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Niedzwecki C, Barbuto A, Mitchell K, Wirt S, Seymour M, Thomas S, Schwabe A. Comparison of outcomes following surgical intervention and inpatient rehabilitation stays in children with cerebral palsy. PM R 2024; 16:449-461. [PMID: 37801614 DOI: 10.1002/pmrj.13075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/28/2023] [Accepted: 09/01/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION Literature is limited on functional outcomes in children with cerebral palsy (CP) following surgical procedures and a subsequent inpatient rehabilitation unit (IRU) stay. OBJECTIVE To compare functional outcomes and length of stay (LOS) in children with CP following a surgical procedure and IRU stay based on the surgical procedure performed, pattern of involvement, etiology, and Gross Motor Function Classification System (GMFCS) level. DESIGN Retrospective cohort study. SETTING Tertiary care pediatrics. PARTICIPANTS Pediatric patients with CP who underwent one of three surgical procedures followed by an IRU stay. INTERVENTIONS Selective dorsal rhizotomy (SDR), single-event multilevel orthopedic surgery (SEMLS), or intrathecal baclofen (ITB) pump implantation and subsequent IRU stay. MAIN OUTCOME MEASURES IRU LOS, Functional Independence Measure for Children (WeeFIM) total score, sub-scores, and efficiency. RESULTS Children undergoing SDR had a longer LOS (p ≤ .015). Children with spastic diplegia, GMFCS level II, and prematurity-based CP had higher WeeFIM efficiency scores (p ≤ .046, ≤.021, and .034 respectively). Greater changes in WeeFIM™ scores were associated with spastic diplegia, SDR, GMFCS level II, longer LOS, and higher admission scores (p ≤ .045). CONCLUSIONS Although statistically and functionally significant improvements in children with CP following surgical interventions and an IRU stay were seen, those with higher WeeFIM change scores tended to have spastic diplegia, to have undergone SDR, GMFCS level II, longer LOS, and higher admission scores.
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Affiliation(s)
- Christian Niedzwecki
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Amy Barbuto
- Department of Physical and Occupational Therapy, Texas Children's Hospital-The Woodlands, The Woodlands, Texas, USA
| | - Katy Mitchell
- Department of Physical Therapy, Texas Woman's University-Houston, Houston, Texas, USA
| | - Steven Wirt
- Department of Physical and Occupational Therapy, Texas Children's Hospital-Main Campus, Houston, Texas, USA
| | - Michelle Seymour
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Sruthi Thomas
- Departments of Physical Medicine & Rehabilitation and Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Aloysia Schwabe
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
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Forst H, Sylvanus T. Impact of Occupational Therapy on Self-Care After Selective Dorsal Rhizotomy Among Children With Cerebral Palsy. Am J Occup Ther 2022; 76:23958. [PMID: 36255304 DOI: 10.5014/ajot.2022.049267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Selective dorsal rhizotomy (SDR) is an established treatment for spastic cerebral palsy (CP). The effects and predictors of occupational therapy's benefit for self-care after SDR in children with CP have not been thoroughly investigated. OBJECTIVE To identify changes in self-care after occupational therapy post-SDR and determine whether changes were affected by age, Gross Motor Function Classification System (GMFCS) level, and number of occupational therapy dressing sessions. DESIGN In this retrospective cohort study, we collected outcomes pre-SDR, at discharge, and at 1-yr follow-up. Paired t tests and regression analysis were performed. SETTING Commission on Accreditation of Rehabilitation Facilities-accredited pediatric inpatient rehabilitation facility. PARTICIPANTS Seventy-three children (GMFCS Levels I-III, ages 4-17 yr) diagnosed with spastic CP who underwent SDR from 2014 to 2018. INTERVENTION After having SDR, each child received an average of twice daily occupational therapy for an average of 37.3 days. OUTCOMES AND MEASURES The Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) and Functional Independence Measure for Children® (WeeFIM) were used to assess self-care performance. RESULTS The mean WeeFIM dressing (upper and lower body) and mean PEDI-CAT daily activities scores from baseline to discharge and mean WeeFIM lower body dressing at 1-yr follow-up improved significantly. The improvement in lower body dressing correlated with GMFCS level and the number of occupational therapy dressing sessions. CONCLUSIONS AND RELEVANCE The improvement in upper and lower extremity dressing and PEDI-CAT daily activities scores suggests that inpatient occupational therapy post-SDR may provide benefits. What This Article Adds: Children diagnosed with CP may undergo surgical interventions to improve their ability to walk. This article demonstrates the benefit of occupational therapy services after SDR to improve upper and lower body dressing skills.
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Affiliation(s)
- Heather Forst
- Heather Forst, MA, OTR/L, BCP, is Occupational Therapist, Rehabilitation Therapies Department, Gillette Children's Specialty Healthcare, Saint Paul, MN;
| | - Tonye Sylvanus
- Tonye Sylvanus, MD, MPH, is Clinical Research Specialist, Neurosciences and Rehabilitation Research Program, Gillette Children's Specialty Healthcare, Saint Paul, MN
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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.
