Functional performance following selective posterior rhizotomy: long-term results determined using a validated evaluative measure

Enhancing Post-Operative Recovery in Spastic Diplegia through Physical Therapy Rehabilitation following Selective Dorsal Rhizotomy: A Case Report and Thorough Literature Analysis

Spasticity is a common issue among children, especially those with bilateral spastic cerebral palsy (CP). Selective dorsal rhizotomy (SDR) is a surgical procedure that is often used to decrease lower limb rigidity, alongside other treatment options such as intrathecal medication, peripheral nerve surgery, and deep brain stimulation (DBS). The objective of these therapies is to improve the standard of living for young individuals. This article intends to explain the motor deficits observed in spastic diplegia and a rehabilitation program using physical therapy after SDR. The information can help with counseling parents about the prognosis and developing a clinical treatment plan. The article presents a case study of a 12-year-old girl who recently underwent L3, L4, and L5 nerve root rhizotomy in the physical therapy department. It highlights the importance of long-term physical therapy follow-up and orthotic usage in the management of spastic diplegia.

A systematic review of complications following selective dorsal rhizotomy in cerebral palsy

PURPOSE

The literature lacks a concise overview of complications secondary to selective dorsal rhizotomy (SDR). The aim of this study was to systematically review the literature regarding post-SDR complications, and to present them concisely.

METHODS

The protocol of the review was registered on Open Science Framework. Studies on SDR in cerebral palsy were included. The studies to be included used SDR for management of spasticity in patients with cerebral palsy. The long-term complications of SDR mentioned in the articles were inventoried.

RESULTS

Thirty studies were included for qualitative review. Twenty-one types of complication were identified. Structural complications were the commonest: scoliosis (214/1,043, 20.5%), hyperlordosis (101/552, 18.2%), spondylolysis (55/574, 9.5%) and kyphosis (67/797, 8.4%). Neurological complications comprised constipation (70/485, 14.4%), hip subluxation (3/29, 10.3%), spastic syndrome (4/47, 8.5%), sensory changes (106/1290, 8.2%) and urinary incontinence (61/1013, 6%).

CONCLUSION

This review should help surgeons and parents alike to know about the potential complications of SDR. Complications may affect quality of life and should be weighed. Although the majority of these complications were managed conservatively, there would still be a physical, psychological and financial burden which should be taken into account. Screening should be continued vigorously throughout skeletal growth and at reduced frequency thereafter, for timely intervention in case of structural complications.

Impact of Occupational Therapy on Self-Care After Selective Dorsal Rhizotomy Among Children With Cerebral Palsy

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.

Systematic review on use and efficacy of selective dorsal rhizotomy (SDR) for the management of spasticity in non-pediatric patients

PURPOSE

Selective dorsal rhizotomy (SDR) has been used to improve mobility and reduce lower extremity spasticity in patients with a various CNS conditions. Incidentally, literature on SDR has been performed in the pediatric population as such there is a paucity of research on the use in adult patients.

METHODS

Studies describing SDR in adults were identified from Medline and Embase databases. Combinations of search terms "Selective Dorsal Rhizotomy," "Selective Posterior Rhizotomy," and "Adult" were used. Only literature in English language on patients over the age of 18 years and that included measures for lower extremity outcome (i.e., spasticity, mobility) were included. Case reports, reviews without primary data, or inaccessible publications were excluded.

RESULTS

One hundred twenty-nine publications between 1970 and 2019 were identified. Twelve of these publications fit the inclusion criteria (n = 141 patients). In series where it was reported, SDR resulted in ambulatory improvement (54%, n = 44 out of 81), reduced spasticity (75.2%, n = 106 out of 141), and minimized muscle and joint pain (74.5%, n = 64 out of 86). SDR also showed improvement in parameters of the activities of daily life. 92.3% (n = 48 out of 52) of patients post-SDR developed new lower limb paresthesia.

CONCLUSION

The success and efficacy appear durable in the short-term, but further follow-up is necessary to validate these findings. The goal of the intervention dictates the ideal adult patient for SDR. Patients seeking ambulatory improvement, any etiology of spasticity besides MS, seem favorable. Positive locomotive predictors include the ability to isolate lower extremity function, lack of contractures, lower limb strength, and post-SDR physiotherapy.

The selective dorsal rhizotomy technique for spasticity in 2020: a review

This review looks at the advances in the surgical technique, selective dorsal rhizotomy, used for the management of spasticity in children.

The progress in the treatment of spastic cerebral palsy with selective dorsal rhizotomy (SDR)

Spasticity is the main disabling clinical manifestation of children with cerebral palsy (CP). Selective dorsal rhizotomy (SDR) has been performed for the treatment of spastic CP in Asia for quite some time from 1990. The purpose of this review is to discuss the historical origin and development of SDR. Our goal here is to identify the current patient selection criteria for SDR and to point out indications and contraindications based on the patients with CP, age from 2 to 18 years-old, over 6000 cases, who received SDR surgery with spasticity of muscle tension more than 3 degrees in our center. We also discuss evidence-based approaches on how to evaluate postoperative patient outcomes of SDR and how complications can be avoided. Finally, we mention progress made in terms of SDR technical advances and how improvements can be made in the future. In conclusion, SDR surgery is a reliable way to improve outcomes of patients with spastic CP and can be done carefully in patients as long as stringent selection criteria are used. However, more research and technological advancements are needed to help address associated complications.

Feasibility and effectiveness of a newly modified protocol-guided selective dorsal rhizotomy via single-level approach to treat spastic hemiplegia in pediatric cases with cerebral palsy

PURPOSE

It still remains challenging to treat CP cases with spastic hemiplegia using SDR via a single-level approach when guided by the traditional EMG response grading system. Our aim was to assess the feasibility and effectiveness of a newly modified protocol-guided single-level laminectomy SDR to treat such pediatric patients.

METHODS

A retrospective cohort review was conducted in the CP cases with spastic hemiplegia undergone our newly modified protocol-guided single-level approach SDR since May 2016 to October 2017, and followed by intensive rehabilitation program for at least 12 months in both Shanghai Children's Hospital and Shanghai Rehabilitation and Vocational Training Center for the Disabled. Inclusion and exclusion criteria were set for the selection of patients in the current study. Our study focused on the setup, EMG recording interpretation, and outcome measures for this newly modified rhizotomy scheme.

