Functional outcomes after selective dorsal rhizotomy followed by minimally invasive tendon lengthening procedures in children with spastic cerebral palsy

Parent-Reported Outcomes of Early Childhood Selective Dorsal Rhizotomy for the Treatment of Spastic Diplegia

Background A selective dorsal rhizotomy (SDR) is employed to treat spastic cerebral palsy. The surgical techniques and patient care protocols vary among hospitals. One of the variations is the age cut-off for SDR. We have been advocating SDR to be performed early - especially at ages 2 and 3. With this study, we are reporting the feasibility and parent-reported surgical outcomes of receiving SDR at an early age for the treatment of spastic diplegia. Objectives Our aim is to examine the safety and benefits of receiving SDR at the ages of 2 and 3 for the treatment of spastic diplegia. Methods The Institutional Review Board (IRB) of Washington University School of Medicine approved this retrospective quality of life survey and chart review (approval #202009056). The subjects of this study were children and teens (ages: 3.9-18.1) with spastic diplegic cerebral palsy who underwent SDR at ages 2 or 3 between years 2005 and 2019 at St. Louis Children's Hospital. Only domestic patients that were minors at the time of the study were selected to be participants in compliance with IRB regulations to protect patient health information that could potentially be breached by sending information to an incorrect or dated email. Thus, all contact was made through postal mail. The study included 141 patients from a total of 362 eligible patients. Parents of eligible patients were sent the research survey via postal mail. Only patients who responded to the survey were included in this study. The survey included questions on demographic information, quality of life, health perception, motor and ambulatory functions, braces and orthotics, pain issues, side effects of SDR, and post-SDR treatment. Results The study included 141 diplegic patients. Of all patients at the time of the study, 91% reported an improvement in walking, 92% in standing, and 89% in sitting. In daily life activities, 87% of patients became more independent after SDR. 65% of patients were able to walk without a walking aid and about 4% were not able to walk. 11% of all patients relied mostly on a wheelchair. Moreover, 43% of patients were able to run independently. Regarding post-SDR orthopedic surgery, 48% of patients received at least one type of orthopedic surgery, with Achilles tendon lengthening, hamstring lengthening, and calf muscle release being the most common types.  Conclusions SDR performed at an early age through a single-level laminectomy was proved feasible and safe. A follow-up until the adult age (18 years) showed improvements in walking and other motor functions. The results support the implementation of early-age SDR for the treatment of spastic diplegia.

Research progress on limb spasmolysis, orthopedics and functional reconstruction of brain-derived paralysis

Brain-derived paralysis is a disease dominated by limb paralysis caused by various brain diseases. The damage of upper motor neurons can lead to spastic paralysis of the limbs in different parts. If it cannot be treated in time and effectively, it will severely affect the motor function and ability of daily living. Treating limb spastic dysfunction in patients with brain-derived paralysis is a global problem. Presently, there are many alternative surgical methods. This article mainly reviews the treatment of limb spastic dysfunction with brain-derived paralysis, focusing on three aspects: limb spasmolysis, orthopedics, and functional reconstruction. Among them, the transposition of the peripheral nerve helps limb function with spastic paralysis and can effectively alleviate limb spasticity.

Intraoperative neurophysiological monitoring in selective dorsal rhizotomy (SDR)

For decades, intraoperative neurophysiological monitoring (IONM) has been used to guide selective dorsal rhizotomy (SDR) for the treatment of spastic cerebral palsy (CP). Electromyography (EMG) interpretation methods, which are the core of IONM, have never been fully discussed and addressed, and their importance and necessity in SDR have been questioned for years. However, outcomes of CP patients who have undergone IONM-guided SDR have been favorable, and surgery-related complications are extremely minimal. In this paper, we review the history of evolving EMG interpretation methods as well as their neuroelectrophysiological basis.

Selective Dorsal Rhizotomy for the Treatment of Spastic Triplegic Cerebral Palsy

Background

Spastic triplegia is a recognized subtype of cerebral palsy (CP). In the course of treating spastic triplegic children with selective dorsal rhizotomy (SDR), we found that some children who had “minimal or mild involvement” in the stronger arm improved strikingly after undergoing SDR. Some of them became independent ambulators, which was an outcome that is not usually achieved in spastic quadriplegic children. However, the literature currently contains no data on the natural clinical course and the effects of CP interventions on spastic triplegia.

Objectives

Our aim was to elucidate the clinical characteristics of spastic triplegia and the effects of SDR on functional outcomes and the quality of life after childhood SDR.

Methods

The Institutional Review Board of the Washington University School of Medicine approved this quality of life survey (number: 201908177). The subjects of this study were children and adults (ages: 3.9-23.8 years at the time of the survey completion; mean: 12.1 ± 5.1 years) with spastic triplegic CP who had undergone SDR (ages: 2.2-15.9 years; mean: 6.1 ± 3.2 years) between 2003 and 2018 at the St. Louis Children’s Hospital. The follow-up period ranged from 1-16 years (mean: 6.0 ± 4.3 years). The study included a 76-patient cohort selected from a total of 253 spastic triplegic CP patients who had undergone SDR. All 253 patients were contacted via email or postal mail soliciting their participation in the study including the survey. The cohort included all patients who responded. The survey included questions on demographic information, quality of life, perceptions of health and the SDR procedure, motor and ambulatory functions, braces and orthotics, pain issues, side effects of SDR, and post-SDR treatment.

Results

Thirteen patients had presented with scissored gait, and these patients had undergone partial ventral rhizotomy (PVR) of L1-3 ventral roots immediately after the completion of SDR. Of note, 91% of 76 patients reported that SDR improved their quality of life, and 93% would recommend the procedure to other patients. After SDR, 21 more patients were able to run, 14 more played recreational sports, and 18 more could walk without using walking aids. Sixteen fewer patients used a wheelchair for long-distance walking and in crowds; 37 and 32 patients reported an improvement in the more affected arm and hand, respectively. Sixty-eight patients were able to regularly strengthened their muscles at least once a week, and 60 patients regularly stretched their legs. However, 53 patients required assistance with bathing or showering, 50 with getting dressed, and 56 with grooming or hygiene. Forty-eight patients had orthopedic surgery after SDR. Percutaneous hamstring-lengthening was the most common type of orthopedic surgery performed. Three of 13 patients who received PVR and SDR required adductor release. Six patients used medications for spasticity or dystonia. No late side effects of SDR were observed.

Conclusions

Our report elucidates the clinical features of spastic triplegia before and after SDR. A distinct clinical feature was the wide variation in ambulatory functions, ranging from total independent walking to wheelchair mobility. The vast majority of patients felt that SDR improved their motor functions and quality of life. PVR also resulted in favorable outcomes, with only three of 13 patients requiring additional adductor release surgery. There were no late complications related to SDR surgery.