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Pu K, Xu R, Han G, Liu J, Liu X, Yin M, Li Q. Modified Selective Dorsal Rhizotomy Exposure Method for Adults With Spastic Paralysis of the Lower Limbs. Oper Neurosurg (Hagerstown) 2023; 26:01787389-990000000-00994. [PMID: 38084948 PMCID: PMC11008659 DOI: 10.1227/ons.0000000000001011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/11/2023] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Spinal deformities are a common complication after selective dorsal rhizotomy (SDR). In this article, we introduce a more minimally invasive SDR procedure in adult patients with spastic paralysis of the lower limbs. METHODS In this retrospective analysis of SDR in 8 adult patients with spastic paralysis of the lower limbs, a modified exposure method was used during the surgery. Only the lower part of the L1 spinous process, upper part of the L2 spinous process, and part of the lamina were resected through L1-2 interlaminar approaches. The motor and sensory roots were found to be completely dependent on electrophysiological monitoring. The sensory roots of the target muscle groups were partially transected. All patients were followed up for 2-4 years. The degree of lower extremity spasm was assessed using the Gross Motor Function Classification Scale, Ashworth grading, Gross Motor Function Measure-66, joint range of motion, and electromyography analysis. RESULTS All 8 patients were successfully operated with the help of intraoperative electrophysiological monitoring. The Ashworth score of the target muscles, Gross Motor Function Measure-66 score, and range of motion of the joints improved significantly after surgery. Two patients achieved cross-grade improvement in their Gross Motor Function Classification Scale scores. No persistent incision pain or spinal deformities were observed during follow-up. CONCLUSION The interspinous process approach provides sufficient surgical space and reduced the damage to the bone structure of the spine. The electrophysiological monitoring protocol is suitable for adult patients with lower extremity spasm.
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Affiliation(s)
- Ke Pu
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Rui Xu
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Guoqing Han
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Jiawen Liu
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Xin Liu
- Department of Neuroelectrophysiology, Tianjin Huanhu Hospital, Tianjin, China
| | - Miaomiao Yin
- Department of Rehabitation, Tianjin Huanhu Hospital, Tianjin, China
| | - Qingguo Li
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
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Jiang W, Zhan Q, Wang J, Wei M, Li S, Mei R, Xiao B. Quantitative identification of ventral/dorsal nerves through intraoperative neurophysiological monitoring by supervised machine learning. Front Pediatr 2023; 11:1118924. [PMID: 37274819 PMCID: PMC10232959 DOI: 10.3389/fped.2023.1118924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/13/2023] [Indexed: 06/07/2023] Open
Abstract
Objective This study aimed to investigate the electro-neurophysiological characteristics of the ventral and dorsal nerves at the L2 segment in a quantitative manner. Methods Medical records of consecutive patients who underwent single-level approach selective dorsal rhizotomy (SDR) from June 2019 to January 2022 were retrospectively reviewed. Intraoperative electro-neurophysiological data were analyzed. Results A total of 74 males and 27 females were included in the current study with a mean age of 6.2 years old. Quadriceps and adductors were two main muscle groups innervated by L2 nerve roots in both ventral and dorsal nerve roots. Dorsal roots have a higher threshold than that of the ventral ones, and muscles that first reached 200 µV innervated by dorsal roots have longer latency and smaller compound muscle action potential (CMAP) than those of the ventral ones. Supervised machine learning can efficiently distinguish ventral/dorsal roots using threshold + latency or threshold + CMAP as predictors. Conclusion Electro-neurophysiological parameters could be used to efficiently differentiate ventral/dorsal fibers during SDR.