RESULTS

Eleven cases were included in the current study. Based on our new rhizotomy protocol, a total of 34 rootlets over our 11 cases were cut (2 in 4, 3 in 4, 4 in 1, and 5 rootlets in 2 cases, respectively). After SDR and the following rehabilitation program at a mean duration of 19 months, muscle tone of those "target muscles" in affected lower extremities which identified during pre-op assessment decreased by a mean of 1.4 degrees (Modified Ashworth Scale) in our cases. Strength of those target muscles and ROM of joints involved in their lower limbs were reported to have improved significantly as well. All cases showed major progress with regard to their motor function. A mean of about 10-point increase of GMFM-66 score was reported, and five of six cases who were with GMFCS level II preoperatively improved their GMFCS level at the last assessment. Kinematics of joints of hip, knee, and ankle on the affected side in our cases demonstrated a major correction, along with improvement of their foot pressure patterns to the ground during their gait cycles. Surgery-related complications, such as cerebral-spinal fluid leak/infection, long-term hypoesthesia, or urinary/bowel incontinence were not recorded in the current study.

CONCLUSION

Single-level SDR when guided by our simplified rhizotomy protocol is feasible and effective to treat pediatric CP cases with spastic hemiplegia.

Clinically practical formula for preoperatively estimating the cutting rate of the spinal nerve root in a functional posterior rhizotomy

OBJECTIVE

A functional posterior rhizotomy (FPR) ideally involves minimal cutting of the posterior root while providing maximal reduction of disabling spasticity. However, the ideal cutting rate has yet to be determined. It was hypothesized that the cutting rate of the posterior root would negatively correlate with preoperative motor function in children with spasticity.

METHODS

Children who underwent an FPR between March 1996 and March 2017 and whose pre- and postoperative data were followed more than a year were enrolled. The preoperative Gross Motor Function Measure (GMFM) score and the overall cutting rate of the posterior root were plotted on a scatter plot, and a simple linear regression analysis was performed. The rationale for the cutting rate of the posterior root was tested by postoperative chronological changes in the GMFM score up to 5 years after the FPR. The Gross Motor Function Classification System (GMFCS) was used to group the children. The postoperative and preoperative GMFM were compared at each GMFCS level.

RESULTS

One hundred thirty-seven children (aged 2 to 19 years old, mean 5.9 years old) met the selection criteria. The cutting rate of the posterior root ranged from 17 to 83%, (mean 48.3%). A scatter plot was then made using GMFM scores between 10 and 90. The formula for the simple linear regression analysis was y = - 0.5539x + 73.896 (x, GMFM score; y, overall cutting rate (%)). The formula was further approximated based on the scatter plot findings as y = 100 - x. The postoperative GMFM showed an improved average score for all GMFCS levels although statistically significant improvement at postoperative 5 years was confirmed in only the GMFCS level 1 group.

CONCLUSIONS

The findings of this study supported the hypothesis of the negative correlation of the cutting rate of the posterior root with preoperative motor function in children with spasticity. The amount of posterior nerve root/rootlet cutting during FPR negatively correlated with the preoperative GMFM score. The approximated formula is simple, practical for clinical use, and helpful for preoperatively estimating the required overall cutting rate for the posterior root. The suggested cutting rate induced by the approximated formula should be used as a reference value and be modified according to preoperative motor function, severity and distribution of spasticity, the result of intraoperative neurophysiology, and other factors.

Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children

BACKGROUND

Selective dorsal rhizotomy (SDR) has been established as an effective surgical treatment for spastic diplegia. The applicability of SDR to the full spectrum of spastic cerebral palsy and the durability of its therapeutic effects remain under investigation. There are currently limited data in the literature regarding efficacy and outcomes following SDR in Gross Motor Function Classification System (GMFCS) IV and V patients. Intrathecal baclofen has traditionally been the surgical treatment of choice for these patients. When utilised primarily as a treatment for the relief of spasticity, it is proposed that SDR represents a rational and effective treatment option for this patient group. We report our outcomes of SDR performed on children with severe cerebral palsy (GMFCS grade IV and V). The commensurate improvement in upper as well as lower limb spasticity is highlighted. Apparent benefit to urological function following SDR in this patient group is also discussed.

METHOD

A retrospective review of prospectively collected data for 54 paediatric patients with severe cerebral palsy (GMFCS IV-V) who received SDR plus specialised physiotherapy. Mean age was 10.2 years (range, 3.0-19.5). SDR guided by electrophysiological monitoring was performed by a single experienced neurosurgeon. All subjects received equivalent physiotherapy. The primary outcome measure was change to the degree of spasticity following SDR. Spasticity of upper and lower limb muscle groups were quantified and standardised using the Ashworth score. Measures were collected at baseline and at 2-, 8- and 14-month postoperative intervals. In addition, baseline and 6-month postoperative urological function was also evaluated as a secondary outcome measure.

RESULTS

The mean lower limb Ashworth score at baseline was 3.2 (range, 0-4). Following SDR, significant reduction in lower limb spasticity scores was observed at 2 months and maintained at 8 and 14 months postoperatively (Wilcoxon rank, p < 0.001). The mean reduction at 2, 8 and 14 months was 3.0, 3.2 and 3.2 points respectively (range, 1-4), confirming a sustained improvement of spasticity over a 1-year period of follow-up. Significant reduction in upper limb spasticity scores following SDR was also observed (mean, 2.9; Wilcoxon rank, p < 0.001). Overall, the improvement to upper and lower limb tone following SDR-generally to post-treatment Ashworth scores of 0-was clinically and statistically significant in GMFCS IV and V patients. Urological assessment identified pre-existing bladder dysfunction in 70% and 90% of GMFCS IV and V patients respectively. Following SDR, improvement in urinary continence was observed in 71% of affected GMFCS IV and 42.8% of GMFCS V patients. No serious postoperative complications were identified.

