1
|
Assumpcao de Monaco B, Alves Du Rocher Candido A, Jacobsen Teixeira M, Lopes Alho EJ. Impact of selective dorsal rhizotomy to cerebral palsy children caregivers' burden. Childs Nerv Syst 2024; 40:1461-1469. [PMID: 38252157 DOI: 10.1007/s00381-024-06291-1] [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: 02/13/2023] [Accepted: 01/12/2024] [Indexed: 01/23/2024]
Abstract
PURPOSE It is known that cerebral palsy (CP) children's caregivers suffer from burden, depression, and stress, impairing their quality of life (QoL). The more severe the CP, the more burden the caregiver has. Psychosocial support, education, therapies, and financial support are inversely related to the level of stress of the caregiver. Most parents of CP patients submitted to selective dorsal rhizotomy (SDR) report improvement not just on spasticity, but also in the functional role of the children, what can impact on caregiver's QoL. Our objective was to evaluate the burden of CP children's caregivers with and without previous SDR. METHODS Spastic CP children caregivers were divided into two groups: those who take care of children without previous SDR (control group) and those that children were previously submitted to SDR (surgical group). The burden index was compared between groups using Burden Interview Questionnaire (BIQ). For statistical analysis, we used SPSS. RESULTS The control group had enrolled 31 participants and the surgical group 36. The mean GMFCS level on the control and surgical groups was 3.94 ± 1.26 and 3.74 ± 1.12 (p = 0.61), respectively. The surgical group caregivers presented less burden related to the feeling that they should be doing more to their child (p = 0.003) and if they could do a better job in caring (p = 0.032), compared to controls. The total BIQ index was not significantly different between groups (surgical 32.14 ± 12.34 vs. control 36.77 ± 12.77; p = 0.87). Low economic status had a weak correlation to a higher BIQ index (R2 = 0.24). After age-matching, there was a significative higher BIQ index in the control group (p = 0.008). CONCLUSION Caregivers of spastic CP children who were previously submitted to SDR presented less burden related to feeling of the amount of given care than those without previous surgery. The impression that they could do a better job with their kids was higher in the control group. The severity of CP and low economic status were related to more burden in both groups. After pairing groups by age, the control group had a significative higher BIQ index compared to the SDR group. CLINICAL TRIAL REGISTRATION Trial registration number: CAAE 73407317.6.0000.0068 (Ethical and Research Committee of University of Sao Paulo, Sao Paulo, Brazil, approved on 08/06/2021). All the subjects were freely given an informed consent to participate in the study that was obtained from all participants. Non-consented ones were excluded from the study.
Collapse
Affiliation(s)
- Bernardo Assumpcao de Monaco
- Neurosurgery Division, Neurology Department, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
- CDF-Clinica de Dor e Funcional, R. Mato Grosso 306, cj1306B, Sao Paulo, SP, Brazil.
| | | | - Manoel Jacobsen Teixeira
- Neurosurgery Division, Neurology Department, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Eduardo Joaquim Lopes Alho
- Neurosurgery Division, Neurology Department, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- CDF-Clinica de Dor e Funcional, R. Mato Grosso 306, cj1306B, Sao Paulo, SP, Brazil
| |
Collapse
|
2
|
Meyer-Sauvage J, Krouma M, Klovan C, Bardot P, Rohon MA, Viton JM, Boulay C, Scavarda D. The effect of selective dorsal rhizotomy on the improvement of the quality of life of children with stage GMFCS IV and V cerebral palsy: Pain, nursing, positioning, and dressing. Childs Nerv Syst 2024; 40:987-995. [PMID: 38393385 DOI: 10.1007/s00381-024-06321-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/08/2024] [Indexed: 02/25/2024]
Abstract
AIM The objective of this study is to evaluate the benefit of selective dorsal rhizotomy on the quality of life of patients with severe spasticity with significant impairment of gross motor functions (GMFCS stages IV and V) according to 4 items: pain, nursing care, positioning, and dressing. MATERIALS AND METHODS We conducted a monocentric retrospective cohort study including patients who underwent selective dorsal rhizotomy between March 2008 and May 2022 at the University Hospital of Marseille. RESULTS Seventy percent of patients showed an improvement in quality of life criteria: dressing, nursing, positioning, and pain at the last follow-up. A small proportion of patients still showed a worsening between the first 2 follow-ups and the last follow-up. Postoperatively, 27.3% of patients were free of joint spasticity treatment, and we have shown that there was a significant decrease in the number of children who received botulinum toxin postoperatively. However, there was no significant reduction in the number of drug treatments or orthopaedic procedures following RDS. For the CPCHILD© scores, an overall gain is reported for GMFCS IV and V patients in postoperative care. The gain of points is more important for GMFCS IV patients. Improvement was mainly observed in 2 domains, "comfort and emotions" and "hygiene and dressing". For the "quality of life" item, only 3 parents out of the 8 noted a positive change. CONCLUSION Our study shows an improvement in nursing care, positioning, and dressing which are associated with a reduction in pain in children with a major polyhandicap GMFCS IV and V who have benefited from a selective dorsal rhizotomy.
Collapse
Affiliation(s)
| | - Manel Krouma
- Department of Pediatric Neurosurgery, CHU Timone Enfant, Marseille, France
| | - Caroline Klovan
- Department of Pediatric Neurosurgery, CHU Timone Enfant, Marseille, France
| | - Philippe Bardot
- Department of Pediatric Rehabilitation, Institut Pomponiana, Hyeres, France
| | - Marie-Ange Rohon
- Department of Pediatric Rehabilitation, Institut Pomponiana, Hyeres, France
| | | | - Christophe Boulay
- Department of Pediatric Orthopedic Surgery, CHU Timone, Marseille, France
| | - Didier Scavarda
- Department of Pediatric Neurosurgery, CHU Timone Enfant, Marseille, France.