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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
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Mortenson P, Sadashiva N, Tamber MS, Steinbok P. Long-term upper extremity performance in children with cerebral palsy following selective dorsal rhizotomy. Childs Nerv Syst 2021; 37:1983-1989. [PMID: 33386960 DOI: 10.1007/s00381-020-05018-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE In children with spastic cerebral palsy, selective dorsal rhizotomy (SDR) is conducted to improve lower limb spasticity. Improvements in upper extremity function have also been noted in early follow-up. The purpose of this study was to determine if upper extremity improvements are sustained in the long term. METHODS A retrospective review of prospectively collected data on children who underwent SDR was conducted. Quality of Upper Extremities Skill Test (QUEST) scores for dissociated movement, grasp and total scores were compared using repeated measures ANOVA for individual patients at three time points: preoperatively, early post-operatively (≤ 2 years) and late post-operatively (9+ years). RESULTS Out of 200+ patients having SDR, 32 had QUEST assessment at all three time points. Significant improvements in QUEST dissociated movement (F = 3.665, p = 0.045), grasp (F = 7.995, p = 0.001) and total scores (F = 9.471, p = 0.001) were found. Pairwise comparisons were significant from pre-operative to early post-operative times for all QUEST scores (p = 0.001, 0.003, 0.001), and this was maintained at late post-operative assessment for grasp and total scores (p = 0.02, p = 0.02). There was no significant change in scores between early and late post-operative assessment time points. CONCLUSION Early improvements in upper extremity QUEST total scores are sustained in the long term following SDR.
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Affiliation(s)
- Patricia Mortenson
- Department of Occupational Therapy, British Columbia Children's Hospital, 4480 Oak Street, Room K3-130, Vancouver, BC, V6H 3V4, Canada. .,Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada.
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Mandeep S Tamber
- Division of Pediatric Neurosurgery, Department of Surgery, University of British Columbia and British Columbia Children's Hospital, Vancouver, Canada
| | - Paul Steinbok
- Division of Pediatric Neurosurgery, Department of Surgery, University of British Columbia and British Columbia Children's Hospital, Vancouver, Canada
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Tacchino CM, Calevo MG, Pavanello M, Lanteri P, Bertamino M. Improved trunk and neck control after selective dorsal rhizotomy in children with spastic cerebral palsy. Childs Nerv Syst 2021; 37:351-352. [PMID: 33236182 DOI: 10.1007/s00381-020-04979-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Chiara Maria Tacchino
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Grazia Calevo
- Epidemiology, Biostatistics and Committees Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marco Pavanello
- Neurosurgery Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Paola Lanteri
- Neurophysiopathology Centre, Fondazione IRCCS, Istituto Neurologico "C. Besta", Milan, Italy
| | - Marta Bertamino
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
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Abbott R. The selective dorsal rhizotomy technique for spasticity in 2020: a review. Childs Nerv Syst 2020; 36:1895-1905. [PMID: 32642977 DOI: 10.1007/s00381-020-04765-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 12/23/2022]
Abstract
This review looks at the advances in the surgical technique, selective dorsal rhizotomy, used for the management of spasticity in children.
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Affiliation(s)
- Rick Abbott
- Albert Einstein College of Medicine, Montefiore Health System, 110 E. 210th St, Bronx, NY, 10467, USA.
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7
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Tu A, Steinbok P. Long term outcome of Selective Dorsal Rhizotomy for the management of childhood spasticity-functional improvement and complications. Childs Nerv Syst 2020; 36:1985-1994. [PMID: 32577879 DOI: 10.1007/s00381-020-04747-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) for the management of lower extremity spasticity is a surgical technique that has existed since the 1900s. While much evidence supports its efficaciousness in reducing tone in the short term, limited information exists detailing the long-term outcome and evolution over time of patients undergoing SDR. METHODS All publications with 10 years or more of outcome data on patients undergoing SDR were identified from Medline and Embase databases using the search term "Rhizotmy." Only publications that were in English included patients with cerebral palsy under the age of 21 and discussed SDR for lower extremity spasticity were included. Case reports, reviews without primary data, or publications not accessible online were excluded from the review. RESULTS A total of 2128 publications were initially identified, of which 19 papers describing 1054 patients fit inclusion and exclusion criteria. GMFCS in most patients improved or remained stable over time after surgery, although durability of improvement and final outcome was dependent on initial functional status. Tone was noted to also substantially improve although a small proportion required additional oral or injectable pharmacologic agents and an even smaller proportion required baclofen pumps. Upper extremity function was also noted to improve substantially after SDR. A significant number of patients were independent for activities of daily living and were engaged in secondary education or gainful employment. A significant proportion of patients still required orthopedic surgery to the lower extremities after SDR, although the incidence of spinal deformity was not observed to be substantially elevated over that of natural history. CONCLUSION SDR offers substantial improvements to a number of domains beyond pure tone reduction. These changes are durable over time, although patient selection is crucial in identifying those patients that will have the most benefit. Long-term follow-up is in important in this population given the potential need for further interventions that still exist in many patients.