CONCLUSIONS

We conclude that SDR is safe and-in combination with physiotherapy-effectively reduces spasticity in GMFCS grade IV and V patients. Our series suggests that spastic quadriplegia is effectively managed with significant improvements in upper limb spasticity that are commensurate with those observed in lower limb muscle groups. These gains are furthermore sustained more than a year postoperatively. In light of these findings, we propose that SDR constitutes an effective treatment option for GMFCS IV and V patients and a rational alternative to intrathecal baclofen.

Functional Outcomes of Childhood Selective Dorsal Rhizotomy 20 to 28 Years Later

BACKGROUND

Selective dorsal rhizotomy (SDR) is a surgical method used to treat childhood spastic cerebral palsy (CP). However, the effects of early SDR on functional outcomes and quality of life decades later in adulthood remains to be elucidated.

OBJECTIVES

To evaluate the long-term outcomes in terms of satisfaction and mobility of adult patients who received childhood SDR.

METHODS

Adult patients who received SDR in childhood were surveyed. The survey questionnaire asked about demographic information, quality of life, health outcomes, SDR surgical outcomes, ambulation, manual ability, pain, braces/orthotics, post-SDR treatment, living situation, education level, and work status.

RESULTS

Our study included 95 patients. The age that patients received SDR was between two and 18 years. The age at the time of survey was between 23 and 37 years (mean ± S.D., 30.2 ± 3.6 years). Post-SDR follow-up ranged from 20 to 28 years (mean ± S.D., 24.3 ± 2.2 years). Seventy-nine percent of patients had spastic diplegia, 20% had spastic quadriplegia, and one percent had spastic triplegia. Ninety-one percent of patients felt that SDR impacted positively the quality of life and two percent felt that the surgery impacted negatively the quality of life after SDR. Compared to pre-operative ambulatory function, 42% reported higher level of ambulation and 42% ambulated in the same level. Eighty-eight percent of patients would recommend the procedure to others and two percent would not. Thirty-eight percent reported pain, mostly in the back and lower limbs, with mean pain level 4.2 ± 2.3 on the Numeric Pain Rating Scale (NPRS). Decreased sensation in patchy areas of the lower limbs that did not affect daily life was reported by eight percent of patients. Scoliosis was diagnosed in 31%. The severity of scoliosis is unknown. Only three percent of them underwent spinal fusion. Fifty-seven percent of patients required some orthopedic surgery after SDR. The soft-tissue tendon lengthening procedures included lengthening on hamstrings, Achilles tendons or adductors. Out of all bone procedures, 24% of patients had hip surgery, five percent had knee surgery, and 10% had derotational osteotomies. No late side effects of SDR surgery were reported in this survey.

CONCLUSIONS

In our 95 adult patients who received SDR in childhood, the surgery had positive effects on the quality of life and ambulation 20-28 years later. There were no late complications of SDR surgery.

Beneficial Effects of Childhood Selective Dorsal Rhizotomy in Adulthood

Background: Selective dorsal rhizotomy (SDR) has been used to treat children with spastic cerebral palsy (CP) for over three decades. However, little is known about the outcomes of childhood SDR in adults. 

Objectives: 1) To study the effects of childhood SDR on the quality of life and ambulatory function in adult life. 2) To determine late side effects of SDR in adults.  

Methods: Adults (> 17.9 years) who underwent SDR in childhood (2 - 17.9 years) between 1987 and 2013 were surveyed in 2015. Patients completed a survey, including questions on demographic information, quality of life, health, surgical outcomes, motor function, manual ability, pain, braces/orthotics, post-SDR treatment, living situation, education level, work status, and side effects of SDR. 

Results: In our study population of 294 patients (18.0 - 37.4 years), patients received SDR during the ages of 2.0 - 17.9 years and were followed up 2.2 to 28.3 years after surgery. Eighty-four percent had spastic diplegia, 12% had spastic quadriplegia, and 4% had spastic triplegia. The majority (88%) of patients reported improved post-SDR quality of life and 1% considered the surgery detrimental. Most (83%) would recommend the procedure to others and 3% would not. However, patients who would not recommend SDR to others ambulated with a walker or were not ambulatory at all prior to SDR. The majority (83%) of patients improved (30%) or remained stable (53%) in ambulation. Twenty-nine percent of patients reported pain, mostly in the back and lower limbs, with a mean pain level of 4.4 ± 2.4 on the Numeric Pain Rating Scale (NPRS). Decreased sensation in small areas of the lower limbs was reported by 8% of patients, though this did not affect daily life. Scoliosis was diagnosed in 28%, with 40% of these patients pursuing treatment. Whether scoliosis was related to SDR is not clear, though scoliosis is known to occur in patients with CP and also in the general population. Only 4% of patients underwent spinal fusion. 

Orthopedic surgeries were pursued by 59% of patients. The most common orthopedic surgeries were hamstring lengthenings (31%), Achilles tendon lengthenings (18%), adductor lengthenings (16%), and derotational osteotomies (16%). Twenty-four percent of all patients later underwent hip surgery and 8% had surgeries on their knees. 

Conclusion: Results of this study indicate that the beneficial effects of childhood SDR extend to adulthood quality of life and ambulatory function without late side effects of surgery.

Selective dorsal rhizotomy: A multidisciplinary approach to treating spastic diplegia

Background:

Spasticity is a motor disorder that interferes with mobility and affects the quality of life. Different approaches have been utilized to address patients with spastic diplegia, among which is selective dorsal rhizotomy (SDR). Although SDR has been shown to be efficacious in treating spastic patients, many neurologists and neurosurgeons are not well aware of the procedure, its indications, and expected outcomes due to the limited number of centers performing this procedure.

Objectives:

The aim of this study is to describe the collaborative multidisciplinary approach between neurosurgeons, neurophysiologists, and physiotherapists in performing SDR. In addition, we delineate three illustrative cases in which SDR was performed in our patients.

Materials and Methods:

A retrospective review and analysis of the clinical records of our three patients who underwent SDR was conducted and reported. Patients’ outcomes were evaluated and compared to preoperative measurements based on clinical examination of power, tone (Ashworth scale), gait, and range of motion, as well as subjective functional assessment, gross motor function classification system, and gross motor function measure with follow-up at 6, 12, and 24 months postoperatively. A detailed description of our neurosurgical technique in performing SDR in collaboration with neurophysiology and physiotherapy monitoring is provided.