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Affiliation(s)
- Wenbin Jiang
- Department of Neurosurgery, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qijia Zhan
- Department of Neurosurgery, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Junlu Wang
- Department of Neurosurgery, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Min Wei
- Department of Neurosurgery, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Sen Li
- Department of Neurosurgery, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Rong Mei
- Department of Neurology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bo Xiao
- Department of Neurosurgery, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Sindou M, Georgoulis G, Joud A, Neromyliotis E, Dinopoulos A. Excitability of the radiculo-medullary circuitry in spastic cerebral palsy: An intraoperative neurophysiological study in children undergoing selective dorsal rhizotomy. Dev Med Child Neurol 2023; 65:78-85. [PMID: 35698904 DOI: 10.1111/dmcn.15315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 05/08/2022] [Accepted: 05/11/2022] [Indexed: 12/01/2022]
Abstract
AIM To explore - through intraoperative neurophysiology mapping and recordings - the comparative distribution of the reflexive excitability of the L2 to S2 radiculo-metameric segments of the spinal cord in a series of children with bilateral spastic cerebral palsy (CP) who underwent selective dorsal rhizotomy (SDR). METHOD Our series included 46 consecutive children (36 males, 10 females; aged 5-16 years, mean 8 years) who underwent SDR, using keyhole interlaminar dorsal rhizotomy. The procedure allowed access to all L2 to S2 roots independently, while preserving the posterior architecture of the lumbar spine. Dorsal roots were stimulated selectively to test reflexive excitability of the corresponding radiculo-metameric levels. Stimulation parameters were identical for all roots for optimal comparison between root levels, with an intensity just above threshold to avoid excessive diffusion. The responses in the main muscular groups in each lower limb were clinically observed and electromyograms recorded. Degrees of excitability were quantified according to Fasano's scale. RESULTS The difference between root levels was highly significant. Median values of excitability were 1, 2, 3, 3, 3, and 3 for the L2, L3, L4, L5, S1, and S2 levels respectively. Lower root levels exhibited significantly more excitability. INTERPRETATION In addition to insight into the spasticity of children with CP, the profile of segmental excitability can be useful in establishing surgical planning when programming SDR. WHAT THIS PAPER ADDS Keyhole interlaminar dorsal rhizotomy modality allowed selective stimulation of all L2-S2 dorsal roots for testing excitability. There were significant differences in reflexive excitability of L2-S2 radiculo-medullary segments. Lower segments of L2-S2 medullary levels have higher excitability. Interindividual variability in excitability of lumbosacral segments justifies intraoperative neurophysiology. This original article is commented on by Young on pages 9-10 of this issue.
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Affiliation(s)
- Marc Sindou
- Medical School Claude-Bernard, University of Lyon, Lyon, France.,IRR Flavigny, UGECAM Nord-Est, Nancy, France.,Pediatric Neurosurgery Department, Centre Hospitalier Regional Universitaire (CHRU) de Nancy, Nancy, France
| | - George Georgoulis
- Department of Neurosurgery, General Hospital of Athens "G. Gennimatas", Athens, Greece.,Medical School, University of Athens, Athens, Greece
| | - Anthony Joud
- IRR Flavigny, UGECAM Nord-Est, Nancy, France.,Pediatric Neurosurgery Department, Centre Hospitalier Regional Universitaire (CHRU) de Nancy, Nancy, France
| | | | - Argyrios Dinopoulos
- Department of Pediatrics, Outpatient Clinic of Cerebral Palsy, General University Hospital of Athens "Attikon", Athens, Greece
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He Z, Wong ST, Law HY, Lao LMM, Chan KFH, Chan NCN, Yam KY. Multidimensional Outcomes of Selective Dorsal Rhizotomy for Children With Spastic Cerebral Palsy: Single-Level Laminectomy vs Multiple-Level Laminotomy Techniques. Neurosurgery 2022; 91:513-524. [PMID: 35881026 DOI: 10.1227/neu.0000000000002036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 03/21/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) reduces lower limb spasticity, improves gait patterns, and restores normal physical and social activity in children with spastic cerebral palsy. Single-level laminectomy (SLL) and multiple-level laminotomy (MLL) are 2 surgical approaches for SDR with limited clinical data comparing their postoperative outcomes. OBJECTIVE To compare the differences in multidimensional outcomes after SDR between SLL and MLL for children with spastic cerebral palsy. METHODS We retrospectively reviewed children who underwent SDR in our hospital from 1997 to 2016. The multidimensional outcomes in spasticity, joint range of motions, gait kinetics, gross motor activities, functional outcomes, and urological outcomes were assessed 1 year postoperatively. Hip dysplasia and scoliosis rate were compared as long-term outcomes. RESULTS Sixty children underwent SDR, including 34 SLL patients and 26 MLL patients. Most improvements in multidimensional outcomes were comparable between SLL and MLL. Patients in the SLL group had larger improvements in ankle dorsiflexion in the midstance phase (SLL 7.59° ± 11.48° vs MLL 0.29° ± 11.30°, P = .027). The rate of scoliosis was similar between the 2 surgical approaches (SLL 12.1% vs MLL 15.4%, P = .722). CONCLUSION SDR for children with spastic cerebral palsy could provide physical, functional, and urological improvements. SLL achieved a higher degree of improvement in ankle dorsiflexion in the midstance phase. The rate of scoliosis was not significantly increased by multiple-level laminotomy.
