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Tu A. Reply to Letter to the Editor: "Improved trunk and neck control after selective dorsal rhizotomy in children with spastic cerebral palsy" by Tacchino et al. (2020). Childs Nerv Syst 2021; 37:353. [PMID: 33179160 DOI: 10.1007/s00381-020-04967-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 11/05/2020] [Indexed: 11/27/2022]
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Agrawal M, Samala R, Doddamani RS, Chandra PS. Letter: predictors of postoperative complications after selective dorsal rhizotomy. Acta Neurochir (Wien) 2021; 163:475. [PMID: 33111153 DOI: 10.1007/s00701-020-04629-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 10/22/2020] [Indexed: 12/15/2022]
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Wach J, Yildiz ÖC, Sarikaya-Seiwert S, Vatter H, Haberl H. Predictors of postoperative complications after selective dorsal rhizotomy. Acta Neurochir (Wien) 2021; 163:463-474. [PMID: 32691268 DOI: 10.1007/s00701-020-04487-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/06/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy (CP). We analyzed potential preoperative predictors of complications after SDR via single-level laminectomy at the conus medullaris. METHODS One hundred and forty SDRs performed in children (2-17 years) with CP were included in this retrospective study (March 2016 to July 2019). Of these children, 69% were ambulatory (Gross Motor Functional Classification System (GMFCS) II and III). Variables associated with wound dehiscence and infections, cerebrospinal fluid (CSF) leaks, and prolonged epidural pain management were analyzed statistically. RESULTS Five children (3.6%) showed prolonged wound healing, which was associated with obesity (BMI z-score ≥ 1.64; odds ratio (OR) 24.4; 95% confidence interval (CI) 3-199; p = 0.003). Two cases (1.4%) had superficial surgical site infections (SSIs), which was associated with obesity (p = 0.004) and thrombocytopenia (< 180,000 G/l; p = 0.028). The area under the curve at ≥ 1.55 BMI z-score for SSI was 0.97 (95% CI 0.93-0.99, p = 0.024), with a sensitivity and specificity for SSI of 100 and 94.9%, respectively. CSF leaks occurred in four (2.9%) children, associated with age ≤ 5 years (p = 0.029). Fifteen (10.7%) children required prolonged (4-5 days) epidural pain treatment, which was associated with non-ambulatory GMFCS levels (IV and V) (OR 3.6; 95% CI 1.2-10.8; p = 0.008). CONCLUSIONS SDR is safe for all GMFCS levels. Obesity predicts prolonged wound healing and SSI. Prolonged pain management via epidural pain catheter is safe, but care should be taken with non-ambulatory children.
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Kuo CC, Huang HP, Wang TM, Hong SW, Hung LW, Kuo KN, Lu TW. Tendon release reduced joint stiffness with unaltered leg stiffness during gait in spastic diplegic cerebral palsy. PLoS One 2021; 16:e0245616. [PMID: 33449939 PMCID: PMC7810324 DOI: 10.1371/journal.pone.0245616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/04/2021] [Indexed: 11/18/2022] Open
Abstract
Biomechanical deviations at individual joints are often identified by gait analysis of patients with cerebral palsy (CP). Analysis of the control of joint and leg stiffness of the locomotor system during gait in children with spastic diplegic CP has been used to reveal their control strategy, but the differences between before and after surgery remain unknown. The current study aimed to bridge the gap by comparing the leg stiffness—both skeletal and muscular components—and associated joint stiffness during gait in 12 healthy controls and 12 children with spastic diplegic CP before and after tendon release surgery (TRS). Each subject walked at a self-selected pace on a 10-meter walkway while their kinematic and forceplate data were measured to calculate the stiffness-related variables during loading response, mid-stance, terminal stance, and pre-swing. The CP group altered the stiffness of the lower limb joints and decreased the demand on the muscular components while maintaining an unaltered leg stiffness during stance phase after the TRS. The TRS surgery improved the joint and leg stiffness control during gait, although residual deficits and associated deviations still remained. It is suggested that the stiffness-related variables be included in future clinical gait analysis for a more complete assessment of gait in children with CP.