Results:

The three patients who underwent SDR using our multidisciplinary approach improved both functionally and objectively after the procedure. No intraoperative or postoperative complications were encountered. All patients were doing well over a long postoperative follow-up period.

Conclusion:

A multidisciplinary approach to treating spastic diplegia with SDR can provide good short-term and long-term outcomes in select patients suffering from spastic diplegia.

Spasticity secondary to Leigh syndrome managed with selective dorsal rhizotomy: a case report

PURPOSE

Selective dorsal rhizotomy (SDR) is a surgical technique used to treat spasticity in children secondary to cerebral palsy (CP).

METHOD

We report, to the best of our knowledge for the first time, the case of a child who underwent SDR for the management of spasticity secondary to Leigh syndrome.

RESULT

SDR resulted in excellent functional outcome with significant improvement in spasticity. This result contributes to the mounting evidence that SDR could be used to alleviate spasticity secondary not only to CP but also to other pathologies as well.

Neurosurgical Management of Childhood Spasticity: Functional Posterior Rhizotomy and Intrathecal Baclofen Infusion Therapy

A paradigm shift is currently ongoing in the treatment of spasticity in childhood in Japan. Functional posterior rhizotomy (FPR), which was first introduced to Japan in 1996, is best indicated for children with spastic cerebral palsy, regardless of the clinical severity of spasticity. Surgery is generally carried out in the cauda equina, where the posterior root is separated from the anterior one, and neurophysiological procedures are used to judge which nerve root/rootlet should be cut. The outcome of FPR is favorable for reducing spasticity in the long-term follow-up. Intrathecal baclofen (ITB) treatment for childhood spasticity was approved in 2007 in Japan and the number of children undergoing ITB pump implantation has been gradually increasing. ITB treatment is best indicated for children with severe spasticity, especially those with dystonia, regardless of the pathological background. Since it is a surgery performed to implant foreign bodies, special attention should be paid to avoid perioperative complications such as CSF leakage, meningitis, and mechanical failure. Severely disabled children with spasticity would benefit most from ITB treatment. We would especially like to emphasize the importance of a strategic approach to the treatment of childhood spasticity. The first step is to reduce spasticity by FPR, ITB, and botulinum toxin injection. The second step is to aim for functional improvement after controlling spasticity. Traditional orthopedic surgery and neuro-rehabilitation form the second step of treatment. The combination of these treatments that allows them to complement each other is the key to a successful treatment of childhood spasticity.

Long-term outcome after selective dorsal rhizotomy in children with spastic cerebral palsy

PURPOSE

The purpose of this study is to evaluate long-term outcomes after selective dorsal rhizotomy (SDR) for children with spastic cerebral palsy.

METHODS

This is a retrospective review of a prospective database of patients who underwent SDR at British Columbia Children's Hospital. Hip adductor spasticity, hip range of motion (ROM), quadriceps strength, and motor function were assessed pre-operatively, at 6 months to 5 years and more than 10 years postoperatively. Patients were stratified by Gross Motor Function Classification System (GMFCS) level into group 1 (GMFCS II and III) and group 2 (GMFCS IV and V).

RESULTS

Forty-four patients, with mean age at SDR of 4.5 years (range 2.9-7.7), were followed for a mean 14.4 years. Spasticity (Modified Ashworth Scale) decreased 1.5 (p < 0.0001) by early postoperative evaluation with further decrease at late evaluation of 0.8 (p < 0.0001). Early improvement in hip ROM of 13.7 degrees (p < 0.0001) was not sustained at late assessment. Motor function improved in both groups at early assessment but was only sustained in group 1. Group 1 increased 10.0 points (p < 0.0001) at early evaluation with subsequent decrease of 3.5, resulting in an overall increase of 6.6 (p = 0.04) from baseline. Group 2 patients had an initial increase of 8.3 [2.0, 14.6] (p = 0.01) but then declined to 4.9 below baseline (p = 0.3).

CONCLUSIONS

SDR yields durable reduction in spasticity after 10 years. Early improvements in motor function are present, but at long-term follow-up, these improvements were attenuated in GMFCS II and III and were not sustained in GMFCS IV and V.

[Long-term outcomes of SDR in various groups of cerebral palsy (CP) patients]

AIM

Long-term outcomes of selective dorsal rhizotomy (SDR) are not sufficiently summarized in the literature. The aim of this study was to systematize and evaluate long-term outcomes of SDR in various groups of cerebral palsy (CP) patients.

MATERIAL AND METHODS

47 patients with spastic CP were operated. In all cases, SDR of the L1-S1 roots was performed under EMG control. In all cases, laminoplasty was used as an approach. Outcomes of surgical treatment were estimated by the Ashworth scale and the GMFM 88 scale. The data were subjected to statistical analysis. The follow-up duration ranged from 12 months to 7 years.

RESULTS

A significant reduction in spasticity from 4.34±0.53 points before surgery to 1.61±0.45 points after surgery (p<0.001) was observed in most cases. The dynamics of locomotor functions was maximal in the 3rd GMFM class: changing from 48±4% points before operation to 52±6% points 12 months after operation (p<0.042). The dynamics of locomotor functions amounted to 2% in the 4th GMFM class and 1% in the 5th GMFM class. The best functional outcomes were obtained in children under 10 years of age. A positive correlation only between the percentage of cut roots and a decrease in spasticity (r= 0.85) was found. No correlation between the amount of cut roots and the dynamics of locomotor functions was observed. No spinal cord deformities were observed during the follow-up period.

CONCLUSION

A reduction in spasticity due to SDR depends on the amount of cut roots. The functional result of SDR is affected not only by a decrease in spasticity but also by the functional status and age of the patient at the time of surgery. In all cases, laminoplasty should be performed to prevent spinal cord deformities.

Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature

AIM

Information regarding the selection procedure for selective dorsal rhizotomy (SDR) in children with spastic cerebral palsy (CP) is scarce. Therefore, the aim of this study was to summarize the selection criteria for SDR in children with spastic CP.

