a promising new treatment option for severe spasticity in CP patients, and its definitive effectiveness remains to be defined in a randomised controlled trial.
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Historische Perspektiven der Neurorehabilitation. NeuroRehabilitation 2010. [DOI: 10.1007/978-3-642-12915-5_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Langerak NG, Vaughan CL, Hoffman EB, Figaji AA, Fieggen AG, Peter JC. Incidence of spinal abnormalities in patients with spastic diplegia 17 to 26 years after selective dorsal rhizotomy. Childs Nerv Syst 2009; 25:1593-1603. [PMID: 19784657 DOI: 10.1007/s00381-009-0993-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate the mechanical status of the spine in patients with spastic diplegia 17-26 years after selective dorsal rhizotomy (SDR). METHODS We compared original radiographic reports from our earlier short-term follow-up study with current X-rays. In addition, we obtained magnetic resonance images (MRI) of the spine and additional information regarding back pain and clinical assessments. RESULTS Thirty patients (17 males and 13 females; median age 26.8 years) participated in the current study, with median follow-up times of 4.0 and 21.4 years. Comparison of the X-ray results showed respectively: scoliosis 0% and 57%; kyphosis 0% and 7%; lordosis 21% and 40%; spondylolysis 18% and 37%; and spondylolisthesis grade I occurred in one patient. The only statistically significant difference was found for scoliosis (p < 0.01). The majority had Cobb angles <30 degrees with only two patients with curves of 35 degrees. MRI scans showed spinal stenosis in 27%, black discs in 10%, and disc protrusion in 3%. Daily back pain was reported in 17%, while 23% reported "moderate disability" as a result of back and leg pain. No patient to date has required any surgical intervention on the spine. CONCLUSIONS Except for spondylolisthesis, spinal deformities did appear to progress with time. However, this increase was not marked, and the development of relatively mild scoliosis was the only statistically significant increase. This group of patients requires continued follow-up. Further studies are required to ascertain the natural history of spinal deformity in adults with spastic diplegia who have not had SDR.
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Affiliation(s)
- Nelleke G Langerak
- MRC/UCT Medical Imaging Research Unit, Department of Human Biology, University of Cape Town, Observatory, Cape Town, Western Cape 7925, South Africa.
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Electrophysiologically guided versus non-electrophysiologically guided selective dorsal rhizotomy for spastic cerebral palsy: a comparison of outcomes. Childs Nerv Syst 2009; 25:1091-6. [PMID: 19484248 DOI: 10.1007/s00381-009-0908-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The perceived need for electrophysiological guidance (EPG) during selective dorsal rhizotomy (SDR) has limited the frequency with which SDR is performed. The need for EPG during SDR has been questioned. At our institution, of >200 children with SDR for spastic cerebral palsy, 22 children underwent SDR without EPG using clinical guidance (no EPG group). Electrophysiological stimulation was used to distinguish dorsal from ventral roots. The remainder had SDR with EPG. The purpose of this study was to compare outcomes between the groups having SDR with and without EPG. METHODS The 22 patients in the no EPG group were matched with 22 controls in whom EPG was used, with respect to Gross Motor Function Classification System score (GMFCS) and age. The 12-month outcomes with respect to motor function score, hip adductor spasticity (Ashworth), hip abduction range of motion (ROM), quadriceps power [Medical Research Council (MRC)], WeeFIM, Quality of Upper Extremities Skills Test (QUEST), and incidence of complications were compared. RESULTS There were no statistically significant differences preoperatively with respect to GMFCS, age, gross motor function, Ashworth or MRC scores, joint ROM, WeeFIM, or QUEST. At 1 year after SDR, there were no differences between the groups in the incidence of complications or outcome measures. Percentage of dorsal roots cut was similar, but the duration of surgery was significantly shorter in the no EPG group. CONCLUSIONS There was no advantage of doing SDR with EPG compared to no EPG. SDR can reasonably be done in centers where EPG is not available, but electrophysiological stimulation to distinguish dorsal from ventral roots may be useful in avoiding complications.