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Peck J, Urits I, Kassem H, Lee C, Robinson W, Cornett EM, Berger AA, Herman J, Jung JW, Kaye AD, Viswanath O. Interventional Approaches to Pain and Spasticity Related to Cerebral Palsy. PSYCHOPHARMACOLOGY BULLETIN 2020; 50:108-120. [PMID: 33633421 PMCID: PMC7901135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Purpose of Review This review will cover seminal and emerging evidence on interventional therapy chronic pain in cerebral palsy (CP). It will cover the background and burden of disease, present the current options, and then weigh the evidence that is available to support interventional therapy and the current indications. Recent Findings CP is a permanent posture and movement disorder from in-utero brain development defects with a 3-4/1,000 incidence in the US. The cost of care for each child is estimated at $921,000. Pain in CP is attributed to musculoskeletal deformities, spasticity, increased muscle tone, dislocations, and GI dysfunction. First-line treatments include physical and occupational therapy and oral pharmacological agents; however, a significant amount of patients remain refractory to these and require further therapy. Injection therapy includes botulinum toxin A (BTA) injections and intrathecal baclofen. BTA injections were shown to control chronic pain effectively and are FDA approved for spastic pain; intra-thecal baclofen, in contrast, was only shown to improve comfort and quality of life with a focus on the pain. Surgical intervention includes selection dorsal rhizotomy (SDR). It may increase range of motion and quality of life and reduce spasticity and pain; however, most evidence is anecdotal, and more research is required. Summary Interventional therapy, including injection and surgical, is the last line of therapy for chronic pain in CP. It extends the possibility of therapy in hard-to-treat individuals; however, more data is required to provide strong evidence to the efficacy of these treatments and guide proper patient selection.
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Abbott R. The selective dorsal rhizotomy technique for spasticity in 2020: a review. Childs Nerv Syst 2020; 36:1895-1905. [PMID: 32642977 DOI: 10.1007/s00381-020-04765-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 12/23/2022]
Abstract
This review looks at the advances in the surgical technique, selective dorsal rhizotomy, used for the management of spasticity in children.
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Sindou M, Joud A, Georgoulis G. Neurophysiological mechanisms of hypertonia and hypotonia in children with spastic cerebral palsy: surgical implications. Childs Nerv Syst 2020; 36:1919-1924. [PMID: 32548670 DOI: 10.1007/s00381-020-04732-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 11/26/2022]
Abstract
Mechanism of hypertonia in cerebral palsy children is dual: a neural component due to spasticity (velocity dependent) and a biomechanical component linked to soft tissue changes. Their differentiation-which might be clinically difficult-is however crucial, as only the first component will respond to anti-spastic treatments, the second to physiotherapy. Furthermore, spasticity is frequently associated with dystonia, which is a sustained hypertonic state induced by attempts at voluntary motion. Spasticity and dystonia have to be carefully distinguished as dorsal rhizotomy will not significantly influence the dystonic component. Spasticity, which by definition opposes to muscle stretching and lengthening, has two important consequences. First, the muscles tend to remain in a shortened position, which in turn results in soft tissue changes and contracture. The second is that movements are restricted. Thus, both hypertonia and lack of mobilization create a vicious circle leading to severe locomotor disability linked to irreducible musculotendinous retraction and joint ankylosis/bone deformities. These evolving consequences should be highly considered during the child's assessment for decision-making. The hypotonic effects of lumbosacral dorsal rhizotomy, which are not only segmental on the lower limbs but also supra-segmental through the reticular formation, are finally discussed.
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Morota N. Pudendal mapping of S1 rootlets in a functional posterior rhizotomy: when an S1 posterior root shows a high pudendal dorsal action potential-a technical note. Childs Nerv Syst 2020; 36:1971-1975. [PMID: 32591876 DOI: 10.1007/s00381-020-04751-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/16/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The standard level for lesioning in a functional posterior rhizotomy (FPR) ranges from L2 to S1/S2. Lesioning of the S1 and S2 rootlets strongly correlates with a reduction in ankle spasticity. In the Japanese population, the S2 root often shows the highest dorsal root action potentials (DAPs) in the afferent fibers of the pudendal nerve and is not lesioned to preserve postoperative urinary function. Thus, cutting of the S1 root plays a key role in reducing ankle spasticity in FPR. However, on rare occasions, even an S1 root may show high DAP in the afferent fibers of the pudendal nerve. PURPOSE The present, brief, technical note aimed to describe how an S1 root with a relatively high DAP in the afferent fibers of the pudendal nerve may be handed. METHODS In the procedure, the S1 root is divided into several rootlets, and each rootlet is tested for the pudendal mapping. A train of electrical stimuli is delivered to each rootlet in the standard FPR. If electromyography (EMG) findings after electrical stimulation are highly abnormal while the pudendal mapping demonstrates no or a relatively low DAPs, the rootlet is cut. In contrast, even if the rootlet shows highly abnormal EMG findings, it is preserved if mapping demonstrates a relatively high DAP. CONCLUSION The S1 pudendal mapping is combined with EMG findings to achieve satisfactory reduction in ankle spasticity while preserving urological function.