METHOD

A systematic review was carried out using the following databases: MEDLINE, CINAHL, EMBASE, PEDro, and the Cochrane Library. Additional studies were identified in the reference lists. Search terms included 'selective dorsal rhizotomy', 'functional posterior rhizotomy', 'selective posterior rhizotomy', and 'cerebral palsy'. Studies were selected if they studied mainly children (<18y of age) with spastic CP, if they had an intervention of SDR, if they had a detailed description of the selection criteria, and if they were in English. The levels of evidence, conduct of studies, and selection criteria for SDR were scored.

RESULTS

Fifty-two studies were included. Selection criteria were reported in 16 International Classification of Functioning, Disability and Health model domains including 'body structure and function' (details concerning spasticity [94%], other movement abnormalities [62%], and strength [54%]), 'activity' (gross motor function [27%]), and 'personal and environmental factors' (age [44%], diagnosis [50%], motivation [31%], previous surgery [21%], and follow-up therapy [31%]). Most selection criteria were not based on standardized measurements.

INTERPRETATION

Selection criteria for SDR vary considerably. Future studies should describe clearly the selection procedure. International meetings of experts should develop more uniform consensus guidelines, which could form the basis for selecting candidates for SDR.

Does loss of spasticity matter? A 10-year follow-up after selective dorsal rhizotomy in cerebral palsy

AIM

The aim of this study was to evaluate the long-term effects of selective dorsal rhizotomy (SDR) in children with cerebral palsy (CP).

METHOD

Nineteen children (four females, 15 males; mean age 4y 7mo, SD 1y 7mo) with bilateral spastic CP, were prospectively assessed at baseline and 18 months, 3 years, and 10 years after SDR. Assessments included the Modified Ashworth Scale for spasticity, the Gross Motor Function Measure 88 (GMFM-88) and the Wilson gait scale for ambulation, neurological investigations, and passive joint range of motion assessment. A 10-year retrospective chart review was added for orthopaedic surgery after SDR.

RESULTS

Baseline muscle tone at the hip, knee, and ankle level displayed a high degree of spasticity that normalized after SDR. After 10 years there was a slight recurrence of spasticity at the knee and ankle. Joint range of motion declined from a maximum at 3 years after SDR to the 10-year follow-up. Median ambulatory status was best 3 years after SDR and then declined. The GMFM-88 score increased from the median baseline value of 51 to 66 (p=0.002) and 76 (p<0.001) at the initial follow-ups. After 10 years there was a decline in gross motor function with a reduction in the GMFM-88 score to 62 (p=0.022). Within 10 years, 16 out of 19 patients had a mean of three orthopaedic surgeries (SD 2.8), soft tissue surgery being the most common.

INTERPRETATION

The spasticity-reducing effect of SDR, although pronounced, did not seem to improve long-term functioning or prevent contractures. This suggests that contracture development in CP is not mediated by spasticity alone.

Long-term outcome and adverse effects of selective dorsal rhizotomy in children with cerebral palsy: a systematic review

AIM

To assess the long-term outcome and adverse events of selective dorsal rhizotomy (SDR) in children with spastic cerebral palsy (CP).

METHOD

Studies were selected based on the following inclusion criteria: children with CP that underwent SDR with a follow-up period of at least 5 years. The following databases were searched: MEDLINE, Web of Science, Embase, PEDro, and the Cochrane library. Studies meeting the inclusion criteria were scored by two reviewers, who graded the level of evidence and the quality/conduct of the studies. Outcomes were classified according to the International Classification of Functioning, Disability and Health (ICF).

RESULTS

Only three of the 21 studies who met the inclusion criteria allowed a tentative conclusion on outcome. There is moderate evidence that SDR has a positive long-term influence on the ICF body structure and body function domains but there is no evidence that SDR has an influence on the ICF activity and participation domains. Spinal abnormalities seem to be common, but no conclusion can be drawn about their relation to SDR.

INTERPRETATION

There is lack of evidence concerning the long-term outcomes after SDR. Future studies need to clarify the long-term influence of SDR - especially in the ICF domains of activity and participation.

Short- and long-term effects of selective dorsal rhizotomy on gross motor function in ambulatory children with spastic diplegia

OBJECT

The primary aim of this prospective cohort study was to evaluate the short-term (1 year) and long-term (mean 6 years) effects of selective dorsal rhizotomy (SDR) on gross motor function and spasticity in ambulatory children with spastic diplegia. Secondary aims were to investigate side effects, additional treatment during follow-up (botulinum toxin type A injections or orthopedic surgery), and parental satisfaction.

METHODS

Thirty-three children who had undergone SDR at a mean age of 6 years and 7 months (± 2 years) were included. There were 7 children at Gross Motor Function Classification System (GMFCS) Level I, 7 at Level II, and 19 at Level III. Gross motor function was assessed with the Gross Motor Function Measure-66 (GMFM-66). Spasticity was measured according to a modified Tardieu scale. Side effects, additional treatment, and parental satisfaction were recorded using a parental questionnaire and medical records.

RESULTS

At 1-year follow-up, mean GMFM-66 scores improved significantly by 4.3 ± 4.1 points. Children at GMFCS Levels I and II showed significantly more improvement (7.2 points) on the GMFM-66 compared with children at GMFCS Level III (2.9 points). On long-term follow-up (mean 6 years ± 22 months), mean GMFM-66 scores improved significantly by 6.5 ± 5.9 points, without a difference between children at GMFCS Levels I and II and Level III. No relapse of spasticity was noted. Ten children (30%) needed orthopedic surgery and 13 children (39%) received botulinum toxin type A treatment after SDR. Twenty (91%) of the 22 parents who answered the questionnaire at long-term follow-up believed that their child's functioning had improved after SDR.

CONCLUSIONS

Selective dorsal rhizotomy resulted in short- and long-term improvements in gross motor function, without relapse of spasticity. However, the majority of the children still needed additional surgery or botulinum toxin A treatment.