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Affiliation(s)
- Albert Tu
- Division of Pediatric Neurosurgery, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON, K1H 8L, Canada.
| | - Paul Steinbok
- Division of Pediatric Neurosurgery, Children's Hospital of British Columbia, Vancouver, Canada
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8
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Wheelwright M, Selvey PJ, Steinbok P, Singhal A, Ibrahim G, Fallah A, Weil AG, Halvorson K, Tu A. Systematic review of spinal deformities following multi-level selective dorsal rhizotomy. Childs Nerv Syst 2020; 36:1025-1035. [PMID: 31595313 DOI: 10.1007/s00381-019-04375-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 09/05/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE Cerebral palsy is a common neurological disorder that involves spasticity of the extremities and can lead to lifelong disability. Selective dorsal rhizotomy (SDR) can improve spasticity and quality of life in these patients, but it may be associated with the development of spinal deformity. Risk factors for spinal deformity after SDR have not yet been systematically examined. METHODS Medline, Embase, and Web of Science databases were queried for clinical studies reporting incidence of new or worsening spinal deformity, including scoliosis, after SDR. Variables that represent possible risk factors for deformity were correlated with reported incidence of deformity. RESULTS Twenty-two articles for a total of 1485 patients met the inclusion criteria for this study. Deformity occurs among all patients with a weighted mean incidence of 28.0%. Scoliosis appears to be the most common deformity occurring with a weighted mean incidence of 31.6%. There is substantial heterogeneity between studies, limiting our analysis. Significant positive correlation was found between percent of patients that developed any type of deformity and the ratio of female to male patients, p = 0.02. Significant positive correlation was also found between percent of patients that develop scoliosis and the ratio of female to male patients, p < 0.01, and between scoliosis and the number of years to follow-up, p < 0.01. CONCLUSION Spinal deformity is an important potential complication of SDR with scoliosis being the most common type of deformity. The major risk factor for postoperative deformity is female sex. Deformity was also found to significantly increase with extended follow-up, indicating a slow process that should be carefully monitored.
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Affiliation(s)
| | - Paige J Selvey
- University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Paul Steinbok
- Children's Hospital of British Columbia, Vancouver, BC, V6H 3N1, Canada
| | - Ash Singhal
- Children's Hospital of British Columbia, Vancouver, BC, V6H 3N1, Canada
| | - George Ibrahim
- University of Toronto, Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Aria Fallah
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Alexander G Weil
- Pediatric Neurosurgery Service, Department of Surgery, CHU Sainte-Justine, University of Montreal, Montreal, QC, H3T 1J4, Canada
| | - Kyle Halvorson
- Division of Neurosurgery, Children's Minnesota, Garden View Medical Building, Suite 301, 347 North Smith Ave., St. Paul, MN, 55102, USA
| | - Albert Tu
- Division of Neurosurgery, Children's Hospital of Eastern Ontario, Rm 3359 CHEO, 401 Smyth Ave, Ottawa, ON, K1H 8L1, Canada.
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Hua XY, Qiu YQ, Li T, Zheng MX, Shen YD, Jiang S, Xu JG, Gu YD, Xu WD. Contralateral Peripheral Neurotization for Hemiplegic Upper Extremity After Central Neurologic Injury. Neurosurgery 2014; 76:187-95; discussion 195. [DOI: 10.1227/neu.0000000000000590] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
BACKGROUND:
Central neurological injury (CNI) is a major contributor to physical disability that affects both adults and children all over the world. The main sequelae of chronic stage CNI are spasticity, paresis of specific muscles, and poor selective motor control. Here, we apply the concept of contralateral peripheral neurotization in spasticity releasing and motor function restoration of the affected upper extremity.
OBJECTIVE:
A clinical investigation was performed to verify the clinical efficacy of contralateral C7 neurotization for rescuing the affected upper extremity after CNI.
METHODS:
In the present study, 6 adult hemiplegia patients received the nerve transfer surgery of contralateral C7 to C7 of the affected side. Another 6 patients with matched pathological and demographic status were assigned to the control group that received rehabilitation only. During the 2-year follow-up, muscle strength of bilateral upper extremities was assessed. The Modified Ashworth Scale and Fugl-Meyer Assessment Scale were used for evaluating spasticity and functional use of the affected upper extremity, respectively.
RESULTS:
Both flexor spasticity release and motor functional improvements were observed in the affected upper extremity in all 6 patients who had surgery. The muscle strength of the extensor muscles and the motor control of the affected upper extremity improved significantly. There was no permanent loss of sensorimotor function of the unaffected upper extremity.
CONCLUSION:
This contralateral C7 neurotization approach may open a door to promote functional recovery of upper extremity paralysis after CNI.