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Pennington M, Summers J, Coker B, Eddy S, Kartha MR, Edwards K, Freeman R, Goodden J, Powell H, Verity C, Peacock JL. Selective dorsal rhizotomy; evidence on cost-effectiveness from England. PLoS One 2020; 15:e0236783. [PMID: 32776949 PMCID: PMC7416930 DOI: 10.1371/journal.pone.0236783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 07/15/2020] [Indexed: 11/18/2022] Open
Abstract
Objectives Selective dorsal rhizotomy (SDR) has gained interest as an intervention to reduce spasticity and pain, and improve quality of life and mobility in children with cerebral palsy mainly affecting the legs (diplegia). We evaluated the cost-effectiveness of SDR in England. Methods Cost-effectiveness was quantified with respect to Gross Motor Function Measure (GMFM-66) and the pain dimension of the Cerebral Palsy Quality of Life questionnaire for Children (CPQOL-Child). Data on outcomes following SDR over two years were drawn from a national evaluation in England which included 137 children, mean age 6.6 years at surgery. The incremental impact of SDR on GMFM-66 was determined through comparison with data from a historic Canadian cohort not undergoing SDR. Another single centre provided data on hospital care over ten years for 15 children undergoing SDR at a mean age of 7.0 years, and a comparable cohort managed without SDR. The incremental impact of SDR on pain was determined using a before and after comparison using data from the national evaluation. Missing data were imputed using multiple imputation. Incremental costs of SDR were determined as the difference in costs over 5 years for the patients undergoing SDR and those managed without SDR. Uncertainty was quantified using bootstrapping and reported as the cost-effectiveness acceptability curve. Results In the base case, the incremental cost-effectiveness ratios (ICERs) for SDR are £1,382 and £903 with respect to a unit improvement in GMFM-66 and the pain dimension of CPQOL-Child, respectively. Inclusion of data to 10 years indicates SDR is cheaper than management without SDR. Incremental costs and ICERs for SDR rose in sensitivity analysis applying an alternative regression model to cost data. Conclusions Data on outcomes from a large observational study of SDR and long-term cost data on children who did and did not receive SDR indicates SDR is cost-effective.
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Lohkamp LN, Coulter I, Ibrahim GM. Selective dorsal rhizotomy for spasticity of genetic etiology. Childs Nerv Syst 2020; 36:1357-1365. [PMID: 32300873 DOI: 10.1007/s00381-020-04601-x] [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: 01/09/2020] [Accepted: 03/30/2020] [Indexed: 11/26/2022]
Abstract
Objective Selective dorsal rhizotomy (SDR) is most commonly applied in the context of the treatment of the spastic diplegic variant of cerebral palsy (CP). Its role in the treatment of spasticity associated with other conditions is not well-established. We sought to review outcomes following SDR for the treatment of functionally limiting spasticity in the setting of a genetic etiology. Methods A systematic literature review was performed using the databases Ovid Medline, Embase, Cochrane Library, and PubMed based on the PRISMA guidelines. Articles were included if they described the application of SDR for spasticity of genetic etiology. Reported outcomes pertaining to spasticity and gross motor function following SDR were summarized. Results Five articles reporting on 16 patients (10 males, 6 females) met the inclusion criteria, of which four reported on SDR for hereditary spastic paraplegia (HSP) and four on syndromic patients or other inherited diseases, with an overall follow-up ranging from 11 to 252 months. These individuals were found to have several genetic mutations including ALS2, SPG4, and SPG3A. The mean age at the time of surgery was 14.9 years (median 10 years, range 3-37 years). Conclusions Although all patients experienced a reduction in spasticity, the long-term gross motor functional outcomes objectively assessed at last follow-up were heterogeneous. There may be a role for SDR in the context of static genetic disorders causing spasticity. Further evidence is required prior to the widespread adoption of SDR for such disorders as, based on the collective observations of this review, spasticity is consistently reduced but the long-term effect on gross motor function remains unclear.
