Modified Selective Dorsal Rhizotomy Exposure Method for Adults With Spastic Paralysis of the Lower Limbs

BACKGROUND AND OBJECTIVES

Spinal deformities are a common complication after selective dorsal rhizotomy (SDR). In this article, we introduce a more minimally invasive SDR procedure in adult patients with spastic paralysis of the lower limbs.

METHODS

In this retrospective analysis of SDR in 8 adult patients with spastic paralysis of the lower limbs, a modified exposure method was used during the surgery. Only the lower part of the L1 spinous process, upper part of the L2 spinous process, and part of the lamina were resected through L1-2 interlaminar approaches. The motor and sensory roots were found to be completely dependent on electrophysiological monitoring. The sensory roots of the target muscle groups were partially transected. All patients were followed up for 2-4 years. The degree of lower extremity spasm was assessed using the Gross Motor Function Classification Scale, Ashworth grading, Gross Motor Function Measure-66, joint range of motion, and electromyography analysis.

RESULTS

All 8 patients were successfully operated with the help of intraoperative electrophysiological monitoring. The Ashworth score of the target muscles, Gross Motor Function Measure-66 score, and range of motion of the joints improved significantly after surgery. Two patients achieved cross-grade improvement in their Gross Motor Function Classification Scale scores. No persistent incision pain or spinal deformities were observed during follow-up.

CONCLUSION

The interspinous process approach provides sufficient surgical space and reduced the damage to the bone structure of the spine. The electrophysiological monitoring protocol is suitable for adult patients with lower extremity spasm.

Surgical Results of Selective Dorsal Rhizotomy for the Treatment of Spastic Cerebral Palsy

Background

Selective dorsal rhizotomy (SDR) is one of the surgical alternatives for treating spasticity, especially in children with spastic diplegia secondary to cerebral palsy (CP). It is becoming increasingly used, and the results of this operation need to be further highlighted.

Aim

The main objective of this article was to present the results of such surgical procedure in a cohort of a specialized center, with a particular focus on a quantitative analysis (goniometry).

Materials and Methods

Retrospective review of the medical records and gait analyses of a cohort of 34 patients diagnosed with CP submitted to elective SDR at our institution, in a period of 6 years, was carried out. All patients underwent a thorough clinical and neurological assessment, gait analysis at a dedicated laboratory, and magnetic resonance imaging of whole neuro-axis.

Statistical Analysis

For continuous quantitative variables (goniometric angles and muscle tone), a t-student test was used. A scatterplot regression analysis was used for the comparison of modified Ashworth scale (mAS) scores and goniometry measurements.

Results and Conclusion

In a mean follow-up of 3.2 years, SDR provides a measurable and consistent improvement in the motor function of spastic patients, as per range of motion and tonus scales, with low complication rates. It also allows for patients to reduce their use of muscle relaxants, even though their global mobility does not change significantly. Therefore, it should be considered for CP patients who suffer with the deleterious effects of spasticity.

Somatosensory corticospinal tract axons sprout within the cervical cord following a dorsal root/dorsal column spinal injury in the rat

The corticospinal tract (CST) is the major descending pathway controlling voluntary hand function in primates, and though less dominant, it mediates voluntary paw movements in rats. As with primates, the CST in rats originates from multiple (albeit fewer) cortical sites, and functionally different motor and somatosensory subcomponents terminate in different regions of the spinal gray matter. We recently reported in monkeys that following a combined cervical dorsal root/dorsal column lesion (DRL/DCL), both motor and S1 CSTs sprout well beyond their normal terminal range. The S1 CST sprouting response is particularly dramatic, indicating an important, if poorly understood, somatosensory role in the recovery process. As rats are used extensively to model spinal cord injury, we asked if the S1 CST response is conserved in rodents. Rats were divided into sham controls, and two groups surviving post-lesion for ~6 and 10 weeks. A DRL/DCL was made to partially deafferent one paw. Behavioral testing showed a post-lesion deficit and recovery over several weeks. Three weeks prior to ending the experiment, S1 cortex was mapped electrophysiologically, for tracer injection placement to determine S1 CST termination patterns within the cord. Synaptogenesis was also assessed for labeled S1 CST terminals within the dorsal horn. Our findings show that the affected S1 CST sprouts well beyond its normal range in response to a DRL/DCL, much as it does in macaque monkeys. This, along with evidence for increased synaptogenesis post-lesion, indicates that CST terminal sprouting following a central sensory lesion, is a robust and conserved response.

Spinal cord injury transiently alters Meissner's corpuscle density in the digit pads of macaque monkeys

Meissner's corpuscles (MCs) are cutaneous mechanoreceptors found in glabrous skin and are exquisitely sensitive to light touch. Along with other receptors, they provide continuous sensory feedback that informs the execution of fine manual behaviors. Following cervical spinal deafferentation injuries, hand use can be initially severely impaired, but substantial recovery occurs over many weeks, even when ~95% of the original input is permanently lost. While most SCI research focuses on central neural pathway responses, little is known about the role of peripheral receptors in facilitating recovery. We begin to address this by asking the following: (1) What is the normal pattern of MCs in the distal pads of all five digits in the macaque monkey (with hands similar to humans)? (2) What happens to these receptors 4-5 months following either a dorsal column lesion (DCL) or a combined dorsal root/dorsal column lesion (DRL/DCL), when functional recovery is largely complete? (3) What happens chronically, 12-14 months later? Our findings show that in normal monkeys, MCs are densest in the distal pads of the opposing thumb and index finger, with the greatest concentration on the thumb. This reflects a close functional relationship between receptor density and precision grip. At 4-5 months post-injury, there was a (~30%) loss of MCs on the deafferented digits of the injured hand compared with the contralateral side. However, 12-14 months after a DRL/DCL, receptor densities had returned to normal levels. Our findings indicate a complex peripheral response and highlight the importance of the periphery in shaping central changes.