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Affiliation(s)
- Xu-Yun Hua
- Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yan-Qun Qiu
- Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Tie Li
- Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Mou-Xiong Zheng
- Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yun-Dong Shen
- Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Su Jiang
- Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jian-Guang Xu
- Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yu-Dong Gu
- Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wen-Dong Xu
- Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China
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Gigante P, McDowell MM, Bruce SS, Chirelstein G, Chiriboga CA, Dutkowsky J, Fontana E, Hyman J, Kim H, Morgan D, Pearson TS, Roye BD, Roye DP, Ryan P, Vitale M, Anderson RCE. Reduction in upper-extremity tone after lumbar selective dorsal rhizotomy in children with spastic cerebral palsy. J Neurosurg Pediatr 2013; 12:588-94. [PMID: 24116982 DOI: 10.3171/2013.9.peds12591] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Randomized clinical trials have established that lumbar selective dorsal rhizotomy (SDR) reduces lower-extremity tone and improves functional outcome in children with spastic cerebral palsy. Significant data exist to support a secondary effect on upper-extremity function in patients with upper-extremity spasticity. The effects of SDR on upper-extremity tone, however, are not well characterized. In this report, the authors sought to assess changes in upper-extremity tone in individual muscle groups after SDR and tried to determine if these changes could be predicted preoperatively. METHODS The authors retrospectively reviewed 42 children who underwent SDR at Columbia University Medical Center/Morgan Stanley Children's Hospital of NewYork-Presbyterian between 2005 and 2011. Twenty-five had upper-extremity spasticity. All underwent pre- and postoperative examination for measuring tone (Modified Ashworth Scale) and assessing functional outcome. Follow-up examinations with therapists were performed at least once at a minimum of 2 months postoperatively (mean 15 months). RESULTS In the upper extremities, 23 (92%) of 25 patients had improvements of at least 1 Ashworth point in 2 or more independent motor groups on the Modified Ashworth Scale, and 12 (71%) of 17 families surveyed reported increases in motor control or spontaneous movement. The mean Modified Ashworth Scale scores for all upper-extremity muscle groups demonstrated an improvement from 1.34 to 1.22 (p < 0.001). Patients with a mean preoperative upper-extremity tone of 1.25-1.75 were most likely to benefit from reduction in tone (p = 0.0019). Proximal and pronator muscle groups were most likely to demonstrate reduced tone. CONCLUSIONS In addition to improvements in lower-extremity tone and function, SDR has demonstrable effects on upper extremities. Greater than 90% of our patients with elevated upper-extremity tone demonstrated reduction in tone in at least 2 muscle groups postoperatively. Patients with a mean Modified Ashworth Scale upper-extremity score of 1.25-1.75 may encounter the greatest reduction in upper-extremity tone.
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Affiliation(s)
- Paul Gigante
- Department of Neurological Surgery, Columbia University; and
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Horínek D, Hoza D, Cerný R, Vyhnálek M, Sturm D, Bojar M, Libý P, Oweimrin M, Tichý M. Two cases of improvement of smooth pursuit eye movements after selective posterior rhizotomy. Childs Nerv Syst 2008; 24:1283-8. [PMID: 18688617 DOI: 10.1007/s00381-008-0673-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Selective posterior rhizotomy (SPR) represents a standard neurosurgical approach in the treatment of spasticity in children with cerebral palsy (CP). Beside the reduction of spasticity in lower limbs, SPR may have suprasegmental effects, considerably above the surgery site. In this communication, we report on the improvement of smooth pursuit eye movements (SPEM) in two children after SPR. MATERIAL AND METHODS Four children with CP underwent SPR. Eye movements were registered by infrared video-oculography before and after the surgery. RESULTS The analysis of SPEM showed the improvement of the correlation coefficient of the eye response to the stimulus after SPR in two subjects. Improvement of SPEM performance was largely due to suppression of spontaneous fixation nystagmus. CONCLUSION SPR may lead to the improvement of SPEM in children with CP. The influence of SPEM improvement on quality of life in a group of severely disabled nonambulant children with CP remains to be assessed.
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Affiliation(s)
- D Horínek
- Department of Neurosurgery, Central Military Hospital, First Faculty of Medicine, Charles University, U Vojenské nemocnice 1200, 160 00, Prague 6, Czech Republic.
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Sorsdahl AB, Moe-Nilssen R, Strand LI. Observer reliability of the Gross Motor Performance Measure and the Quality of Upper Extremity Skills Test, based on video recordings. Dev Med Child Neurol 2008; 50:146-51. [PMID: 18201304 DOI: 10.1111/j.1469-8749.2007.02023.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to examine observer reliability of the Gross Motor Performance Measure (GMPM) and the Quality of Upper Extremity Skills Test (QUEST) based on video clips. The tests were administered to 26 children with cerebral palsy (CP; 14 males, 12 females; range 2-13y, mean 7y 6mo), 24 with spastic CP, and two with dyskinesia. Respectively, five, six, five, four, and six children were classified in Gross Motor Function Classification System Levels I to V; and four, nine, five, five, and three children were classified in Manual Ability Classification System levels I to V. The children's performances were recorded and edited. Two experienced paediatric physical therapists assessed the children from watching the video clips. Intraobserver and interobserver reliability values of the total scores were mostly high, intraclass correlation coefficient (ICC)(1,1) varying from 0.69 to 0.97 with only one coefficient below 0.89. The ICCs of subscores varied from 0.36 to 0.95, finding'Alignment'and'Weight shift'in GMPM and'Protective extension'in QUEST highly reliable. The subscores'Dissociated movements'in GMPM and QUEST, and'Grasp'in QUEST were the least reliable, and recommendations are made to increase reliability of these subscores. Video scoring was time consuming, but was found to offer many advantages; the possibility to review performance, to use special trained observers for scoring and less demanding assessment for the children.