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Affiliation(s)
- Zhexi He
- Department of Neurosurgery, Tuen Mun Hospital, New Territories, Hong Kong
| | - Sui To Wong
- Department of Neurosurgery, Tuen Mun Hospital, New Territories, Hong Kong
| | - Hing Yuen Law
- Department of Neurosurgery, Tuen Mun Hospital, New Territories, Hong Kong
| | - Lai Mio Miko Lao
- Department of Physiotherapy, Tuen Mun Hospital, New Territories, Hong Kong
| | | | - Nar Chi Nerita Chan
- Department of Allied Health, Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Kwong Yui Yam
- Department of Neurosurgery, Tuen Mun Hospital, New Territories, Hong Kong
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Joud A, Sindou M, Stella I, Wiedemann A, Klein O. Dorsal rhizotomy in cerebral palsy: how root sectioning is influenced by intraoperative neuromonitoring. Neurochirurgie 2022; 68:e16-e21. [PMID: 35150726 DOI: 10.1016/j.neuchi.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 12/10/2021] [Accepted: 01/29/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND OBJECTIVE Dorsal rhizotomy is a controversial procedure for treating spasticity in children with cerebral palsy, particularly regarding the influence of intraoperative neuromonitoring (ION). The objective of this study was to evaluate the influence of ION in adjusting root sectioning compared the preoperative program established by the multidisciplinary team. MATERIAL AND METHODS Twenty-four consecutive children with spastic diplegia or quadriplegia, operated on between 2017 and 2020 in the University Hospital of Nancy, France, were studied. All underwent the same procedure: Keyhole Intralaminar Dorsal rhizotomy (KIDr) with enlarged multilevel interlaminar openings to access all roots from L2 to S2. The Ventral Root (VR) was stimulated to map radicular myotomes, and the Dorsal Root (DR) to test excitability of the segmental circuitry. Muscle responses were observed independently by the physiotherapist and by EMG-recordings. The study compared final root sectioning per radicular level and per side after ION versus the preoperative program determined by the multidisciplinary team. RESULTS ION resulted in significant differences in final percentage root sectioning (p<0.05), with a decrease for L2 and L3 and an increase for L5. ION modified the symmetry of sectioning, with 32% instead of 5% in preoperative program. Only 5 children showed change in GMFC score 6 months after surgery. CONCLUSION The use of ION during dorsal rhizotomy led to important modifications of root sectioning during surgery, which justifies individual control of each root, level by level and side by side, to optimize the therapeutic effect.
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Affiliation(s)
- A Joud
- Department of Pediatric Neurosurgery, Nancy University Hospital, University of Lorraine, France.
| | - M Sindou
- Department of Pediatric Neurosurgery, Nancy University Hospital, University of Lorraine, France
| | - I Stella
- Department of Pediatric Neurosurgery, Nancy University Hospital, University of Lorraine, France
| | - A Wiedemann
- Department of Pediatric Reanimation, Nancy University Hospital, University of Lorraine, France
| | - O Klein
- Department of Pediatric Neurosurgery, Nancy University Hospital, University of Lorraine, France
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Jiang W, Jiang S, Yu Y, Zhan Q, Wei M, Mei R, Chen F, Guo Y, Xiao B. Improvement of the gait pattern after selective dorsal rhizotomy derives from changes of kinematic parameters in the sagittal plane. Front Pediatr 2022; 10:1047227. [PMID: 36619509 PMCID: PMC9822718 DOI: 10.3389/fped.2022.1047227] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Selective dorsal rhizotomy (SDR) can decrease spasticity in children suffering from spastic cerebral palsy (SCP) and thus improve their moving ability when supplemented with the post-operational rehabilitation program. In this case, the study aims to investigate the gait changes in children with mild SCP after SDR in short-term follow-up. METHODS The information of ambulatory SCP cases who underwent SDR in our center was retrospectively reviewed, and comparisons of changes in spasticity, motor function and data of gait analysis before and after SDR were analyzed. RESULTS In total, 32 cases were included in this study, with a mean age of 5.9 ± 2.1 years old. Noticeable decrease was found in the median value of the pre-operational MAS score after SDR at last follow-up in both sides of adductors, gastrocnemius, soleus, and left hamstrings. The Gross Motor Function Measure-66 score increased from 70.6 ± 9.2 to 73.4 ± 8.2, and the gait deviation index increased after SDR compared with the pre-operational data (right side: 65.8 ± 8.8 vs. 60.1 ± 10.7; left side: 63.5 ± 10.1 vs. 57.0 ± 9.9). Noticeable changes were found that the maximum angle of affected ankles in the sagittal plane (the dorsal-flexion angle) increased from 2.5° to 8.2°, the angles at initial contact (1% gait cycle) of affected knees in the sagittal plane decreased from 34.0° to 27.8°, and the angles at the end of swing phase (100% gait cycle) of affected knees in the sagittal plane decreased from 35.8° to 28.3°. CONCLUSION In short-term follow-up, SDR can lower spasticity in children with SCP. Post-operational gait analysis showed improvements in gross motor function and gait, which derived from the changes in the sagittal plane (ankle and knee). A longer follow-up duration is thus needed to clarify the long-term outcome.
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Affiliation(s)
- Wenbin Jiang
- Department of Neurosurgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shuyun Jiang
- Department of Gait Analysis, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yan Yu
- Department of Gait Analysis, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qijia Zhan
- Department of Neurosurgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Min Wei
- Department of Neurosurgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Rong Mei
- Department of Neurosurgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fang Chen
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yao Guo
- Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China
| | - Bo Xiao
- Department of Neurosurgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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