| |
Collapse
|
3
|
Gillespie CS, Hall BJ, George AM, Hennigan D, Sneade C, Cawker S, Silva AHD, Vloeberghs M, Aquilina K, Pettorini B. Selective dorsal rhizotomy in non-ambulant children with cerebral palsy: a multi-center prospective study. Childs Nerv Syst 2024; 40:171-180. [PMID: 37439914 PMCID: PMC10761507 DOI: 10.1007/s00381-023-06062-4] [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: 03/12/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE Assess the effects of selective dorsal rhizotomy (SDR) on motor function and quality of life in children with a Gross Motor Function Classification System (GMFCS) level of IV or V (non-ambulatory). METHODS This is a prospective, observational study in three tertiary neurosurgery units in England, UK, performing SDR on children aged 3-18 with spastic diplegic cerebral palsy, and a GMFCS level of IV or V, between 2012 and 2019. The primary outcome measure was the change in the 66-item Gross Motor Function Measure (GMFM-66) from baseline to 24 months after SDR, using a linear mixed effects model. Secondary outcomes included spasticity, bladder function, quality of life, and pain scores. RESULTS Between 2012 and 2019, 144 children who satisfied these inclusion criteria underwent SDR. The mean age was 8.2 years. Fifty-two percent were female. Mean GMFM-66 score was available in 77 patients (53.5%) and in 39 patients (27.1%) at 24 months after SDR. The mean increase between baseline and 24 months post-SDR was 2.4 units (95% CI 1.7-3.1, p < 0.001, annual change 1.2 units). Of the 67 patients with a GMFM-66 measurement available, a documented increase in gross motor function was seen in 77.6% (n = 52). Of 101 patients with spasticity data available, mean Ashworth scale decreased after surgery (2.74 to 0.30). Of patients' pain scores, 60.7% (n = 34) improved, and 96.4% (n = 56) of patients' pain scores remained the same or improved. Bladder function improved in 30.9% of patients. CONCLUSIONS SDR improved gross motor function and reduced pain in most patients at 24 months after surgery, although the improvement is less pronounced than in children with GMFCS levels II and III. SDR should be considered in non-ambulant patients.
Collapse
Affiliation(s)
- Conor S Gillespie
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Trust, Liverpool, UK.
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
- Department of Neurology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK.
| | - Benjamin J Hall
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Alan M George
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Dawn Hennigan
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Christine Sneade
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Stephanie Cawker
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Adikarige Haritha Dulanka Silva
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Michael Vloeberghs
- Department of Neurosurgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Benedetta Pettorini
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| |
Collapse
|
4
|
Lumsden DE. Neurosurgical management of elevated tone in childhood: interventions, indications and uncertainties. Arch Dis Child 2023; 108:703-708. [PMID: 36690424 DOI: 10.1136/archdischild-2020-320907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/15/2022] [Indexed: 01/25/2023]
Abstract
Elevated tone (hypertonia) is a common problem in children with physical disabilities. Medications intended to reduce tone often have limited efficacy, with use further limited by a significant side effect profile. Consequently, there has been growing interest in the application of Neurosurgical Interventions for the Management of Posture and Tone (NIMPTs). Three main procedures are now commonly used: selective dorsal rhizotomy (SDR), intrathecal baclofen (ITB) and deep brain stimulation (DBS). This review compares these interventions, along with discussion on the potential role of lesioning surgery. These interventions variably target spasticity and dystonia, acting at different points in the distributed motor network. SDR, an intervention for reducing spasticity, is most widely used in carefully selected ambulant children with cerebral palsy. ITB is more commonly used for children with more severe disability, typically non-ambulant, and can improve both dystonia and spasticity. DBS is an intervention which may improve dystonia. In children with certain forms of genetic dystonia DBS may dramatically improve dystonia. For other causes of dystonia, and in particular dystonia due to acquired brain injury, improvements following surgery are more modest and variable. These three interventions vary in terms of their side-effect profile and reversibility. There are currently populations of children for who it is unclear which intervention should be considered (SDR vs ITB, or ITB vs DBS). Concerns have been raised as to the equity of access to NIMPTs for children across the UK, and whether the number of surgeries performed each year meets the clinical need.
Collapse
Affiliation(s)
- Daniel E Lumsden
- Children's Neurosciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
5
|
Asma A, Ulusaloglu AC, Howard JJ, Rogers KJ, McManus M, Miller F, Shrader MW. Does intrathecal baclofen therapy decrease the progression of hip displacement in young patients with cerebral palsy? Dev Med Child Neurol 2023; 65:1112-1117. [PMID: 36649172 DOI: 10.1111/dmcn.15509] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/11/2022] [Accepted: 12/10/2022] [Indexed: 01/18/2023]
Abstract
AIM To evaluate the effects of intrathecal baclofen pump (ITBP) therapy on hip dysplasia in young patients with cerebral palsy (CP). METHOD This was a retrospective cohort series of prospectively collected data. Inclusion criteria were all patients with CP in Gross Motor Function Classification System (GMFCS) levels IV or V who underwent ITBP placement under 8 years old with at least 5 years of follow-up. Thirty-four patients were matched to a control group of 71 patients based on GMFCS level, motor type, medical comorbidities, worst hip migration percentage at ITBP placement, age, and Modified Ashworth scale scores. Patients were followed for at least 5 years or until they had hip reconstructive surgery. The primary outcome was the development of hip displacement as measured by the migration percentage at the latest follow-up or the preoperative migration percentage before hip reconstruction. RESULTS The migration percentage at last follow-up was not statistically different between groups (ITBP: 36.2%, non-ITBP: 44.4%, p = 0.14). The rates of future preventative, reconstructive, and recurrent hip surgery were not different between groups. INTERPRETATION The use of ITBP as an early treatment of spasticity did not alter the natural history of progressive hip displacement in non-ambulatory patients with CP and hip displacement is likely multifactorial, not solely due to spasticity.