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Affiliation(s)
- Anne Brit Sorsdahl
- Department of Public Health and Primary Health Care, Section for Physiotherapy Science, University of Bergen, Bergen, Norway.
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Haga N, van der Heijden-Maessen HC, van Hoorn JF, Boonstra AM, Hadders-Algra M. Test-Retest and Inter- and Intrareliability of the Quality of the Upper-Extremity Skills Test in Preschool-Age Children With Cerebral Palsy. Arch Phys Med Rehabil 2007; 88:1686-9. [DOI: 10.1016/j.apmr.2007.07.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2007] [Revised: 06/19/2007] [Accepted: 07/19/2007] [Indexed: 11/16/2022]
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Farmer JP, Sabbagh AJ. Selective dorsal rhizotomies in the treatment of spasticity related to cerebral palsy. Childs Nerv Syst 2007; 23:991-1002. [PMID: 17643249 DOI: 10.1007/s00381-007-0398-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Indexed: 12/21/2022]
Abstract
RATIONALE Selective dorsal rhizotomy (SDR) is a surgical technique developed over the past decades to manage patients diagnosed with cerebral palsy suffering from spastic diplegia. It involves selectively lesioning sensory rootlets in an effort to maintain a balance between elimination of spasticity and preservation of function. Several recent long-term outcome studies have been published. In addition, shorter follow-up randomized controlled studies have compared the outcome of patients having undergone physiotherapy alone with those that received physiotherapy after selective dorsal rhizotomy. MATERIALS AND METHODS In this account, we will discuss the rationale and outcome after SDR. The outcome is addressed in terms of the gross motor function measurement scale (GMFM), degree of elimination of spasticity, strength enhancement, range of motion, fine motor skills, activity of daily living, spastic hip, necessity for postoperative orthopedic procedures, bladder and sphincteric function, and finally possible early or late complications associated with the procedure. CONCLUSION We conclude that SDR is a safe procedure, which offers durable and significant functional gains to properly selected children with spasticity related to cerebral palsy.
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Affiliation(s)
- Jean-Pierre Farmer
- The Montreal Children's Hospital, McGill University Health Center, Room C-811, 2300 Tupper Street, Montreal, QC, H3H 1P3, Canada.
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16
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Abstract
OBJECTIVE The purpose of this report is to review the historical development, current operative techniques, selection criteria, outcomes, and complications of selective dorsal rhizotomy (SDR) for treatment of spastic cerebral palsy (CP). MATERIALS AND METHODS This review is based on a review of literature and personal observations. RESULTS SDR has evolved from the 1960s onwards into a standard neurosurgical procedure for spastic CP. There is much variation in the operative technique among surgeons with respect to the level of exposure, electrophysiological guidance, and extent of rhizotomies. Appropriate selection of patients for SDR requires determination that spasticity, not dystonia, is the major disabling hypertonia and that the lower limbs are maximally involved. Positive outcomes have been well demonstrated in the impairment, functional limitations, and disability dimensions, as per the National Center for Medical Rehabilitation Research Model of Dimensions of the Disabling Process. Complications have been relatively few. CONCLUSIONS SDR is the procedure of choice for treatment of spasticity in spastic diplegic CP and in selected children with spastic quadriplegic CP. Optimal selection and outcomes are achieved using a multidisciplinary approach.
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Affiliation(s)
- Paul Steinbok
- Division of Pediatric Neurosurgery, Department of Surgery, British Columbia's Children's Hospital, British Columbia, Canada.
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Abstract
The purpose of this report was to outline the various options currently used for treatment of spastic cerebral palsy (CP) and to discuss factors involved in selecting the appropriate treatment modalities for the individual child. In a review of the literature and his personal observations, the author presents an outline of treatment options and the criteria for using each. Therapeutic options include the following: physiotherapy; occupational therapy; oral spasmolytic and antidystonic drugs; botulinum toxin injections; orthopedic procedures; continuous infusion of intrathecal baclofen (ITB); selective dorsal rhizotomy (SDR); and selective peripheral neurotomy. The most commonly used neurosurgical procedures are ITB pump placement and SDR, and these are discussed in the most detail. The author's personal schema for assessment of the child to determine the nature of the hypertonia, the impact of the hypertonia, and the appropriate therapeutic intervention is presented. There are factors that help guide the optimal treatment modalities for the child with spastic CP. The treatment of these children is optimized in the setting of a multidisciplinary team.