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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: 6] [Impact Index Per Article: 1.5] [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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Tedroff K, Hägglund G, Miller F. Long-term effects of selective dorsal rhizotomy in children with cerebral palsy: a systematic review. Dev Med Child Neurol 2020; 62:554-562. [PMID: 31342516 PMCID: PMC7187377 DOI: 10.1111/dmcn.14320] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 12/22/2022]
Abstract
AIM To evaluate the long-term effects of selective dorsal rhizotomy (SDR) 10 years or more after the procedure and complications observed any time after SDR in children with cerebral palsy (CP). METHOD Embase, PubMed, and the Cochrane Library were searched from their individual dates of inception through 1st June 2018 for full-text original articles in English that described long-term follow-up after SDR in children with CP. The authors independently screened publications to determine whether they met inclusion criteria; thereafter all authors extracted data on patient characteristics, the proportion of the original cohort being followed-up, and the reported outcomes. RESULTS Of the 199 studies identified, 16 were included in this evaluation: 14 were case series and two studies reported a retrospectively assigned comparison group. Evidence concerning function was limited by study design differences, clinical variability, loss to follow-up, and heterogeneity across trials. INTERPRETATION At 10 years or more follow-up, available studies generate low-level evidence with considerable bias. No functional improvement of SDR over routine therapy is documented. Furthermore, the long-term effects of SDR with respect to spasticity reduction is unclear, with many studies reporting a high amount of add-on spasticity treatment. More long-term follow-up using robust scientific protocols is required before it can be decided whether the use of SDR as routine therapy for children with CP is to be recommended or not. WHAT THIS PAPER ADDS Ten years after selective dorsal rhizotomy, available studies supply inconclusive evidence on functional outcomes. The long-term effect on spasticity is uncertain, studies reported a substantial need for add-on treatment. Short- and long-term complications seem frequent but are not reported in a consistent manner.
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Almoajil H, Dawes H, Hopewell S, Toye F, Jenkinson C, Theologis T. Development of a core outcome set for lower limb orthopaedic surgical interventions in ambulant children and young people with cerebral palsy: a study protocol. BMJ Open 2020; 10:e034744. [PMID: 32139490 PMCID: PMC7059521 DOI: 10.1136/bmjopen-2019-034744] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Musculoskeletal deformities and gait deviations are common features in ambulatory cerebral palsy (CP). Deformity correction through lower limb orthopaedic surgery is the standard form of care aimed at improving or preserving motor function. Current research on CP care does not always take into account individual patients' expectations and needs. There is a wide range of outcome domains and outcome measures used to assess outcome from treatment. This can lead to reporting bias and make it difficult to compare and contrast studies. A core outcome set (COS) would enhance the efficiency, relevance and overall quality of CP orthopaedic surgery research. The aim of this study is to establish a standardised COS for use in evaluating lower limb orthopaedic surgery for ambulatory children and young people with CP. METHODS/ANALYSIS A set of outcomes domains and outcome measures will be developed as follows: (1) a qualitative evidence synthesis to identify relevant outcomes from children and young people and family perspective; (2) a scoping review to identify relevant outcomes and outcome measures; (3) qualitative research to explore the experience of key stakeholders; (4) prioritisation of outcome domains will be achieved through a two-round Delphi process with key stakeholders; (5) a final COS will be developed at a consensus meeting with representation from key stakeholder groups. ETHICS AND DISSEMINATION Ethical approval for this study was granted in the UK by the Oxfordshire Research Ethics Committee B (REC reference 19/SC/0357). Informed consent will be obtained from participants taking part in the qualitative research and Delphi process. Study findings will be published in an open access journal and presented at relevant national and international conferences. Charities and associations will be engaged to promote awareness of the project COS results. TRIAL REGISTRATION NUMBER COMET registration: 1236. PROSPERO REGISTRATION NUMBER CRD42018089538.
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Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, Langdon K, Namara MM, Paton MC, Popat H, Shore B, Khamis A, Stanton E, Finemore OP, Tricks A, Te Velde A, Dark L, Morton N, Badawi N. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep 2020; 20:3. [PMID: 32086598 PMCID: PMC7035308 DOI: 10.1007/s11910-020-1022-z] [Citation(s) in RCA: 401] [Impact Index Per Article: 100.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019. RECENT FINDINGS Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.