Collapse
Affiliation(s)
- Ali Asma
- Department of Orthopedic Surgery, Nemours Children's Health, Delaware, USA
| | | | - Jason J Howard
- Department of Orthopedic Surgery, Nemours Children's Health, Delaware, USA
| | - Kenneth J Rogers
- Department of Orthopedic Surgery, Nemours Children's Health, Delaware, USA
| | - Maura McManus
- Division of Physical Medicine and Rehabilitation, Nemours Children's Health, Delaware, USA
| | - Freeman Miller
- Department of Orthopedic Surgery, Nemours Children's Health, Delaware, USA
| | - M Wade Shrader
- Department of Orthopedic Surgery, Nemours Children's Health, Delaware, USA
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Rasadurai A, Frank NA, Greuter LA, Licci M, Weber P, Jünemann S, Guzman R, Soleman J. Patient- and Caregiver-Reported Outcome Measures after Single-Level Selective Dorsal Rhizotomy in Pediatric and Young Adult Patients with Spastic Cerebral Palsy. Pediatr Neurosurg 2023; 58:128-135. [PMID: 37075708 PMCID: PMC10614523 DOI: 10.1159/000530748] [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: 01/15/2023] [Accepted: 04/11/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION The aim of this cohort study was to assess the outcome of single-level selective dorsal rhizotomy (SDR) in children and young adults with spastic cerebral palsy (CP) treated at our institution, focusing on patient-reported outcome measures (PROMs) and quality of life (QoL) of patients and their caregivers. METHODS We included consecutive patients undergoing SDR from 2018 to 2020 at our institution. Subjective outcome was measured through PROMs, while functional outcome was measured through baseline characteristics, operative outcome, as well as short- and long-term follow-up. Furthermore, the effect of age at the time of surgery on patient/caregiver satisfaction was analyzed. RESULTS Seven patients (3 female, 43%) with a median age at surgery of 11.9 years (IQR 8.7-15.5) were included. All patients had a Gross Motor Function Classification (GMFCS) score of at least IV before surgery. Five surgeries were palliative and two non-palliative. Based on PROMs, SDR showed very good QoL and health-related outcome measures for both palliative and non-palliative patients. Patient/caregiver satisfaction was higher for the early subgroup (age ≤11) than the late subgroup (age >11). Functional outcome showed reduced spasticity in both groups. Blood transfusions were never needed, while no cerebrospinal fluid leak, infection, or permanent morbidity was seen. CONCLUSION Based on PROMs, SDR leads to high satisfaction and improved QoL, especially if done at an early age. Further studies with larger cohorts are necessary to underline and confirm our observations.
Collapse
Affiliation(s)
- Abeelan Rasadurai
- Faculty of Medicine, University of Basel, Basel, Switzerland,
- Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland,
- Department of Neurosurgery and Pediatric Neurosurgery, University Hospital and Children's Hospital of Basel, Basel, Switzerland,
| | - Nicole Alexandra Frank
- Department of Neurosurgery and Pediatric Neurosurgery, University Hospital and Children's Hospital of Basel, Basel, Switzerland
| | - Ladina Aurea Greuter
- Department of Neurosurgery and Pediatric Neurosurgery, University Hospital and Children's Hospital of Basel, Basel, Switzerland
| | - Maria Licci
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery and Pediatric Neurosurgery, University Hospital and Children's Hospital of Basel, Basel, Switzerland
| | - Peter Weber
- Department of Neuropediatrics, University Children's Hospital of Basel (UKBB), Basel, Switzerland
| | - Stephanie Jünemann
- Department of Neuropediatrics, University Children's Hospital of Basel (UKBB), Basel, Switzerland
| | - Raphael Guzman
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery and Pediatric Neurosurgery, University Hospital and Children's Hospital of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery and Pediatric Neurosurgery, University Hospital and Children's Hospital of Basel, Basel, Switzerland
| |
Collapse
|
8
|
Oraee-Yazdani S, Tavanaei R, Rezaee-Naserabad SS, Khannejad S, Alizadeh Zendehrood S, Yazdani KO, Zali A. Safety and Potential Efficacy of Selective Dorsal Rhizotomy in Adults with Spinal Cord Injury-Induced Spasticity: An Open-Label, Non-Randomized, Single-Arm Trial. World Neurosurg 2023; 170:e806-e816. [PMID: 36460198 DOI: 10.1016/j.wneu.2022.11.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Despite the abundant literature on the use of selective dorsal rhizotomy (SDR) in spastic cerebral palsy, no investigation has evaluated its use in adult patients with chronic spinal cord injury (SCI)-induced spasticity. The present investigation aimed to evaluate the safety and potential efficacy of SDR in chronic SCI-induced spasticity for the first time. METHODS In this open-label, single-arm, non-randomized clinical trial, all patients were assigned to the single study intervention arm and underwent SDR. The primary outcome measure was the safety profile of SDR. Secondary outcome measures were Modified Ashworth Scale, Penn Spasm Frequency Scale, visual analog scale for spasticity, Spinal Cord Injury Spasticity Tool, Spinal Cord Independence measure version III, and Short Form 36 Health Survey Questionnaire. RESULTS Six patients with cervical SCI and 4 with thoracic SCI were allocated to the single study intervention arm. No adverse event attributable to the SDR was found. Moreover, all secondary outcome measures of the study improved significantly over the study period (P < 0.001). Multiple regression analysis also found a significant association between level of injury and changes in average Modified Ashworth Scale scores (P = 0.041), Spinal Cord Injury Spasticity Tool score (P = 0.013), and Spinal Cord Independence measure version III total (P = 0.002) and mobility domain scores (P = 0.004) at 12-month postoperatively. CONCLUSIONS This clinical trial indicated that SDR is a safe and potentially effective procedure in patients with severe and intractable SCI-induced spasticity. However, future clinical trials with larger sample sizes and adequate power are required to validate our findings regarding efficacy.
Collapse
Affiliation(s)
- Saeed Oraee-Yazdani
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Roozbeh Tavanaei
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyyed Saeed Rezaee-Naserabad
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samin Khannejad
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Siamak Alizadeh Zendehrood
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kaveh Oraii Yazdani
- Department of cardiovascular diseases, Zahedan University of Medical Science, Zahedan, Iran
| | - Alireza Zali
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
9
|
Abstract
Spasticity is characterized by an enhanced size and reduced threshold for activation of stretch reflexes and is associated with "positive signs" such as clonus and spasms, as well as "negative features" such as paresis and a loss of automatic postural responses. Spasticity develops over time after a lesion and can be associated with reduced speed of movement, cocontraction, abnormal synergies, and pain. Spasticity is caused by a combination of damage to descending tracts, reductions in inhibitory activity within spinal cord circuits, and adaptive changes within motoneurons. Increased tone, hypertonia, can also be caused by changes in passive stiffness due to, for example, increase in connective tissue and reduction in muscle fascicle length. Understanding the cause of hypertonia is important for determining the management strategy as nonneural, passive causes of stiffness will be more amenable to physical rather than pharmacological interventions. The management of spasticity is determined by the views and goals of the patient, family, and carers, which should be integral to the multidisciplinary assessment. An assessment, and treatment, of trigger factors such as infection and skin breakdown should be made especially in people with a recent change in tone. The choice of management strategies for an individual will vary depending on the severity of spasticity, the distribution of spasticity (i.e., whether it affects multiple muscle groups or is more prominent in one or two groups), the type of lesion, and the potential for recovery. Management options include physical therapy, oral agents; focal therapies such as botulinum injections; and peripheral nerve blocks. Intrathecal baclofen can lead to a reduction in required oral antispasticity medications. When spasticity is severe intrathecal phenol may be an option. Surgical interventions, largely used in the pediatric population, include muscle transfers and lengthening and selective dorsal root rhizotomy.