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Affiliation(s)
- Paul Steinbok
- Division of Pediatric Neurosurgery, Department of Surgery, British Columbia's Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
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Kim HS, Steinbok P, Wickenheiser D. Predictors of poor outcome after selective dorsal rhizotomy in treatment of spastic cerebral palsy. Childs Nerv Syst 2006; 22:60-6. [PMID: 15906043 DOI: 10.1007/s00381-005-1160-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Revised: 12/20/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of the study was to determine if there are preoperative clinical characteristics that might be predictive of a poor outcome after selective dorsal rhizotomy (SDR) surgery in children with spastic cerebral palsy (CP). METHODS A retrospective analysis was performed on 174 children who had undergone SDR from 1983 to 2001. Patients were divided into two groups according to their outcome at approximately 1 year after surgery: "acceptable" or "poor" outcome. As predictors of outcome, the factors compared were age at operation, types of CP (diplegia, quadriplegia), history of prematurity, prior lower limb orthopedic surgeries, history of seizures, dystonic limbs, opisthotonic posturing, lumbar hyperlordosis, truncal hypotonia, preoperative ambulatory function, preoperative Gross Motor Function Classification System (GMFCS) scores, and presence of intellectual delay and speech delay. RESULTS Eleven children (6.3%) had a "poor" outcome. The type of CP (P<0.001) and intellectual delay (P=0.015) were significant predictors of outcome in the univariate regression analysis, but only the type of CP retained significant predictive power in the multivariate analysis. CONCLUSION These data suggest that preoperative diagnosis is the strongest predictor of outcome after SDR. Intellectual delay demonstrated predictive power only in the univariate model, suggesting that it might have some prognostic value but less than the diagnosis.
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Affiliation(s)
- Hyeon Sook Kim
- Division of Pediatric Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
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19
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Abstract
The management of the upper limb in cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, occupational therapists, physiotherapists, orthotists and upper extremity surgeons. Interventions are generally aimed at improving function and cosmesis by spasticity management, preventing contractures and correcting established deformities. Treatment objectives vary according to each child and range from static correction of deformities to ease nursing care, to improvements in dynamic muscle balance to augment hand function. Botulinum toxin A therapy has been shown to relieve spasticity and improve function in the short term. Surgery is also effective but requires careful patient selection, as many children with cerebral palsy are not candidates for surgery. Occupational therapy and physiotherapy have small treatment effects alone but are essential adjuncts to medical and surgical management.
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Affiliation(s)
- Terence Y P Chin
- Department of Orthopaedics, Royal Children's Hospital, Parkville, Victoria, Australia
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20
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Abstract
Clinical experience thus far has shown BoNT-A to be a safe and efficacious method in the short to medium term management of spasticity of the upper limb in cerebral palsy. The relaxation of hypertonic musculature allows for improvement in function and posture, reduction of pain, and in some patients, improvement in cosmesis. It is also a valuable tool in predicting response to and guiding contemplated muscle-tendon surgery. Careful patient selection, detailed clinical assessment of deformity and disability, and a clear outline of treatment goals are essential to good outcomes. Further work needs to be done to determine optimum doses of BoNT-A for individual muscles and to evaluate the long-term outcome of repeated injections.
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Affiliation(s)
- Terence Y P Chin
- Department of Orthopaedic Surgery, Royal Children's Hospital, Melbourne, Flemington Road, Parkville 3052, Victoria, Australia
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21
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Abstract
For children whose spasticity and movement disorders are inadequately treated by oral medications and botulinum toxins, neurosurgical procedures are now available to effectively treat spasticity, tremor, and many cases of dystonia. Spastic diplegia can be treated with selective lumbar rhizotomies, which significantly decrease spasticity, increase range of motion, and improve Gross Motor Function Measure scores. Children with spastic quadriparesis and those with secondary dystonia can be treated with intrathecal baclofen, which diminishes both spasticity and dystonia and is associated with improved function and quality of life. Children with primary dystonia and those with tremor can be treated with deep brain stimulation of the internal globus pallidus and thalamus, respectively. Some children with chorea respond to deep brain stimulation. There are no effective neurosurgical treatments for athetosis or ataxia. The effectiveness of neurosurgical treatments of pediatric movement disorders has increased significantly in the past 15 years.
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Affiliation(s)
- A Leland Albright
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Mittal S, Farmer JP, Al-Atassi B, Montpetit K, Gervais N, Poulin C, Benaroch TE, Cantin MA. Functional performance following selective posterior rhizotomy: long-term results determined using a validated evaluative measure. J Neurosurg 2002; 97:510-8. [PMID: 12296632 DOI: 10.3171/jns.2002.97.3.0510] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. Selective posterior rhizotomy (SPR) may result in considerable benefit for children with spastic cerebral palsy. To date, however, there have been few studies in which validated functional outcome measures have been used to report surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine long-term functional performance outcomes in patients who underwent lumbosacral dorsal rhizotomy performed using intraoperative electrophysiological monitoring.
Methods. The study population was composed of children with debilitating spasticity who underwent SPR and were evaluated by a multidisciplinary team preoperatively and at 6 months and 1 year postoperatively. Quantitative standardized assessments of activities of daily living (ADL) were obtained using the Pediatric Evaluation of Disability Inventory (PEDI). Of 57 patients who met the entry criteria for the study, 41 completed the 3-year assessments and 30 completed the 5-year assessments.
Statistical analysis demonstrated significant improvement in the mobility and self-care domains of the functional skills dimension at 1 year after SPR. The preoperative and 1-, 3-, and 5-year postoperative scaled scores for the mobility domain were 56, 64, 77.2, and 77.8, respectively. The scaled score for the self-care domain increased from 59 presurgery to 67.9, 81.6, and 82.4 at the 1-, 3-, and 5-year postoperative assessments, respectively.
Conclusions. The results of this study support the presence of significant improvements in functional performance, based on PEDI scores obtained 1 year after SPR. The improvements persisted at the 3- and 5-year follow-up examinations. The authors conclude that SPR performed using intraoperative stimulation is valuable in the augmentation of motor function and self-care skills essential to the performance of ADL.