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Gaytán-Fernández S, Chaidez P, García-Galicia A, Martínez-Asención P, Barragán-Hervella RG, Corpus-Mariscal E, Jiménez-Reyes M, Montiel-Jarquín AJ. [Analysis to determine optimal age for surgical management of equinus foot in patients with childhood cerebral palsy]. ACTA ORTOPEDICA MEXICANA 2020; 34:2-5. [PMID: 33230991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Childhood cerebral palsy, a non-progressive brain injury, occurs before, during or after delivery, with variable neurological damage from mild to disabling. The deformity in equine is treated conservatively at an early age, but when is surgical management indicated? OBJECTIVE Our goal was to determine the optimal age for surgical management of the equine foot in CCP patients. MATERIAL AND METHODS Retrospective study, in patients diagnosed with CCP (all types), treated surgically with open or percutaneous Achilles tendon elongation, assessed with external consultation notes, in patients aged 1-16 years, and average follow-up of 6 years, evaluating progress with relapse of deformity and gait with plantigrade support. RESULTS 55 patients, 74 equinus feet (29 in girls, 45 in boys) were analyzed with surgical treatment. Those treated before six years old presented relapses, with vulnerable period in 4-6 years. Monoplegia presented 100% relapses, and triplegia presented 0%. Open surgery presented 50% recurrence and percutaneous technique only 19%. CONCLUSION In our institution, the optimal age is suggested in 6-12 years. Percutaneous technique over the open, should be preferred, and greater attention should be paid to monitoring monoplexy.
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Wolter S, Haberl H, Spies C, Sargut TA, Martin JH, Tafelski S, van Riesen A, Küchler I, Wegner B, Scholtz K, Thomale UW, Michael T, Murphy JF, Schulz M. Frequency distribution in intraoperative stimulation-evoked EMG responses during selective dorsal rhizotomy in children with cerebral palsy-part 2: gender differences and left-biased asymmetry. Childs Nerv Syst 2020; 36:1955-1965. [PMID: 32588175 PMCID: PMC7434795 DOI: 10.1007/s00381-020-04735-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Spinal reflexes reorganize in cerebral palsy (CP), producing hyperreflexia and spasticity. CP is more common among male infants, and gender might also influence brain and spinal-cord reorganization. This retrospective study investigated the frequency of higher-graded EMG responses elicited by electrical nerve-root stimulation during selective dorsal rhizotomy (SDR), prior to partial nerve- root deafferentation, considering not only segmental level and body side, but also gender. METHODS Intraoperative neuromonitoring (IOM) was used in SDR to pinpoint the rootlets most responsible for exacerbated stimulation-evoked EMG patterns recorded from lower-limb muscle groups. Responses were graded according to an objective response-classification system, ranging from no abnormalities (grade 0) to highly abnormal (grade 4+), based on ipsilateral spread and contralateral involvement. Non-parametric analysis of data with repeated measures was primarily used in investigating the frequency distribution of these various EMG response grades. Over 7000 rootlets were stimulated, and the results for 65 girls and 81 boys were evaluated, taking changes in the composition of patient groups into account when considering GMFCS levels. RESULTS The distribution of graded EMG responses varied according to gender, laterality, and level. Higher-graded EMG responses were markedly more frequent in the boys and at lower segmental levels (L5, S1). Left-biased asymmetry in higher-graded rootlets was also more noticeable in the boys and in patients with GMFCS level I. A close link was observed between higher-grade assessments and left-biased asymmetry. CONCLUSIONS Detailed insight into the patient's initial spinal-neurofunctional state prior to deafferentation suggests that differences in asymmetrical spinal reorganization might be attributable to a hemispheric imbalance.
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Abstract
This article overviews the surgical options for hypertonia management in cerebral palsy, both spasticity and dystonia. We review the history and use of intrathecal baclofen. We contrast its use with the indications for selective dorsal rhizotomy and review how it is the optimal technique to lower tone in the ambulatory spastic diplegic patient with cerebral palsy. This article reviews the advent of deep brain stimulation, with an emphasis on selection criteria and expected outcomes in this population. The article reviews the principles and use of selective peripheral neurotomy as it is applied to focal spasticity not requiring systemic tone reduction.