Collapse
Affiliation(s)
- Jonathan Marsden
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth, United Kingdom.
| | - Valerie Stevenson
- Department of Therapies and Rehabilitation, National Hospital for Neurology and Neurosurgery UCLH, London, United Kingdom
| | - Louise Jarrett
- Department of Neurology, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| |
Collapse
|
10
|
O’Malley JA. Diagnosing Common Movement Disorders in Children. Continuum (Minneap Minn) 2022; 28:1476-1519. [DOI: 10.1212/con.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
11
|
Mansur A, Morgan B, Lavigne A, Phaneuf-Garand N, Diabira J, Yan H, Narayanan UG, Fehlings D, Milo-Manson G, Dalziel B, Breitbart S, Mercier C, Venne D, Marois P, Weil AG, Raskin JS, Thomas SP, Ibrahim GM. Comparison of intrathecal baclofen pump insertion and selective dorsal rhizotomy for nonambulatory children with predominantly spastic cerebral palsy. J Neurosurg Pediatr 2022; 30:217-223. [PMID: 35901772 DOI: 10.3171/2022.4.peds21576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In nonambulatory children with predominantly spastic cerebral palsy (CP), the authors compared care needs, symptom burden, and complications after surgical treatment with either intrathecal baclofen (ITB) pump insertion or selective dorsal rhizotomy (SDR). The patients were treated at two Canadian centers with variability in practice pertaining to these surgical options. METHODS The authors performed a retrospective analysis of nonambulatory children with predominantly spastic quadriplegic or diplegic CP who underwent treatment with ITB or SDR. These two strategies were retrospectively assessed by comparing patient data from the two treatment groups for demographic characteristics, outcomes, and complications. A partial least-squares analysis was performed to identify patient phenotypes associated with outcomes. RESULTS Thirty patients who underwent ITB and 30 patients who underwent SDR were included for analysis. Patients in the ITB group were older and had lower baseline functional status, with greater burdens of spasticity, dystonia, pain, deformity, bladder dysfunction, and epilepsy than patients in the SDR group. In addition, children who underwent SDR had lower Gross Motor Function Classification System (GMFCS) levels and were less likely to experience complications than those who underwent ITB. However, children treated with SDR had fewer improvements in pain than children treated with ITB. A single significant latent variable explaining 88% of the variance in the data was identified. CONCLUSIONS Considerable baseline differences exist within this pediatric CP patient population. Factors specific to individual children must be taken into account when determining whether ITB or SDR is the appropriate treatment.
Collapse
Affiliation(s)
- Ann Mansur
- 1Division of Neurosurgery, Department of Surgery, Faculty of Medicine, and
| | - Benjamin Morgan
- 2Department of Medical Imaging, Faculty of Medicine, University of Toronto, Ontario
| | - Alexandre Lavigne
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
- 4Brain and Child Development Axis, CHU Sainte-Justine Research Center, Montreal, Quebec
| | - Nicolas Phaneuf-Garand
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
- 4Brain and Child Development Axis, CHU Sainte-Justine Research Center, Montreal, Quebec
| | - Jocelyne Diabira
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
- 4Brain and Child Development Axis, CHU Sainte-Justine Research Center, Montreal, Quebec
| | - Han Yan
- 1Division of Neurosurgery, Department of Surgery, Faculty of Medicine, and
| | - Unni G Narayanan
- 5Division of Orthopedic Surgery, Hospital for Sick Children, Toronto, Ontario
| | - Darcy Fehlings
- 6Division of Developmental Paediatrics, Department of Paediatrics, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Ontario
| | - Golda Milo-Manson
- 6Division of Developmental Paediatrics, Department of Paediatrics, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Ontario
| | - Blythe Dalziel
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
| | - Sara Breitbart
- 7Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Claude Mercier
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
| | - Dominic Venne
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
| | - Pierre Marois
- 4Brain and Child Development Axis, CHU Sainte-Justine Research Center, Montreal, Quebec
| | - Alexander G Weil
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
| | - Jeffrey S Raskin
- 8Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sruthi P Thomas
- 9Department of Pediatrics and
- 10Department of Physical Medicine and Rehabilitation and Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - George M Ibrahim
- 1Division of Neurosurgery, Department of Surgery, Faculty of Medicine, and
- 7Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
12
|
Paget SP, Campbell L, Blaxland A, Lewis J, Morrow AM, Wimalasundera N. 'Life-changing surgery': English-language news media representation of selective dorsal rhizotomy. Child Care Health Dev 2021; 47:844-850. [PMID: 34251700 DOI: 10.1111/cch.12894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 01/26/2021] [Accepted: 07/02/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) is a neurosurgical intervention to reduce spasticity in children with cerebral palsy. Parents researching SDR for their child may be influenced by framing of SDR in news media articles they read. This study examined framing of SDR in English-language news media. METHODS Content analysis of English-language news media articles including the search term 'rhizotomy' in the Factiva database published July 2015 to July 2018 in online or print form in Canada, New Zealand, Australia, United States of America and the United Kingdom. RESULTS One hundred and eighty-six articles were identified describing 91 different children (45 male), almost all with cerebral palsy, median age 4 years old. One hundred and twenty-six articles were written prior to surgery; in many articles, SDR surgery involved travel overseas and/or fundraising. SDR was described universally in positive terms with little discussion of risks. Content of articles variably included the specialized nature of SDR, parental frustration with their local health system and their hope for positive outcomes. There was geographical variation in both numbers of articles and content. CONCLUSIONS SDR is a common focus in cerebral palsy news media articles in some countries. Framing in these articles supports SDR as a beneficial and specialized procedure and may lead families to believe they need to work outside their local health systems. As news media are likely an important influence on families' attitudes to SDR, clinicians should be aware of this influence.