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Affiliation(s)
- Sandeep Mittal
- Division of Neurosurgery, Montreal Children's Hospital, McGill University Health Centre, Quebec, Canada
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23
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Mittal S, Farmer JP, Al-Atassi B, Gibis J, Kennedy E, Galli C, Courchesnes G, Poulin C, Cantin MA, Benaroch TE. Long-term functional outcome after selective posterior rhizotomy. J Neurosurg 2002; 97:315-25. [PMID: 12186459 DOI: 10.3171/jns.2002.97.2.0315] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Selective posterior rhizotomy (SPR) is a well-recognized treatment for children with spastic cerebral palsy (CP). Few investigators have used quantitative outcome measures to assess the surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine the long-term functional outcome of children who had undergone selective dorsal rhizotomy accompanied by intraoperative electrophysiological monitoring. METHODS The study population was composed of children with spastic CP who underwent SPR and were evaluated by a multidisciplinary team preoperatively, and at 6 months and 1 year postoperatively. Quantitative standardized assessments of lower-limb spasticity, passive range of motion, muscle strength, and ambulatory function were obtained. Of the 93 patients who met the entry criteria for the study, 71 completed the 3-year and 50 completed the 5-year assessments, respectively. Statistical analysis demonstrated significant improvements in spasticity, range of motion, and functional muscle strength at 1 year after SPR. The preoperative, 1-, 3-, and 5-year values for the global score of the Gross Motor Function Measure were 64.6, 70.8, 80, and 85.6, respectively. The greatest improvement occurred in the dimensions reflecting lower-extremity motor function, where the mean change was 10.1% at 1 year, 19.9% at 3 years, and 34.4% at the 5-year follow-up review in comparison with the baseline value. This was associated with a lasting improvement in alignment and postural stability during developmental positions, as well as increased ability to perform difficult transitional movements. CONCLUSIONS The results of this study support the presence of significant improvements in lower-limb functional motor outcome 1 year after SPR, and the improvements persist at 3 and 5 years. The authors conclude that SPR in conjunction with intraoperative stimulation is valuable for permanently alleviating lower-limb spasticity while augmenting motor function.
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Affiliation(s)
- Sandeep Mittal
- Division of Neurosurgery, Montreal Children's Hospital, McGill University Health Centre, Quebec, Canada
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Mittal S, Farmer JP, Al-Atassi B, Montpetit K, Gervais N, Poulin C, Cantin MA, Benaroch TE. Impact of selective posterior rhizotomy on fine motor skills. Long-term results using a validated evaluative measure. Pediatr Neurosurg 2002; 36:133-41. [PMID: 11919447 DOI: 10.1159/000048368] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Suprasegmental effects following selective posterior rhizotomy have been frequently reported. However, few studies have used validated functional outcome measures to report the surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine the long-term impact of lumbosacral dorsal rhizotomy on fine motor skills. The study population comprised children with debilitating spasticity who underwent SPR and were evaluated by a multidisciplinary team preoperatively, at 6 months and 1 year postoperatively. Quantitative standardized assessments of upper extremity function were obtained using the fine motor skills section of the Peabody Developmental Motor Scales (PDMS) test. Of 70 patients who met the entry criteria for the study, 45 and 25 completed the 3- and 5-year assessments, respectively. Statistical analysis demonstrated significant improvements in grasping, hand use, eye-hand coordination, and manual dexterity at 1 year after SPR. More importantly, all improvements were maintained at 3 and 5 years following SPR. This study supports that significant improvements in upper extremity fine motor function using the PDMS evaluative measure are present after SPR and that these suprasegmental benefits are durable.
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Affiliation(s)
- Sandeep Mittal
- Division of Neurosurgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, P.Q., Canada
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Boyd RN, Morris ME, Graham HK. Management of upper limb dysfunction in children with cerebral palsy: a systematic review. Eur J Neurol 2001; 8 Suppl 5:150-66. [PMID: 11851744 DOI: 10.1046/j.1468-1331.2001.00048.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Effective use of the upper limb can impact on educational outcomes, participation in activities of daily living and vocational options for many children with cerebral palsy (CP). This article presents the results of a systematic review of the literature on the management of upper limb dysfunction in children with CP. The range of management options includes therapies such as physiotherapy, occupational therapy, neurodevelopmental therapy and conductive education; peripheral splinting and casting; focal or generalized pharmacotherapy; and surgery to improve upper limb function or correct deformity. A literature search identified 60 papers, of which four were randomized controlled trials and 44 were prospective studies with objective outcome measures. Principal studies undertaken for each type of treatment and the efficacy of the different types of treatment were critically evaluated. In addition, the current level of evidence for each study was evaluated according to Sackett's (1989) model and ICIDH-2 classification. A close examination of two relatively new treatments for upper limb spasticity, constraint induced movement therapy and botulinum toxin type A (BTX-A) was conducted with reference to more extensive data on the efficacy of BTX-A in the lower limb.
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Affiliation(s)
- R N Boyd
- Hugh Williamson Gait Laboratory, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Australia.