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Nazareth A, Rethlefsen S, Sousa TC, Mueske NM, Wren TAL, Kay RM. Percutaneous Hamstring Lengthening Surgery is as Effective as Open Lengthening in Children With Cerebral Palsy. J Pediatr Orthop 2019; 39:366-371. [PMID: 31305380 DOI: 10.1097/bpo.0000000000000924] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical lengthening of the hamstrings is often performed to correct crouch gait in children with cerebral palsy (CP). Previous studies have demonstrated the effectiveness of open hamstring lengthening (oHSL) in improving knee extension static and dynamic range of motion; however, literature regarding percutaneous hamstring lengthening (pHSL) is limited. The purpose of this study was to investigate the effect of open versus pHSL for improving crouch gait and knee function in children with CP. METHODS This retrospective cohort study included 87 ambulatory children with CP who underwent HLS surgery with both preoperative and postoperative gait analysis (mean time, 29.4±19.9 mo after surgery) testing between 1997 and 2015. In total, 65 patients underwent oHLS surgery (mean age, 8.5±2.5 y) and 22 patients underwent pHSL surgery (mean age, 8.3±2.3 y). Lower extremity three-dimensional kinematic data were collected while subjects walked at a self-selected speed. Outcome variables for operative limbs were compared within and between groups using t tests, χ tests, and multiple regression analysis. RESULTS Significant postoperative decreases in knee flexion at initial contact were seen for both open (Δ12.7±13.4 degrees; P<0.001) and percutaneous (Δ19.1±13.1 degrees; P<0.001) groups. Increased postoperative maximum knee extension in stance was found for both open (Δ8.2±16.8 degrees; P=0.001) and percutaneous (Δ14.4±16.5 degrees; P=0.001) groups. No significant differences between open and percutaneous groups were found when comparing postoperative changes in kinematic variables between groups after adjusting for covariates. Postoperative changes in static range of motion were similar between lengthening groups. CONCLUSIONS pHSL is as effective as open lengthening in improving stance phase knee kinematics during gait in children with CP. This is the first study to compare the kinematic effects of open versus pHSL in the pediatric population. Percutaneous lengthening is tolerated well by patients, and as it allows for rapid rehabilitation it may be preferable to the open procedure. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Changing practice and altering national policy-selective dorsal rhizotomy. Arch Dis Child 2019; 104:721. [PMID: 31272967 DOI: 10.1136/archdischild-2019-317777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2019] [Indexed: 11/04/2022]
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O’Sullivan R, Leonard J, Quinn A, Kiernan D. The short-term effects of selective dorsal rhizotomy on gait compared to matched cerebral palsy control groups. PLoS One 2019; 14:e0220119. [PMID: 31361785 PMCID: PMC6667201 DOI: 10.1371/journal.pone.0220119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/09/2019] [Indexed: 11/21/2022] Open
Abstract
Objectives To examine the short-term effects of selective dorsal rhizotomy (SDR) ± soft-tissue surgery on gait in cerebral palsy (CP) compared to matched controls with no surgical intervention. Methods Participants had gait analysis before and one year after SDR. Non SDR participants were retrospectively matched for age and all significant gait parameters. The SDR group was further subdivided into those who had concomitant orthopaedic surgery and those who had SDR only. Results The SDR group consisted of 29 participants (mean age 5.8 years at baseline, 7.7 years at follow-up). Of these, 13 had concomitant orthopaedic surgery. The non SDR group consisted of 18 participants (mean age at baseline 6.1 years, 8.1 years at follow-up). SDR ± soft-tissue surgery significantly improved step-lengths, knee flexion at initial contact and mid-stance, ankle dorsiflexion, foot progression and timing of peak knee flexion. None of these improvements in gait were seen without surgical intervention. While more improvements were seen in those who had SDR and orthopaedic surgery, SDR only resulted in improved step-lengths, knee extension, foot progression and timing of peak knee flexion. Conclusions SDR ± soft-tissue surgery results in short-term improvements in gait which are not seen without surgical intervention. While those who had SDR and soft-tissue surgery demonstrated more changes in gait, many improvements were attributable to SDR only.