Collapse
Affiliation(s)
- Simon Paul Paget
- The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Lani Campbell
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Anneliese Blaxland
- The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jennifer Lewis
- The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Angela Mary Morrow
- The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | | |
Collapse
|
13
|
Sindou M, Joud A, Georgoulis G. How I do it: Selective dorsal rhizotomy, using interlaminar approaches, for spastic diplegia/quadriplegia in children with cerebral palsy. Acta Neurochir (Wien) 2021; 163:2845-2851. [PMID: 33624116 DOI: 10.1007/s00701-021-04770-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Dorsal rhizotomy is considered the gold standard for treating spastic diplegia/quadriplegia in children with cerebral palsy, when rehabilitation programs reveal insufficient to control excess of spasticity. METHOD The Keyhole Interlaminar Dorsal rhizotomy modality has been developed to access-individually-all L2-S2 roots, intradurally at the corresponding dural sheath, and preserve the posterior spine architecture. Intraoperative neuromonitoring consists of stimulating each ventral root, to verify its myotomal innervation, and dorsal roots, to explore their reflexive muscular responses in order to help determination of the proportion of rootlets to be cut. CONCLUSION This modality, which requires 5 ± 1 h duration, offers tailored accuracy.
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
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: 14] [Impact Index Per Article: 4.7] [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.
Collapse
|
16
|
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.
Collapse
Affiliation(s)
- Johannes Wach
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany.
| | - Ömer Can Yildiz
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
| | - Sevgi Sarikaya-Seiwert
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
| | - Hannes Haberl
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
| |
Collapse
|
17
|
Gillespie CS, George AM, Hall B, Toh S, Islim AI, Hennigan D, Kumar R, Pettorini B. The effect of GMFCS level, age, sex, and dystonia on multi-dimensional outcomes after selective dorsal rhizotomy: prospective observational study. Childs Nerv Syst 2021; 37:1729-1740. [PMID: 33599808 PMCID: PMC8084767 DOI: 10.1007/s00381-021-05076-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/04/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE Investigate the effect of age category (1-9 years vs 10-18 years), sex, Gross Motor Function Classification System (GMFCS) level, and presence of dystonia on changes in eight function test parameters 24 months after selective dorsal rhizotomy (SDR). METHODS Prospective, single-center study of all children aged 3-18 years with bilateral cerebral palsy with spasticity who underwent SDR at a tertiary pediatric neurosurgery center between 2012 and 2019. A linear mixed effects model was used to assess longitudinal changes. RESULTS From 2012 to 2019, 42 children had follow-up available at 24 months. Mean GMFM-66 scores increased after SDR (mean difference 5.1 units: 95% CI 3.05-7.13, p < 0.001). Statistically significant improvements were observed in CPQoL, PEDI Self-care and Mobility, 6MWT, Gillette, and MAS scores. There was no significant difference in the improvements seen for age category, sex, GMFCS level, and presence of dystonia for most of the parameters tested (5/8, 6/8, 5/8, and 6/8 respectively). CONCLUSION SDR may improve gross and fine motor function, mobility and self-care, quality of life, and overall outcome based on extensive scoring parameter testing at 24 months. Atypical patient populations may benefit from SDR if appropriately selected. Multi-center, prospective registries investigating the effect of SDR are required.
Collapse
Affiliation(s)
- Conor Scott Gillespie
- Department of Neurosurgery, Alder Hey Children's Hospital NHS Trust, Liverpool, UK. .,Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Biosciences Building, Crown Street, Liverpool, L69 7BE, UK.
| | - Alan Matthew George
- grid.417858.70000 0004 0421 1374Present Address: Department of Neurosurgery, Alder Hey Children’s Hospital NHS Trust, Liverpool, UK ,grid.6572.60000 0004 1936 7486Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Benjamin Hall
- grid.452080.b0000 0000 8948 3192Aintree University Hospitals NHS Foundation Trust, Liverpool, UK ,grid.10025.360000 0004 1936 8470School of Medicine, University of Liverpool, Liverpool, UK
| | - Steven Toh
- grid.10025.360000 0004 1936 8470School of Medicine, University of Liverpool, Liverpool, UK
| | - Abdurrahman Ismail Islim
- grid.10025.360000 0004 1936 8470School of Medicine, University of Liverpool, Liverpool, UK ,grid.269741.f0000 0004 0421 1585Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Dawn Hennigan
- grid.417858.70000 0004 0421 1374Present Address: Department of Neurosurgery, Alder Hey Children’s Hospital NHS Trust, Liverpool, UK
| | | | - Ram Kumar
- grid.417858.70000 0004 0421 1374Present Address: Department of Neurosurgery, Alder Hey Children’s Hospital NHS Trust, Liverpool, UK
| | - Benedetta Pettorini
- grid.417858.70000 0004 0421 1374Present Address: Department of Neurosurgery, Alder Hey Children’s Hospital NHS Trust, Liverpool, UK
| |
Collapse
|
18
|
Chirurgische Therapieoptionen bei spastischen Bewegungsstörungen der Extremitäten. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01033-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Zusammenfassung
Hintergrund
Schäden des 1. Motoneurons führen zu spastischen Lähmungen an den Extremitäten, die bei Kindern und Erwachsenen einschneidende Veränderungen der Bewegungsfähigkeit zur Folge haben und Lebensqualität sowie -teilhabe durch Funktionsverlust und Schmerzen einschränken.
Methode
Auf Grundlage eigener Behandlungserfahrungen in Verbindung mit einer PubMed-Literaturrecherche werden aktuelle Diagnose- und Behandlungsverfahren sowie deren Kombinationen vorgestellt.
Ergebnisse
Prinzipiell stehen Physio- und Ergotherapie mit vereinbarten alltagsrelevanten Therapiezielen, Medikamente (Botulinumtoxin und Baclofen) und Orthetik im Vordergrund. Chirurgische Maßnahmen an Muskeln, Sehnen, Gelenken und Knochen können dem betroffenen Patienten zu verbesserter Beweglichkeit, Wachstumskorrektur und vereinfachter Alltagsbewältigung verhelfen. Die selektive Neurektomie bei fokaler Spastik erlebt derzeit eine Renaissance. Die intrathekale Baclofentherapie kann bei entsprechend hoher Katheterlage auch eine Tonusreduktion an der oberen Extremität erreichen.
Collapse
|
19
|
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.