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26
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Grabb PA, Doyle JS. The Contemporary Surgical Management of Spasticity in Children. Phys Med Rehabil Clin N Am 2001. [DOI: 10.1016/s1047-9651(18)30038-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rodda J, Graham HK. Classification of gait patterns in spastic hemiplegia and spastic diplegia: a basis for a management algorithm. Eur J Neurol 2001; 8 Suppl 5:98-108. [PMID: 11851738 DOI: 10.1046/j.1468-1331.2001.00042.x] [Citation(s) in RCA: 208] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Classifications of gait and postural patterns in spastic hemiplegia and spastic diplegiía are presented, based on the work of previous authors. The classifications are used as a biomechanical basis, linking spasticity, musculoskeletal pathology in the lower limbs, and the appropriate intervention strategies. The choice of target muscles for spasticity management, the muscle contractures requiring lengthening and the choice of orthotics are then linked to the underlying gait pattern.
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Affiliation(s)
- J Rodda
- Hugh Williamson Gait Laboratory, Royal Children's Hospital, Parkville, Victoria, Australia
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von Koch CS, Park TS, Steinbok P, Smyth M, Peacock WJ. Selective posterior rhizotomy and intrathecal baclofen for the treatment of spasticity. Pediatr Neurosurg 2001; 35:57-65. [PMID: 11549915 DOI: 10.1159/000050392] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Spasticity occurs in children and adults due to a wide range of conditions, including cerebral palsy, head and spinal cord trauma, cerebrovascular accidents and multiple sclerosis. Multiple treatment options have been described, including medical and surgical treatments. Medical treatments include intramuscular botulinum A toxin, oral baclofen and supportive bracing. Surgical approaches include selective posterior rhizotomy, intrathecal baclofen and orthopedic procedures to address deformities. Many reports have been published on these different treatment options, but rarely has a comparison been made between them. Therefore, this review is aimed at comparing selective posterior rhizotomy and intrathecal baclofen injection for spasticity due to cerebral palsy, especially in children.
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Affiliation(s)
- C S von Koch
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0112, USA.
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Mittal S, Farmer JP, Poulin C, Silver K. Reliability of intraoperative electrophysiological monitoring in selective posterior rhizotomy. J Neurosurg 2001; 95:67-75. [PMID: 11453400 DOI: 10.3171/jns.2001.95.1.0067] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Selective posterior rhizotomy is a well-established treatment for spasticity associated with cerebral palsy. At most medical centers, responses of dorsal rootlets to electrical stimulation are used to determine ablation sites; however, there has been some controversy regarding the reliability of intraoperative stimulation. The authors analyzed data obtained from the McGill Rhizotomy Database to determine whether motor responses to dorsal root stimulation were reproducible. METHODS A series of 77 patients underwent selective dorsal rhizotomy at a single medical center. The dorsal roots from L-2 to S-2 were stimulated to determine the threshold amplitude. The roots were then stimulated at 2 to 4 times the highest threshold with a 1-second 50-Hz train. A second stimulation run of the entire dorsal root was performed before it was divided into rootlets. Rootlets were individually stimulated and sectioned according to the extent of abnormal electrophysiological propagation. Motor responses were recorded by electromyography and were also assessed by a physiotherapist, and grades of 0 to 4+ were assigned. The difference in grades between the first and second stimulation trains was determined for 752 roots. Statistical analysis demonstrated a clear consistency in motor responses between the two stimulation runs, both in the electromyographic readings and the physiotherapist's assessment. More than 93% of dorsal roots had either no change or a difference of only one grade between the two trials. Furthermore, the vast majority of dorsal roots assigned a grade of 4+ at the first trial maintained the same maximally abnormal electrophysiological response during the second stimulation run. CONCLUSIONS This study indicates that currently used techniques are reproducible and reliable for selection of abnormal rootlets. Intraoperative electrophysiological stimulation can be valuable in achieving a balance between elimination of spasticity and preservation of underlying strength.
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Affiliation(s)
- S Mittal
- Division of Neurosurgery, Montreal Children's Hospital, McGill University Health Center, Quebec, Canada
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Petersen MC, Palmer FB. Advances in prevention and treatment of cerebral palsy. MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES RESEARCH REVIEWS 2001; 7:30-7. [PMID: 11241880 DOI: 10.1002/1098-2779(200102)7:1<30::aid-mrdd1005>3.0.co;2-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In recent years there have been a number of advances in understanding of predisposing and protective factors in the development of cerebral palsy in infants. Multiple gestation births, maternal infection, and maternal and fetal thrombophilic conditions all predispose to the development of CP in the infant. Opportunities for prevention of CP may develop from an improved understanding of these factors and their mechanisms of operation. Similar progress has been made in the evaluation of treatments for CP and the effects of these treatments on the individual's impairment, function, and disability. Selective posterior rhizotomy and Botulinum toxin A are now widely used in the treatment of spasticity. The challenge remains to determine how effectively these promising interventions can alter long-term function and quality of life outcomes in children and adults with CP.
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Affiliation(s)
- M C Petersen
- University of Tennessee, The Health Science Center, College of Medicine, Memphis, Tennessee, USA
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