Surgical management of spasticity in persons with cerebral palsy

Cerebral palsy is a disorder that primarily affects the neurologic system but secondarily affects the musculoskeletal system through the effects of spasticity, dystonia, and other movement disorders. The treatment of cerebral palsy requires a multidisciplinary approach with treatment aimed at modulating the movement disorder through oral medication, injectable drugs (phenol, botulinum toxin), and physical and occupational therapy. Treatment of the neurologic effects of the central movement disorders include selective dorsal rhizotomy, intrathecal baclofen pump placement, and potentially deep brain stimulation. Although any effect on tone is temporary, orthopedic surgery has an important role in the treatment of the musculoskeletal deformities and contractures present in the child with cerebral palsy. Orthopedic surgery improves function by lengthening the musculotendinous structures, transferring tendons, performing osteotomies to reduce dislocated joints, and normalizing rotation and fusion of selected joints to improve stability. Neurosurgical techniques are not as widely used, but may reduce spasticity in select individuals. The combined approach of managing tone and normalizing the biomechanics of the spine and upper and lower extremities through orthopedic surgery and neurosurgery and subsequent rehabilitation is the cornerstone of treatment of the child and adult with cerebral palsy.

An acute pain service improves postoperative pain management for children undergoing selective dorsal rhizotomy

BACKGROUND

A continuous epidural infusion of morphine is the pain treatment modality for children undergoing selective dorsal rhizotomy (SDR) in our institution. The aim of the study was to evaluate the impact of having an organized acute pain service (APS) on postoperative pain management of these children.

METHODS

We conducted a retrospective cohort study using anesthetic records and the APS database to compare the postoperative pain management of children undergoing SDR before and after the introduction of the APS at the Montreal Children's Hospital in April 2001. Ninety-two consecutive children who had their surgery between January 1997 and July 2006 were included. We collected data regarding postoperative pain, opioid-induced side effects, complications (sedation, desaturations < 92%), and hospital length of stay.

RESULTS

Pain scores were documented more frequently after the implementation of the APS (61% vs 48.5%). Sedation scores were documented only after the implementation of the APS. Postoperative desaturation was significantly more frequent in the pre-APS group compared to the APS group (45.5% vs 6.8%, P < 0.001). Despite the fact that the epidural catheter was in place for the same duration for both groups [median of 3 days (3-3 25-75%ile)], the duration of hospitalization was 1 day shorter in the APS group compared to the pre-APS group [median of 5 (5-5 25-75%ile) vs 6 (5-6 25-75%ile) days, P < 0.001].

CONCLUSIONS

Although we recognize that it is possible that there were changes in care not related specifically to the introduction of a dedicated APS that occurred in our institution that resulted in improvements in general postoperative care and in length of stay, our study did show that having an organized APS allowed to significantly decrease the incidence of postoperative oxygen desaturation and to decrease the hospital length of stay by 1 day.

Functional status of patients with cerebral palsy according to the International Classification of Functioning, Disability and Health model: a 20-year follow-up study after selective dorsal rhizotomy

OBJECTIVE

To determine functional status of patients with cerebral palsy 20 years after they received selective dorsal rhizotomy (SDR).

DESIGN

A prospective 20-year follow-up study.

SETTING

Red Cross Children's Hospital (SDR operation and 1-year follow-up assessment) and at institutional or private locations nearby patients' homes (20-year follow-up assessment).

PARTICIPANTS

Referred sample of 14 patients with spastic diplegia (6 women, 8 men; mean age, 27y; range, 22-33y) who were preoperatively ambulant and fulfilled strict selection criteria for SDR operation in 1985.

INTERVENTIONS

Patients were assessed before and 1 and 20 years after SDR.

MAIN OUTCOME MEASURES

Standardized assessments of function according to 2 dimensions of the International Classification of Functioning, Disability and Health (ICF) model: (1) body structure and function (muscle tone, joint stiffness, voluntary movement) and (2) activity (rolling, sitting, kneeling, crawling, standing, walking, transitions) were obtained. In addition, based on assessments and questionnaires, Gross Motor Function Classification System (GMFCS) levels were determined before and at 1 year after SDR retrospectively and currently at 20 years after SDR.

RESULTS

One year after SDR, functional outcomes based on the 2 dimensions of the ICF model improved significantly, and these improvements were maintained at 20 years after surgery. Patients showed a shift in their GMFCS levels 1 and 20 years after SDR.

CONCLUSIONS

In line with our 20-year follow-up study with gait parameters as outcome measures, patients with spastic diplegia still show improvements in their functional status 20 years after SDR. We acknowledge the presence of possible confounding factors and a small sample size, but we argue that the improvements found in this study were caused mainly by SDR. Finally, changes in GMFCS levels suggest a possible role for this tool to detect changes after an intervention.

Long-term outcomes five years after selective dorsal rhizotomy

BACKGROUND

Selective dorsal rhizotomy (SDR) is a well accepted neurosurgical procedure performed for the relief of spasticity interfering with motor function in children with spastic cerebral palsy (CP). The goal is to improve function, but long-term outcome studies are rare. The aims of this study were to evaluate long-term functional outcomes, safety and side effects during five postoperative years in all children with diplegia undergoing SDR combined with physiotherapy.

METHODS

This study group consisted of 35 children, consecutively operated, with spastic diplegia, of which 26 were Gross Motor Function Classification System (GMFCS) levels III-V. Mean age was 4.5 years (range 2.5-6.6). They were all assessed by the same multidisciplinary team at pre- and at 6, 12, 18 months, 3 and 5 years postoperatively. Clinical and demographic data, complications and number of rootlets cut were prospectively registered. Deep tendon reflexes and muscle tone were examined, the latter graded with the modified Ashworth scale. Passive range of motion (PROM) was measured with a goniometer. Motor function was classified according to the GMFCS and measured with the Gross Motor Function Measure (GMFM-88) and derived into GMFM-66. Parent's opinions about the children's performance of skills and activities and the amount of caregiver assistance were measured with Pediatric Evaluation Disability Inventory (PEDI).

RESULTS

The mean proportion of rootlets cut in S2-L2 was 40%. Muscle tone was immediately reduced in adductors, hamstrings and dorsiflexors (p < 0.001) with no recurrence of spasticity over the 5 years. For GMFCS-subgroups I-II, III and IV-V significant improvements during the five years were seen in PROM for hip abduction, popliteal angle and ankle dorsiflexion (p = 0.001), capacity of gross motor function (GMFM) (p = 0.001), performance of functional skills and independence in self-care and mobility (PEDI) (p = 0.001).

CONCLUSION

SDR is a safe and effective method for reducing spasticity permanently without major negative side effects. In combination with physiotherapy, in a group of carefully selected and systematically followed young children with spastic diplegia, it provides lasting functional benefits over a period of at least five years postoperatively.