Collapse
Affiliation(s)
- Rick Abbott
- Albert Einstein College of Medicine, Montefiore Health System, 110 E. 210th St, Bronx, NY, 10467, USA.
| |
Collapse
|
20
|
The role of intra-operative neuroelectrophysiological monitoring in single-level approach selective dorsal rhizotomy. Childs Nerv Syst 2020; 36:1925-1933. [PMID: 31686140 DOI: 10.1007/s00381-019-04408-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 10/02/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Selective dorsal rhizotomy via a single-level approach (SL-SDR) to treat spasticity 100% relies on the interpretation of results from the intra-operative neuroelectrophysiological monitoring. The current study is to investigate the role EMG interpretation plays during SL-SDR procedure with regard to the selection of nerve rootlets for partially sectioning in pediatric cases with spastic cerebral palsy (CP). METHODS A retrospective study was conducted in pediatric patients with spastic CP undergone our modified rhizotomy protocol-guided SL-SDR from May 2016 to Mar. 2019 in our hospital. Our study focused on intra-operative EMG interpretation and its correlation with pre-op evaluation results, and dorsal rootlet selection difference when data of our intra-operative EMG recordings interpreted using different rhizotomy protocols. RESULTS Clinical and intra-operative neuroelectrophysiological monitoring data of a total of 318 consecutive cases were reviewed, which include 231 boys and 87 girls with 32 hemiplegias, 161 diplegias, and 125 quadriplegias. Age at the time of SL-SDR in those cases was between 3.0-14.0 (5.9 ± 1.9) years. The number of targeted muscle ranged from 2 to 8 over these cases (the muscle in lower limbs with its pre-op muscle tone ≥ 2 grade, Modified Ashworth scale). Among 21,728 nerve rootlets tested (68.3 ± 8.2/case), 6272 (28.9%) were identified sphincter related by our intra-operative neuromonitoring. In the rest of 15,456 (48.6 ± 7.6/case) nerve rootlets which neuromonitoring suggested associated with lower limbs, 11,009 were taken as the dorsal ones (34.6 ± 7.4/case). A total of 3370 (10.6 ± 4.7/case) rootlets matched our rhizotomy criteria with 3061 (9.6 ± 4.1/case) sectioned 50% and 309 (1.0 ± 1.0/case) cut 75%. The rhizotomy ratio (partially transected nerve rootlets/all dorsal rootlets associated with lower limbs in a particular case) was 15.8%, 22.3%, 33.4%, 41.8%, and 45.7% across cases with their pro-op GMFCS level from I to V, respectively. Rootlets required 75% cut had a tendency to increase as well in our cases with their pro-op GMFCS level from I to V, which comprising 1.5%, 4.8%, 8.5%, 14.1%, and 15.2% of all rootlets transected, respectively. The muscle tone of 2068 targeted muscles in these cases at the time of 3 weeks after the SL-SDR was revealed a significant decrease when compared to pre-op (1.7 ± 0.5 vs. 2.7 ± 0.6). Further investigation to compare our rootlet selection with the one guided by the traditional rhizotomy criteria using our intro-operative EMG recordings in 318 cases, revealed that the overlap ratio had a tendency to increase in cases when their pre-op GMFCS level increased (39.5%, 41.3%, 52.2%, 54.1%, and 62.8% in cases with levels I-V, respectively). While our modified rhizotomy protocol successfully identified 2-23 rootlets for sectioning in all of our 318 cases, the traditional rhizotomy protocol failed to distinguish any for cutting in about 20% of cases with their pre-op GMFCS levels I and II. CONCLUSIONS The rhizotomy criteria fully rely on the EMG interpretation making intra-operative neuroelectrophysiological monitoring crucial when SDR is performed via a single-level approach. Our modified rhizotomy protocol is feasible, safe, and effective to guide SL-SDR to treat all types of spastic CP cases by decreasing muscle tone in particular spastic muscle groups in their lower limbs. Data of EMG responses during SL-SDR procedure and as well as the clinical outcomes based on their interpretation could help clinicians to further understand how neuronal circuits work in the spinal cord of these patients.
Collapse
|
21
|
Concurrent Validity of the School Outcomes Measure and the School Function Assessment in Elementary Students. Pediatr Phys Ther 2020; 32:180-188. [PMID: 32604356 DOI: 10.1097/pep.0000000000000710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Examine the concurrent validity of the School Outcomes Measure (SOM) and the School Function Assessment (SFA) in students kindergarten through sixth grade. METHODS Twenty-four school-based therapists completed the SOM and the SFA for 42 students, representing Gross Motor Function Classification System (GMFCS) levels I to V. RESULTS Correlation coefficients between SOM Self-Care, Mobility, and Assuming Student's Role median total scores and the 21 SFA Activity Performance scale median criterion scores were statistically significant. There were significant correlation coefficients between SOM Expressing Learning and Behavior and SFA median criterion scores. The SOM differentiated between GMFCS groups for all physical tasks but not cognitive/behavioral tasks, and the SFA for half of the physical tasks. CONCLUSIONS Overall, student performance on the SOM was consistent with participation on the SFA, which lends support to the preliminary validity of the SOM. The GMFCS analysis suggests that the SOM differentiates between the GMFCS levels for physical tasks.
Collapse
|
22
|
Davidson B, Schoen N, Sedighim S, Haldenby R, Dalziel B, Breitbart S, Fehlings D, Milo-Manson G, Narayanan UG, Drake JM, Ibrahim GM. Intrathecal baclofen versus selective dorsal rhizotomy for children with cerebral palsy who are nonambulant: a systematic review. J Neurosurg Pediatr 2020; 25:69-77. [PMID: 31628286 DOI: 10.3171/2019.8.peds19282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral palsy (CP) is the most common childhood physical disability. Historically, children with hypertonia who are nonambulatory (Gross Motor Function Classification System [GMFCS] level IV or V) were considered candidates for intrathecal baclofen (ITB) therapy to facilitate care and mitigate discomfort. Selective dorsal rhizotomy (SDR) was often reserved for ambulant children to improve gait. Recently, case series have suggested SDR as an alternative to ITB in selected children functioning at GMFCS level IV/V. The objective for this study was to systematically review the evidence for ITB and SDR in GMFCS level IV or V children. METHODS Medline, Embase, Web of Science, and Cochrane databases were systematically searched. Articles were screened using the following inclusion criteria: 1) peer-reviewed articles reporting outcomes after SDR or ITB; 2) outcomes reported using a quantifiable scale or standardized outcome measure; 3) patients were < 19 years old at the time of operation; 4) patients had a diagnosis of CP; 5) patients were GMFCS level IV/V or results were reported based on GMFCS status and included some GMFCS level IV/V patients; 6) article and/or abstract in English; and 7) primary indication for surgery was hypertonia. Included studies were assessed with the Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) tool. RESULTS Twenty-seven studies met inclusion criteria. The most commonly reported outcomes were spasticity (on the Mean Ashworth Scale) and gross motor function (using the Gross Motor Function Measure), although other outcomes including frequency of orthopedic procedures and complications were also reported. There is evidence from case series that suggests that both ITB and SDR can lower spasticity and improve gross motor function in this nonambulatory population. Complication rates are decidedly higher after ITB due in part to the ongoing risk of device-related complications. The heterogeneity among study design, patient selection, outcome selection, and follow-up periods was extremely high, preventing meta-analysis. There are no comparative studies, and meaningful health-related quality of life outcomes such as care and comfort are lacking. This review is limited by the high risk of bias among included studies. Studies of SDR or ITB that did not clearly describe patients as being GMFCS level IV/V or nonambulatory were excluded. CONCLUSIONS There is a lack of evidence comparing the outcomes of ITB and SDR in the nonambulatory CP population. This could be overcome with standardized prospective studies using more robust methodology and relevant outcome measures.