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Niiler TA, Nicholson K, Fischer L, Lennon N. Factors influencing post-surgical variability in StepWatch data in youth with cerebral palsy. Gait Posture 2019; 72:234-238. [PMID: 31284160 DOI: 10.1016/j.gaitpost.2019.06.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Over the past several years, activity monitors have become very popular in the general population, and due to their low cost and ease of use, are starting to be seen as clinical tools for the assessment of interventions. This presents researchers with the opportunity to better understand how activity, or lack thereof, is related to the recovery of patients. However, even in individuals without disabilities, there is a high degree of variability in activity monitor data which must be better understood in order to produce clinically meaningful interpretation of such data. RESEARCH QUESTION What sources of variability contribute the most to the daily scatter in activity data as measured by StepWatches in youth with Cerebral Palsy (CP)? In particular, do non-clinical factors such as weather and location contribute to this variability significantly? METHODS This was a retrospective study making use of data from our activity monitoring protocol of youths with CP who obtain single event multi-level surgeries. Before and after these surgeries, 57 such youths aged 4.2-21.3 years were issued StepWatches to monitor daily activity for 8 day periods over 24 months duration. Weather data and walk scores for the patients' home locations were collected from online databases. Steps per hour were predicted from clinical and environmental data using bootstrapped regression to determine the stability of regression coefficients and the percent variability explained by each variable. RESULTS Time since surgery, age, season, GMFCS level, and surgical burden were significant variables in the model. Of them, GMFCS level was most important and explained nearly 16% of the variability in the data. Temperature, precipitation, and walk score had small effects on step count variance. SIGNIFICANCE Understanding sources of variability in step-counts is important if such a measure is to be used as a clinical measure of recovery, and may be important in the consideration of future surgical planning.
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Lewis J, Bear N, Baker F, Fowler A, Lee O, McLennan K, Richardson E, Scheinberg A, Smith N, Thomason P, Tidemann A, Wynter M, Paget S. Australian children undergoing selective dorsal rhizotomy: protocol for a national registry of multidimensional outcomes. BMJ Open 2019; 9:e025093. [PMID: 31048430 PMCID: PMC6502035 DOI: 10.1136/bmjopen-2018-025093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Selective dorsal rhizotomy (SDR) is a neurosurgical intervention intended to permanently reduce spasticity in the lower limbs and improve mobility in selected children with cerebral palsy (CP). Despite SDR having been performed worldwide for the past 30 years, there is moderate quality of evidence that SDR is effective in reducing spasticity with low to very low evidence of its effectiveness in improving gait, function and participation, using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Published studies have described outcomes for groups that differ in selection, surgical technique and postoperative rehabilitation making it difficult for clinicians to use this information to advise families on best management. There is substantial community interest in SDR. A small number of children with CP undergo SDR in Australia each year and some families seek the intervention at international sites. Capturing clinical outcomes and adverse event (AE) data for Australian children undergoing SDR will provide clinicians with information to help guide families considering SDR. METHODS AND ANALYSIS The Australian SDR Research Registry is a national registry of multidimensional outcomes for Australian children undergoing SDR in an Australian or overseas centre. Data will be collected for up to 10 years following the surgery, to include surgery and admission details, surgical and long-term AEs, and outcome measures across the body structure and functions, activity and participation domains of the International Classification of Functioning, Disability and Health. Data will be collected at baseline, during inpatient admission and at 1, 2, 5 and 10 years post. The aim of collecting these data is to improve understanding of short-, medium- and long-term outcomes and adverse effects of the intervention. ETHICS AND DISSEMINATION This study was approved by the individual Human Research and Ethics committees at the five Australian tertiary hospitals involved. Results will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12618000985280; Pre-results.