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Neurophysiologic Intraoperative Monitoring During Selective Dorsal Rhizotomy. J Clin Neurophysiol 2009; 26:82-4. [DOI: 10.1097/wnp.0b013e31819f9077] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Nordmark E, Josenby AL, Lagergren J, Andersson G, Strömblad LG, Westbom L. Long-term outcomes five years after selective dorsal rhizotomy. BMC Pediatr 2008; 8:54. [PMID: 19077294 PMCID: PMC2633339 DOI: 10.1186/1471-2431-8-54] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2008] [Accepted: 12/14/2008] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) is a well accepted neurosurgical procedure performed for the relief of spasticity interfering with motor function in children with spastic cerebral palsy (CP). The goal is to improve function, but long-term outcome studies are rare. The aims of this study were to evaluate long-term functional outcomes, safety and side effects during five postoperative years in all children with diplegia undergoing SDR combined with physiotherapy. METHODS This study group consisted of 35 children, consecutively operated, with spastic diplegia, of which 26 were Gross Motor Function Classification System (GMFCS) levels III-V. Mean age was 4.5 years (range 2.5-6.6). They were all assessed by the same multidisciplinary team at pre- and at 6, 12, 18 months, 3 and 5 years postoperatively. Clinical and demographic data, complications and number of rootlets cut were prospectively registered. Deep tendon reflexes and muscle tone were examined, the latter graded with the modified Ashworth scale. Passive range of motion (PROM) was measured with a goniometer. Motor function was classified according to the GMFCS and measured with the Gross Motor Function Measure (GMFM-88) and derived into GMFM-66. Parent's opinions about the children's performance of skills and activities and the amount of caregiver assistance were measured with Pediatric Evaluation Disability Inventory (PEDI). RESULTS The mean proportion of rootlets cut in S2-L2 was 40%. Muscle tone was immediately reduced in adductors, hamstrings and dorsiflexors (p < 0.001) with no recurrence of spasticity over the 5 years. For GMFCS-subgroups I-II, III and IV-V significant improvements during the five years were seen in PROM for hip abduction, popliteal angle and ankle dorsiflexion (p = 0.001), capacity of gross motor function (GMFM) (p = 0.001), performance of functional skills and independence in self-care and mobility (PEDI) (p = 0.001). CONCLUSION SDR is a safe and effective method for reducing spasticity permanently without major negative side effects. In combination with physiotherapy, in a group of carefully selected and systematically followed young children with spastic diplegia, it provides lasting functional benefits over a period of at least five years postoperatively.
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Affiliation(s)
- Eva Nordmark
- Division of Physiotherapy, Department of Health Sciences, Lund University, Lund, Sweden
- Children's hospital, University Hospital, SE-221 85 Lund, Sweden
| | - Annika Lundkvist Josenby
- Division of Physiotherapy, Department of Health Sciences, Lund University, Lund, Sweden
- Children's hospital, University Hospital, SE-221 85 Lund, Sweden
| | - Jan Lagergren
- Children's hospital, University Hospital, SE-221 85 Lund, Sweden
- Division of Paediatrics, Department of Clinical Sciences (Lund), Lund University, Lund, Sweden
| | - Gert Andersson
- Division of Clinical Neurophysiology, Department of Clinical Sciences (Lund), Lund University, Lund, Sweden
- University Hospital, SE-221 85 Lund, Sweden
| | - Lars-Göran Strömblad
- University Hospital, SE-221 85 Lund, Sweden
- Division of Neurosurgery, Department of Clinical Sciences (Lund), Lund University, Lund, Sweden
| | - Lena Westbom
- Children's hospital, University Hospital, SE-221 85 Lund, Sweden
- Division of Paediatrics, Department of Clinical Sciences (Lund), Lund University, Lund, Sweden
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Gupta A, Srivastava A, Taly AB, Murali T. Single-stage multilevel soft-tissue surgery in the lower limbs with spastic cerebral palsy: Experience from a rehabilitation unit. Indian J Orthop 2008; 42:448-453. [PMID: 19753234 PMCID: PMC2740361 DOI: 10.4103/0019-5413.43395] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND To assess the effect of single-stage multilevel soft-tissue surgery (Single Event Multiple Level Resections, SEMLR) on deformities and locomotion in patients with cerebral palsy (CP) with static contracture(s) in lower limbs. PATIENTS AND METHODS Study included 34 patients (M:F, 23:11) with mean age of 9.53 +/- 3.92 years (4-16 years). Among them 22 had diplegia and four each had quadriplegia and right and left hemiplegia. Fourteen patients (41.2%) had their intelligence quotient (IQ) in the normal range (IQ >/= 80), while others had mental retardation (MR) of varying severity: borderline MR (IQ = 70-79) in 12, mild MR (IQ = 50-69) in 5, and moderate MR (IQ = 35-49) in patients 3. All patients underwent surgery (total number of procedures 153, average 4.5 procedures/patient) over a period of 30 months (April 2005 to September 2007). Improvement in functional abilities and locomotion was assessed using Gross Motor Functional Classification Scale (GMFCS) scores and by physical examination. RESULTS Significant improvement in function was observed (P = 0.000) after surgery when comparing the preoperative and postoperative GMFCS scores. All patients were maintaining ambulation at a mean follow-up duration of 13.12 +/- 6.07 months (3-24 months), with five patients using knee-ankle-foot orthoses (KAFO), 22 using ankle-foot orthoses (AFO), and six patients using knee gaiters. Sixteen patients were using walker, and two were using crutches as assistive devices. CONCLUSION This study suggests that CP patients with good trunk control and static contractures at multiple joints in the lower limbs can be made ambulant with single-stage multilevel soft-tissue surgery. It has to be a team effort of the surgeon and the rehabilitation team in the postoperative period for the attainment of satisfactory goal.
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Affiliation(s)
- Anupam Gupta
- Department of Psychiatric and Neurological Rehabilitation, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
| | - Abhishek Srivastava
- Department of Psychiatric and Neurological Rehabilitation, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
| | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
| | - Thyloth Murali
- Department of Psychiatric and Neurological Rehabilitation, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
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