Collapse
Affiliation(s)
| | - Nathan Schoen
- 2University of Miami, Miller School of Medicine, Miami, Florida
| | - Shaina Sedighim
- 2University of Miami, Miller School of Medicine, Miami, Florida
| | - Renée Haldenby
- 3Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Blythe Dalziel
- 3Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Sara Breitbart
- 4Division of Orthopaedics, Hospital for Sick Children, University of Toronto; and
| | - Darcy Fehlings
- 3Department of Pediatrics, University of Toronto, Ontario, Canada
| | | | - Unni G Narayanan
- 4Division of Orthopaedics, Hospital for Sick Children, University of Toronto; and
| | - James M Drake
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Hospital for Sick Children, Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, University of Toronto, Ontario, Canada
| | - George M Ibrahim
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Hospital for Sick Children, Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, University of Toronto, Ontario, Canada
| |
Collapse
|
23
|
Zhan Q, Yu X, Jiang W, Shen M, Jiang S, Mei R, Wang J, Xiao B. Whether the newly modified rhizotomy protocol is applicable to guide single-level approach SDR to treat spastic quadriplegia and diplegia in pediatric patients with cerebral palsy? Childs Nerv Syst 2020; 36:1935-1943. [PMID: 31502037 PMCID: PMC7434794 DOI: 10.1007/s00381-019-04368-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/02/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Our aim was to test whether the newly modified rhizotomy protocol which could be effectively used to guide single-level approach selective dorsal rhizotomy (SL-SDR) to treat spastic hemiplegic cases by mainly releasing those spastic muscles (target muscles) marked pre-operatively in their lower limbs was still applicable in spastic quadriplegic or diplegic cerebral palsy (CP) cases in pediatric population. METHODS In the current study, we retrospectively conducted a cohort review of cases younger than 14 years of age diagnosed with spastic quadriplegic or diplegic CP who undergone our modified protocol-guided SL-SDR in the Department of Neurosurgery, Children's Hospital of Shanghai since July 2016 to November 2017 with at least 12 months post-op intensive rehabilitation program (pre-op GMFCS level-based). Clinical data including demographics, intra-operative EMG responses interpretation, and relevant assessment of included cases were taken from the database. Inclusion and exclusion criteria were set for the selection of patients in the current study. Muscle tone (modified Ashworth scale) and strength of those spastic muscles (muscle strength grading scale), range of motion (ROM) of those joints involved, the level of Gross Motor Function Classification System (GMFCS), and Gross Motor Function Measure 66 items (GMFM-66) score of those cases were our focus. RESULTS A total of 86 eligible cases were included in our study (62 boys). Among these patients, 61.6% were quadriplegic. Pre-operatively, almost 2/3 of our cases were with GMFCS levels II and III. Mean age at the time of surgery in these cases was 6.2 (3.5-12) years. Pre-op assessment marked 582 target muscles in these patients. Numbers of nerve rootlets tested during SDR procedure were between 52 and 84 across our cases, with a mean of 66.5 ± 6.7/case. Among those tested (5721 in 86 cases), 47.9% (2740) were identified as lower limb-related sensory rootlets. Our protocol successfully differentiated sensory rootlets which were considered to be associated with spasticity of target muscles across all our 86 cases (ranged from 3 to 21). Based on our protocol, 871 dorsal nerve rootlets were sectioned 50%, and 78 were cut 75%. Muscle tone of those target muscles reduced significantly right after SL-SDR procedure (3 weeks post- vs. pre-op, 1.7 ± 0.5 vs. 2.6 ± 0.7). After an intensive rehabilitation program for 19.9 ± 6.0 months, muscle tone continued to decrease to 1.4 ± 0.5. With the reduction of muscle tone, strength of those target muscles in our cases improved dramatically with statistical significance achieved (3.9 ± 1.0 at the time of last follow-up vs. 3.3 ± 0.8 pre-op), and as well as ROM. Increase in GMFCS level and GMFM-66 score was observed at the time of last follow-up with a mean of 0.4 ± 0.6 and 6.1 ± 3.2, respectively, when compared with that at pre-op. In 81 cases with their pre-op GMFCS levels II to V, 27 (33.3%) presented improvement with regard to GMFCS level upgrade, among which 4 (4.9%) even upgraded over 2 levels. Better results with regard to upgrading in level of GMFCS were observed in cases with pre-op levels II and III when compared with those with levels IV and V (24/57 vs. 3/24). Upgrading percentage in cases younger than 6 years at surgery was significantly greater than in those older (23/56 vs. 4/25). Cases with their pre-op GMFM-66 score ≥ 50 had greater score increase of GMFM-66 when compared with those less (7.1 ± 3.4 vs. 5.1 ± 2.8). In the meanwhile, better score improvement was revealed in cases when SDR performed at younger age (6.9 ± 3.3 in case ≤ 6 years vs. 4.7 ± 2.7 in case > 6 years). No permanent surgery-related complications were recorded in the current study. CONCLUSION SL-SDR when guided by our newly modified rhizotomy protocol was still feasible to treat pediatric CP cases with spastic quadriplegia and diplegia. Cases in this condition could benefit from such a procedure when followed by our intensive rehabilitation program with regard to their motor function.
Collapse
Affiliation(s)
- Qijia Zhan
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xidan Yu
- Department of Rehabilitation Medicine, Shanghai Rehabilitation and Vocational Training Center for the Disabled, Shanghai, China
| | - Wenbin Jiang
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Min Shen
- Department of Rehabilitation Medicine, Shanghai Rehabilitation and Vocational Training Center for the Disabled, Shanghai, China
| | - Shuyun Jiang
- grid.412540.60000 0001 2372 7462Gait and Motion Analysis Center, Yueyang Hospital of Integrated Traditional and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rong Mei
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Junlu Wang
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bo Xiao
- Department of Neurosurgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.
| |
Collapse
|
24
|
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.
