The therapeutic effects of ablative neurosurgical procedures on the spinal cord for intractable spinal spasticity

Retrograde Epidural Spinal Cord Stimulation for the Treatment of Intractable Neuropathic Pain Following Spinal Cord and Cauda Equina Injuries: A Case Report and Literature Review

Spinal cord stimulation (SCS) offers an alternative treatment for refractory pain resulting from various etiologies. Generally, SCS electrodes are inserted in an anterograde fashion, moving from caudal to rostral direction. However, there are instances where anterograde placement is unfeasible due to technical limitations. We present the use of retrograde surgical electrode placement in SCS for a patient with extensive epidural fibrosis at the site intended for electrode insertion. A 48-year-old female suffering from refractory neuropathic pain caused from injuries to the conus medullaris and cauda equina opted for SCS. During the SCS trial procedure, challenges emerged when attempting percutaneous electrode insertion at the site of a prior T12 laminectomy. However, the trial stimulation resulted in significant pain relief. For the permanent placement of the stimulator, utilizing a surgical electrode centered at T11 vertebral level, a considerable amount of epidural fibrosis was encountered at the entry of the spine, particularly at the T12 vertebral level. To avoid dural injury and ensure accurate electrode positioning, a retrograde technique for surgical electrode was employed via partial laminectomies at the T9-T10 level. The final electrode positioning was in accordance with the preoperative plan, well-centered at the T11 vertebral level. The patient experienced sustained relief from neuropathic pain over the long term. Retrograde epidural SCS is a suitable option for cases characterized by extensive epidural fibrosis resulting from a previous spinal surgery or when the anterograde placement of the electrode is unattainable due to aberrant vertebral anatomy.

Intrathecal baclofen, selective dorsal rhizotomy, and extracorporeal shockwave therapy for the treatment of spasticity in cerebral palsy: a systematic review

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.

Blessing or burden? Long-term maintenance, complications and clinical outcome of intrathecal baclofen pumps

AIM

The intrathecal baclofen pump is an effective treatment for spasticity. However, long-term results have reported patients' dissatisfaction and perception of disability. Potential causes include a frequent need for baclofen pump refill and risks of complications. The aim of the present study was to evaluate the long-term maintenance, complications and clinical outcome of intrathecal baclofen pumps.

PATIENTS AND METHODS

We conducted a 16-year retrospective cohort study of patients with spasticity treated with an intrathecal baclofen pump at a university hospital from 2000 to 2016. The primary outcome was the rate of infection per puncture for baclofen pump refill. Secondary outcomes included the incidence of other complications, such as running out of baclofen causing symptomatic withdrawal symptoms, pump mechanical failure, pump battery end of life and the need for pump replacement. The clinical outcome was assessed by the Modified Ashworth Scale (mAS).

RESULTS

In total, 340 follow-up episodes with pump refill procedures were recorded. The average interval between each pump refill was 57.3 days (±15.4 days). The average duration of admission for each pump refill was 4 h and 49 min (from 2 h 23 min to 10 h). There were two events with established infection after puncture for the refill, giving rise to an infection rate per puncture of 0.6 percent (2/340).For the long-term clinical outcome, at an average follow-up period of 7.6 years, the postoperative mAS for spasticity was 2.0 ± 0.756, which was significantly better than the preoperative mAS at 3.75 ± 0.462 (P = 0.001).

CONCLUSION

Long-term aftercare with baclofen pump refill was safe, with an infection rate of 0.6 per cent per puncture for each refill. Long-term intrathecal baclofen pump was effective in the treatment of spasticity with persistent significant improvement in the spasticity scale.

Dorsal Longitudinal T-Myelotomy (Bischof II Technique): A Useful, Antiquated Procedure for the Treatment of Intractable Spastic Paraplegia

OBJECTIVE

Dorsal longitudinal T-myelotomy is a long-established operation to treat severe spastic paraplegia. The present study aimed to report this surgical technique and investigate the efficacy of T-myelotomy for spasticity relief.

METHODS

All cases undergoing T-myelotomy for treatment of intractable spastic paraplegia during 2009-2017 were included. The severity of spasticity was evaluated with the Modified Ashworth Scale, Penn Spasm Frequency Scale, Adductor Tone Rating Scale, degree of passive range of motion, and occurrence of abdominal muscle spasms. Other clinical assessments included deep tendon reflex assessed by the National Institute of Neurological Disorders and Stroke scale, Babinski sign, healing of decubitus ulcers, and ambulatory status.

RESULTS

Fourteen patients with a mean age of 39.3 ± 13.4 years were included. The 7 patients with abdominal muscle spasms before surgery had no spasms after surgery. The Babinski sign was absent in all cases after surgery. Unhealed pressure ulcers in all 9 cases were healed after surgery. All 4 patients with a preoperative bed-bound condition were able to ambulate with a wheelchair. A statistically significant improvement in mean Modified Ashworth Scale score, degree of passive range of motion, and National Institute of Neurological Disorders and Stroke scale score was found in the subgroup and overall analyses. There was also a statistically significant improvement in the Penn Spasm Frequency Scale and Adductor Tone Rating Scale scores.

CONCLUSIONS

Dorsal longitudinal T-myelotomy remains an effective option for the treatment of intractable spastic paraplegia. It is suitable for, and may be an alternative to, intrathecal baclofen therapy for patients with complete spinal cord lesion or patients without hope of regaining motor function.

Comparison of efficacy between dorsal root entry zone lesioning and selective dorsal rhizotomy for spasticity of cerebral origin

BACKGROUND

Severe spasticity adversely affects patient functional status and caregiving. No previous study has compared efficacy between dorsal root entry zone lesioning (DREZL) and selective dorsal rhizotomy (SDR) for reduction of spasticity. This study aimed to investigate the efficacy of DREZL and SDR for attenuating spasticity, and to compare efficacy between these two methods.

METHODS

All patients who underwent DREZL, SDR, or both for treatment of intractable spasticity caused by cerebral pathology at Siriraj Hospital during 2009 to 2016 were recruited. Severity of spasticity was assessed using Modified Ashworth Scale (MAS) and Adductor Tone Rating Scale (ATRS). Ambulatory status was also evaluated.

RESULTS

Fifteen patients (13 males) with a mean age of 30.3 ± 17.5 years were included. Eight, six, and one patient underwent DREZL, SDR, and combined cervical DREZL and lumbosacral SDR, respectively. Eight of ten patients with preoperative bed-bound status had postoperative improvement in ambulatory status. Spasticity was significantly reduced in the DREZL group (p < 0.001), the SDR group (p < 0.001), and in overall analysis (p < 0.001). SDR was effective in both pediatric and adult spasticity patients. A significantly greater reduction in spasticity as assessed by MAS score (p < 0.001) and ATRS score (p = 0.015) was found in the DREZL group. Transient lower limb weakness was found in a patient who underwent SDR.

CONCLUSIONS

DREZL is more effective for reducing spasticity, but is more destructive than SDR. DREZL should be preferred for bed-ridden patients, and SDR for ambulatory patients. Both operations are helpful for improving ambulatory status. Gait improvement was observed only in patients who underwent SDR. Adult patients with spasticity of cerebral origin benefit from SDR.