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Brooks JT, Yaszay B, Bartley CE, Bastrom TP, Sponseller PD, Shah SA, Samdani A, Cahill PJ, Miyanji F, Newton PO. Do All Patients With Cerebral Palsy Require Postoperative Intensive Care Admission After Spinal Fusion? Spine Deform 2019; 7:112-117. [PMID: 30587303 DOI: 10.1016/j.jspd.2018.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 05/31/2018] [Accepted: 06/02/2018] [Indexed: 11/19/2022]
Abstract
STUDY DESIGN Retrospective review of a prospective cohort. OBJECTIVE To identify patient and surgical factors that alter the length of postoperative intensive care unit (ICU) stays after spinal fusion/instrumentation in patients with neuromuscular scoliosis secondary to cerebral palsy (CP). SUMMARY OF BACKGROUND DATA High perioperative complication rates in patients with CP contribute to the practice of utilizing the ICU postoperatively for monitoring. However, this is costly and little is known regarding which patients truly need this increased acuity of care. METHODS A prospective, multicenter database was queried for patients with CP who underwent spinal fusion and instrumentation. Patients with an ICU length of stay (LOS) ≤1 day were assumed to not have required postoperative ICU admission. Demographic and surgical characteristics were compared between those with ICU LOS of ≤1 day versus >1 day. A classification and regression tree (CART) analysis was utilized to create a decision algorithm for postoperative ICU admission. RESULTS Three hundred twenty-four patients were identified with a mean ICU LOS of 4.7 days (range 0-47). Sixty-eight patients (21%) had an ICU LOS ≤1 day and 256 patients (79%) had an ICU LOS >1 day. CART analysis demonstrated that the institution where the surgery was performed was the primary predictor with two groups: sites that almost routinely had ICU stay >1 day (92%) and those that were split (50.5% >1 day). In the latter group, an operative time greater than 4 hours was a risk factor for a longer ICU stay. CONCLUSION Because of their heterogeneous makeup, CP patients should be evaluated individually and their postoperative disposition should not be based on institutional tradition but instead on objective surgical factors. For those patients with surgical times less than 4 hours, discussions should be held regarding the safety of a postoperative disposition to a regular floor. LEVEL OF EVIDENCE Level III.
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Enslin JMN, Langerak NG, Fieggen AG. The Evolution of Selective Dorsal Rhizotomy for the Management of Spasticity. Neurotherapeutics 2019; 16:3-8. [PMID: 30460456 PMCID: PMC6361072 DOI: 10.1007/s13311-018-00690-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Selective dorsal rhizotomy is a key technique in the surgical management of spasticity in patients with cerebral palsy. The technique evolved from the late 1800s when pioneers like Dana and Abbe performed dorsal rhizotomy in their treatment of refractory pain. These surgeons noted a reduction in muscle tone associated with the operation. When Sherrington then published his Nobel prize-winning work on the corticospinal tract and its role in the neuromuscular system in the 1890s, the course was set for modifying spasticity by aiming surgery at the dorsal roots. This procedure underwent multiple modifications through the next century and today it is, arguably, the most commonly performed operation to treat cerebral palsy children with spasticity. Selective dorsal rhizotomy is a technique that still teaches us a great deal about neurophysiology on a daily basis and it is thanks to the pioneers, described in this article, that we have this tool in our armamentarium.
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Desai VR, Gadgil N, Saad S, Raskin JS, Lam SK. Measures of Health-Related Quality of Life Outcomes in Pediatric Neurosurgery: Literature Review. World Neurosurg 2018; 122:252-265. [PMID: 30399472 DOI: 10.1016/j.wneu.2018.10.194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/25/2018] [Accepted: 10/27/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Improving value in healthcare means optimizing outcomes and minimizing costs. The emerging pay-for-performance era requires understanding of the effect of healthcare services on health-related quality of life (HRQoL). Pediatric and surgical subspecialties have yet to fully integrate HRQoL measures into practice. The present study reviewed and characterized the HRQoL outcome measures across various pediatric neurosurgical diagnoses. METHODS A literature review was performed by searching PubMed and Google Scholar with search terms such as "health-related quality of life" and "pediatric neurosurgery" and then including the specific pathologies for which a HRQoL instrument was found (e.g., "health-related quality of life" plus "epilepsy"). Each measurement was evaluated by content and purpose, relative strengths and weaknesses, and validity. RESULTS We reviewed 68 reports. Epilepsy, brain tumor, cerebral palsy, spina bifida, hydrocephalus, and scoliosis were diagnoses found in reported studies that had used disease-specific HRQoL instruments. Information using general HRQoL instruments was also reported. Internal, test-retest, and/or interrater reliability varied across the instruments, as did face, content, concurrent, and/or construct validity. Few instruments were tested enough for robust reliability and validity. Significant variability was found in the usage of these instruments in clinical studies within pediatric neurosurgery. CONCLUSIONS The HRQoL instruments used in pediatric neurosurgery are currently without standardized guidelines and thus exhibit high variability in use. Clinicians should support the development and application of these methods to optimize these instruments, promote standardization of research, improve performance measures to reflect clinically modifiable and meaningful outcomes, and, ultimately, lead the national discussion in healthcare quality and patient-centered care.
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