Collapse
Affiliation(s)
- Sruthi P Thomas
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, 6701 Fannin Street, Suite 1280, Houston, TX 77030, USA; Department of Neurosurgery, Section of Pediatric Neurosurgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA. https://twitter.com/ThomasMDPhD
| | - Angela P Addison
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA
| | - Daniel J Curry
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA.
| |
Collapse
|
25
|
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: 8] [Impact Index Per Article: 1.6] [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
| |
Collapse
|
26
|
Davidson B, Fehlings D, Milo-Manson G, Ibrahim GM. Improving access to selective dorsal rhizotomy for children with cerebral palsy. CMAJ 2019; 191:E1205-E1206. [PMID: 31685663 DOI: 10.1503/cmaj.191065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Benjamin Davidson
- Division of Neurosurgery (Davidson, Ibrahim), Department of Surgery and Department of Paediatrics (Fehlings, Milo-Manson), University of Toronto; Division of Neurosurgery (Ibrahim), The Hospital for Sick Children; Program in Neuroscience and Mental Health (Ibrahim), The Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ont
| | - Darcy Fehlings
- Division of Neurosurgery (Davidson, Ibrahim), Department of Surgery and Department of Paediatrics (Fehlings, Milo-Manson), University of Toronto; Division of Neurosurgery (Ibrahim), The Hospital for Sick Children; Program in Neuroscience and Mental Health (Ibrahim), The Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ont
| | - Golda Milo-Manson
- Division of Neurosurgery (Davidson, Ibrahim), Department of Surgery and Department of Paediatrics (Fehlings, Milo-Manson), University of Toronto; Division of Neurosurgery (Ibrahim), The Hospital for Sick Children; Program in Neuroscience and Mental Health (Ibrahim), The Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ont
| | - George M Ibrahim
- Division of Neurosurgery (Davidson, Ibrahim), Department of Surgery and Department of Paediatrics (Fehlings, Milo-Manson), University of Toronto; Division of Neurosurgery (Ibrahim), The Hospital for Sick Children; Program in Neuroscience and Mental Health (Ibrahim), The Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ont.
| |
Collapse
|
27
|
Chambers HG. Complexity of gait in a child with spasticity. Dev Med Child Neurol 2019; 61:1123. [PMID: 30908600 DOI: 10.1111/dmcn.14219] [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: 11/30/2022]
Affiliation(s)
- Hank G Chambers
- Rady Children's Hospital, University of California San Diego, CA, USA
| |
Collapse
|
28
|
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
|
29
|
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: 0.8] [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: 05/02/2019] [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.
Collapse
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
| |
Collapse
|
30
|
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] [Received: 07/04/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [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.
Collapse
Affiliation(s)
- Jennifer Lewis
- The Children’s Hospital at Westmead, Kids Rehab, Sydney, New South Wales, Australia
| | - Natasha Bear
- Child and Adolescent Health Service Western Australia, Perth, Western Australia, Australia
| | - Felicity Baker
- Rehabilitation Department, Women’s and Children’s Hospital Adelaide Women’s and Babies Division, North Adelaide, South Australia, Australia
| | - Adam Fowler
- Department of Neurosurgery, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Olivia Lee
- Victorian Paediatric Rehabilitation Service, Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
| | - Kim McLennan
- Lady Cilento Children’s Hospital, South Brisbane, Queensland, Australia
| | - Emma Richardson
- Department of Paediatric Rehabilitation, Princess Margaret Hospital for Children, Perth, Australia
| | - Adam Scheinberg
- Victorian Paediatric Rehabilitation Service, Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
- University of Melbourne Melbourne Medical School, Melbourne, Victoria, Australia
| | - Nadine Smith
- Department of Paediatric Rehabilitation, Princess Margaret Hospital for Children, Perth, Australia
| | - Pam Thomason
- Hugh Williamson Gait Analysis Laboratory, Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
| | - Andrew Tidemann
- Paediatric Rehabilitation Department, Women’s and Children’s Hospital Adelaide, North Adelaide, Australia
| | - Meredith Wynter
- Lady Cilento Children’s Hospital, South Brisbane, Queensland, Australia
| | - Simon Paget
- Kids Rehab, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- University of Sydney, Sydney Medical School, Sydney, New South Wales, Australia
| |
Collapse
|
31
|
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) is a surgical procedure for treating spasticity in ambulant children with cerebral palsy (CP). However, controversies remain regarding indications, techniques and outcomes. CURRENT EVIDENCE SUMMARY Because SDR is an irreversible procedure, careful patient selection, a multi-disciplinary approach in assessment and management and division of the appropriate proportion of dorsal rootlets are felt to be paramount for maximizing safety. Reliable evidence exists that SDR consistently reduces spasticity, in a predictable manner and to a substantial degree. However, functional improvements are small in the short-term with long-term benefits difficult to assess. FUTURE OUTLOOK There is a need for high-quality studies utilizing long-term functional outcomes and well-matched control groups. Collaborative, multicentre efforts are required to further define the role of SDR as part of the management paradigm in maximizing physical function in spastic CP.
Collapse
Affiliation(s)
- K. K. Wang
- Center for Gait and Motion Analysis, Gillette Children’s Specialty Healthcare, Twin Cities, Minnesota, USA,Department of Orthopedic Surgery, Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - M. E. Munger
- Center for Gait and Motion Analysis, Gillette Children’s Specialty Healthcare, Twin Cities, Minnesota, USA,Department of Orthopedic Surgery and Department of Health Policy and Management, University of Minnesota, Twin Cities, Minnesota, USA
| | - B. P.-J. Chen
- Center for Gait and Motion Analysis, Gillette Children’s Specialty Healthcare, Twin Cities, Minnesota, USA,Department of Orthopedic Surgery, University of Minnesota, Twin Cities, Minnesota, USA
| | - T. F. Novacheck
- Center for Gait and Motion Analysis, Gillette Children’s Specialty Healthcare, Twin Cities, Minnesota, USA,Department of Orthopedic Surgery, University of Minnesota, Twin Cities, Minnesota, USA, Correspondence should be sent to T. F. Novacheck, Center for Gait and Motion Analysis, Gillette Children’s Specialty Healthcare, 200 University Ave E, St Paul, MN 55101, United States. E-mail:
| |
Collapse
|
32
|
|