Does ketamine affect intraoperative electrophysiological monitoring in children undergoing selective posterior rhizotomy?

OBJECTIVE

Direct dorsal rootlet stimulation with intraoperative electrophysiological monitoring is an adjunct to clinical evaluation during selective posterior rhizotomy. The purpose of this study was to evaluate the impact of ketamine on intraoperative electrophysiological monitoring during selective posterior rhizotomy. Specifically, we sought to determine if low dose ketamine given as part of the anesthesia was associated with changes in intraoperative electrophysiological monitoring in patients who underwent selective posterior rhizotomy.

METHODS

A retrospective cohort study was conducted using anesthetic records and electrophysiological records of 32 children who had intraoperative electrophysiological monitoring during selective posterior rhizotomy under general anesthesia. Administration and dosage of ketamine preceding the stimulation of dorsal roots was determined from the anesthetic record. A pediatric neurologist, blinded to patient, and to ketamine exposure, evaluated different electrophysiological criteria.

RESULTS

Eight children received ketamine and 24 did not receive it. The mean average dose of ketamine was 0.18 mg x kg(-1) (sd: 0.04). We did not find any statistically significant difference in intraoperative electrophysiological response between the ketamine and the control groups. However, we noted some trends: Administration of ketamine preceding the stimulation of dorsal roots was associated with a lower maximal threshold (2.7 mA vs 3.5 mA, P = 0.663) and root thresholds compared with children who did not receive ketamine. In addition, the train response following delivery of the suprastimulation tended to last longer with the presence of ketamine.

CONCLUSIONS

Administration of low dose ketamine preceding the stimulation of dorsal roots during selective posterior rhizotomy might be associated with lower maximal thresholds and a more sustained train response following stimulation. Physicians should be aware of this finding in order to avoid misinterpreting intraoperative electrophysiological monitoring.

Effectiveness of selective dorsal rhizotomy in 2 patients with progressive spasticity due to neurodegenerative disease

Selective dorsal rhizotomy at the lumbar level is a neurosurgical procedure, which reduces spasticity in the legs. Its effect has mainly been studied in children with spastic cerebral palsy. Little is known about the outcome of selective dorsal rhizotomy in patients with neurodegenerative disorders. We report the clinical course after selective dorsal rhizotomy in 2 patients with progressive spasticity. Leg spasticity was effectively and persistently reduced in both patients, facilitating care and improving sitting comfort. However, spasticity of the arms and other motor disturbances, such as spontaneous extension spasms and the ataxia, increased gradually in time. Selective dorsal rhizotomy leads to a disappearance of leg spasticity in patients with a neurodegenerative disease. Other motor signs are not influenced and may increase due to the progressive nature of the underlying disease.

Surgical treatment of spasticity in children: comparison of selective dorsal rhizotomy and intrathecal baclofen pump implantation

INTRODUCTION

Neurosurgical treatments for spasticity in children include the traditional selective dorsal rhizotomy (SDR) and intrathecal baclofen pumps (ITBPs), which have been widely used in the past decade as an attractive alternative. The purpose of the study was to examine and compare the outcomes of these two procedures in the treatment of children with severe spasticity.

MATERIALS AND METHODS

A consecutive series of 71 children who underwent SDR for treatment of spasticity was compared with a group of 71 children matched by age and preoperative score on the Gross Motor Function Classification System (GMFCS) who underwent ITBP placement. Change in GMFCS score, lower-extremity tone (based on the Modified Ashworth-Bohannon Scale), and lower-extremity passive range of movement (PROM) at 1 year as well as the need for subsequent orthopedic procedures and parents' satisfaction were selected as outcome measures.

RESULTS

At 1 year, both SDR and ITBP decreased tone, increased PROM, and improved function. Both procedures resulted in a high degree of patient satisfaction. Compared with ITBP, SDR provided a larger magnitude of improvement in tone (-2.52 vs -1.23, p < 0.0001), PROM (-0.77 vs -0.39, p = 0.0138), and gross motor function (-0.66 vs -0.08, p < 0.0001). In addition, fewer patients in the SDR group required subsequent orthopedic procedures (19.1 vs 40.8%, p = 0.0106).

CONCLUSIONS

For children with moderate to severe spasticity, SDR and ITBP are both effective surgical treatments. Our results indicate SDR is more effective in reducing the degree of spasticity and improving function than ITBP is in this group of patients.

Functional posterior rhizotomy: the Tokyo experience

PURPOSE

The author describes the history of functional posterior rhizotomy (FPR), the surgical procedure currently used, and the results together with its future perspective in Japan. The modern form of FPR was introduced to Japan in 1995, and the first surgery was carried out in 1996. Despite initial resistance from orthopedic surgeons, the procedure has eventually gained wide recognition in the country.

MATERIALS AND METHODS

The author has operated on 98 patients (60 boys and 38 girls, aged from 2 to 19 years old) by the end of 2006. Most patients were mild to severely disabled children with spastic hypertonia because of cerebral palsy and other diseases. The surgical procedure used is based on the Peacock's procedure with some modification for the mildly disabled children whose spasticity was predominantly the muscles of the ankle joint. Intraoperative neurophysiology was an indispensable tool for preserving urogenital function and for judging which root/rootlet to be cut.

RESULTS

Seventeen to 83% of the root/rootlets were found to be abnormal and were cut, clearly correlating with the degree of disability. However, there was a wide difference in the cutting rate, even in children with the same degree of disability. The result of surgery in this group of patients was the same as in previously published data. Twenty out of 51 patients (39%) followed for more than a year at the current institute showed improved locomotion after FPR. Thirty patients (59%) demonstrated suprasegmental effects after FPR.

CONCLUSION

The role of FPR will grow in importance as a treatment for spasticity in Japan in the future.

Selective dorsal rhizotomies in the treatment of spasticity related to cerebral palsy

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.

Selective dorsal rhizotomy for spastic cerebral palsy: a review

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.

Spinal deformities following selective dorsal rhizotomy

OBJECT

Selective dorsal rhizotomy (SDR) has been shown to provide considerable benefit to children with spastic cerebral palsy (CP). The authors sought to evaluate the risks of postoperative spinal deformities in patients following SDR.

METHODS

All patients who underwent SDR at McGill University between 1991 and 2001 were identified. Hospital charts and radiographic spinal studies (both preoperative and the latest postoperative) were systematically reviewed. Univariate and multivariate regression analyses were conducted to test all independent variables of potential interest to determine risk factors more likely to be associated with spinal deformity. There were 98 patients whose mean age at surgery was 5.1 years; the mean radiographic follow-up duration was 5.8 years. Thirty-nine (44.8%) of 87 patients in whom postoperative weight-bearing radiographs were obtained had mild scoliosis, and 17 in whom standing radiographs were acquired had hyperlordosis. In all, 18 of 94 patients (19.1%) who had postoperative radiographs on which the lumbosacral junction was visible were found to have spondylolisthesis. Regression analysis identified the severity of preoperative CP as an important predictor, and less ambulatory patients were more likely to have scoliotic curves. Younger age at surgery and male sex were factors associated with a lower rate of hyperlordosis. Spondylolisthesis developed only in ambulatory children. None of the patients experienced clinically significant deficits.

CONCLUSIONS

There was a high rate of radiologically documented deformities in patients with CP who underwent SDR. Ambulatory function, CP severity, age at surgery, and sex may be contributing factors.

Selective dorsal rhizotomy and postoperative pain management. A worldwide survey

BACKGROUND

Selective dorsal rhizotomy (SDR) is an operation method that decreases the degree of spasticity with long-lasting beneficial effects for children with spastic diplegia. Children undergoing SDR are postoperatively in severe pain, a pain related to both the extensive surgical exposure with multilevel laminectomy and the nerve root manipulation. Various pain management strategies for children undergoing SDR have been published. The postoperative pain treatment is a vital part of the management. The aim of this study was to estimate the number of centers performing SDR, the frequency of SDR surgery and to investigate pain management of the different centers.

METHODS

A questionnaire comprising 7 questions was sent by mail and/or e-mail to a total of 59 potential centers performing SDR, centers that have published material concerning SDR or centers that have been recommended. Forty-seven (80%) centers responded to the questionnaire; 11 of them do not presently perform SDR surgery, and the remaining 36 centers constitute the material of the present study.

RESULTS

23 of the 36 centers use Peacock's operation technique and 8 centers use Park's technique. Continuous intravenous infusion of opioids for postoperative pain treatment is used by 17 (47%) of the centers. Seven (19%) centers use the epidural (ED) approach for treating postoperative pain and 6 (17%) centers use intrathecal (IT) pain treatment. The duration of intravenous ED or IT pain relief ranged from 24 h up to 7 days. To evaluate pain relief, 25 (70%) centers used some form of pain scale.

CONCLUSION

The most common operation techniques in use today are described by Peacock or by Park, with an estimated number of procedures of more than 487/year in 36 centers. The majority of the centers seem to have a satisfactory pain management strategy. These centers administer continuous infusions of opioids, with an intravenous, ED or IT approach, and incorporate the use of a pain assessment tool to evaluate pain relief.

The child with cerebral palsy: diagnosis and beyond

Cerebral palsy (CP) is one of the most common conditions we follow in our pediatric neurology offices. This review will hopefully convince you that the care of children with CP extends far beyond the diagnosis. The review addresses issues surrounding diagnosis, coimpairments, prognosis, and family-centeredness of care. It will also deal with routine office follow-up to prevent or identify complications, management of spasticity and other morbidities, alternative and complementary therapies, and finally transition.

A review of orthopedic surgeries after selective dorsal rhizotomy

Selective dorsal rhizotomy (SDR) is an evidence-based treatment for cerebral palsy (CP) spasticity. During their lifetime, patients with CP spasticity may require orthopedic surgery for muscles and joints to correct physical deformities and provide a better quality of life. In this review, the authors discuss the timing of such orthopedic surgery, its necessity, and whether it is influenced by the performance of SDR. A review of findings from the authors' 19 years of experience yields the following conclusions: 1) that SDR reduces orthopedic surgery requirements when compared with historical controls; 2) that SDR performed in patients at a young age (2-4 years) can reduce future orthopedic surgery requirements; 3) that independent walkers and diplegic patients will have the smallest amount of orthopedic surgery post-SDR; and 4) that patients who need assistance walking and those with quadriplegia will have the greatest amount, although the frequency of orthopedic surgery for quadriplegic patients is not as high as popularly believed.

Selection of treatment modalities in children with spastic cerebral palsy

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.

Selective Posterior Rhizotomy for Painful Spasticity in the Lower Limbs of Hemiplegic Patients After Stroke: Report of Two Cases

OBJECTIVE AND IMPORTANCE

Selective posterior rhizotomy (SPR) has been performed mainly in children with cerebral palsy. Seldom has the use of SPR been reported for reduction of spasticity after stroke. We describe two elderly patients with hemiplegia who underwent unilateral SPR for pain caused by spasticity after stroke.

CLINICAL PRESENTATION

The first patient was a 68-year-old woman who experienced spasticity and pain in her right leg during the chronic stage of a left cerebral infarction. The second patient was an 89-year-old man who had intolerable spastic pain in his left hemiplegic leg 3 months after a right cerebral infarction.

INTERVENTION

Both patients underwent unilateral SPR on the spastic side to reduce the pain. After surgery, the patients' pain resolved. In the first patient, the ability to perform activities of daily living also improved.

CONCLUSION

Antispastic medications are often sufficient for treatment of post-stroke spasticity. In selected cases, however, SPR can be beneficial for improving painful spasticity.

Use of botulinum toxin type A and type B for spasticity in upper and lower limbs

BT is likely effective in controlling spasticity in the smaller muscles of the arm and hand, although there has been only one large controlled trial. For lower limb spasticity, the outcomes are more mixed. No large randomized, controlled trials have been done, and the larger size of the muscles results in a decreased ability to treat widespread spasticity. For more focal treatment in the legs and feet, however, and when combined with other denervating agents or physical modalities, BT is probably effective. Careful analysis is warranted before performing any chemodenervation on a limb muscle or muscles.

Neurosurgical treatment of spasticity and other pediatric movement disorders

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.