Dorsal rhizotomy for children with spastic diplegia of cerebral palsy origin: usefulness of intraoperative monitoring

OBJECTIVE The utility of intraoperative neuromonitoring (ION), namely the study of muscle responses to radicular stimulation, remains controversial. The authors performed a prospective study combining ventral root (VR) stimulation for mapping anatomical levels and dorsal root (DR) stimulation as physiological testing of metameric excitability. The purpose was to evaluate to what extent the intraoperative data led to modifications in the initial decisions for surgical sectioning established by the pediatric multidisciplinary team (i.e., preoperative chart), and thus estimate its practical usefulness. METHODS Thirteen children with spastic diplegia underwent the following surgical protocol. First, a bilateral intradural approach was made to the L2-S2 VRs and DRs at the exit from or entry to their respective dural sheaths, through multilevel interlaminar enlarged openings. Second, stimulation-just above the threshold-of the VR at 2 Hz to establish topography of radicular myotome distribution, and then of the DR at 50 Hz as an excitability test of root circuitry, with independent identification of muscle responses by the physiotherapist and by electromyographic recordings. The study aimed to compare the final amounts of root sectioning-per radicular level, established after intraoperative neuromonitoring guidance-with those determined by the multidisciplinary team in the presurgical chart. RESULTS The use of ION resulted in differences in the final percentage of root sectioning for all root levels. The root levels corresponding to the upper lumbar segments were modestly excitable under DR stimulation, whereas progressively lower root levels displayed higher excitability. The difference between root levels was highly significant, as evaluated by electromyography (p = 0.00004) as well as by the physiotherapist (p = 0.00001). Modifications were decided in 11 of the 13 patients (84%), and the mean absolute difference in the percentage of sectioning quantity per radicular level was 8.4% for L-2 (p = 0.004), 6.4% for L-3 (p = 0.0004), 19.6% for L-4 (p = 0.00003), 16.5% for L-5 (p = 0.00006), and 3.2% for S-1 roots (p = 0.016). Decreases were most frequently decided for roots L-2 and L-3, whereas increases most frequently involved roots L-4 and L-5, with the largest changes in terms of percentage of sectioning. CONCLUSIONS The use of ION during dorsal rhizotomy led to modifications regarding which DRs to section and to what extent. This was especially true for L-4 and L-5 roots, which are known to be involved in antigravity and pelvic stability functions. In this series, ION contributed significantly to further adjust the patient-tailored dorsal rhizotomy procedure to the clinical presentation and the therapeutic goals of each patient.

Morphine-induced changes in delta opioid receptor trafficking are linked to somatosensory processing in the rat spinal cord

An in vivo fluorescent deltorphin (Fluo-DLT) internalization assay was used to assess the distribution and regulation of pharmacologically available delta opioid receptors (deltaORs) in the rat lumbar (L4-5) spinal cord. Under basal conditions, intrathecal injection of Fluo-DLT resulted in the labeling of numerous deltaOR-internalizing neurons throughout dorsal and ventral horns. The distribution and number of Fluo-DLT-labeled perikaryal profiles were consistent with that of deltaOR-expressing neurons, as revealed by in situ hybridization and immunohistochemistry, suggesting that a large proportion of these cells was responsive to intrathecally administered deltaOR agonists. Pretreatment of rats with morphine for 48 hr resulted in a selective increase in Fluo-DLT-labeled perikaryal profiles within the dorsal horn. These changes were not accompanied by corresponding augmentations in either deltaOR mRNA or (125)I-deltorphin-II binding levels, suggesting that they were attributable to higher densities of cell surface deltaOR available for internalization rather than to enhanced production of the receptor. Unilateral dorsal rhizotomy also resulted in increased Fluo-DLT internalization in the ipsilateral dorsal horn when compared with the side contralateral to the deafferentation or to non-deafferented controls, suggesting that deltaOR trafficking in dorsal horn neurons may be regulated by afferent inputs. Furthermore, morphine treatment no longer increased Fluo-DLT internalization on either side of the spinal cord after unilateral dorsal rhizotomy, indicating that microOR-induced changes in the cell surface availability of deltaOR depend on the integrity of primary afferent inputs. Together, these results suggest that regulation of deltaOR responsiveness through microOR activation in this region is linked to somatosensory information processing.

Progressive transneuronal changes in the brainstem and thalamus after long-term dorsal rhizotomies in adult macaque monkeys

This study deals with a potential brainstem and thalamic substrate for the extensive reorganization of somatosensory cortical maps that occurs after chronic, large-scale loss of peripheral input. Transneuronal atrophy occurred in neurons of the dorsal column (DCN) and ventral posterior lateral thalamic (VPL) nuclei in monkeys subjected to cervical and upper thoracic dorsal rhizotomies for 13-21 years and that had shown extensive representational plasticity in somatosensory cortex and thalamus in other experiments. Volumes of DCN and VPL, number and sizes of neurons, and neuronal packing density were measured by unbiased stereological techniques. When compared with the opposite, unaffected, side, the ipsilateral cuneate nucleus (CN), external cuneate nucleus (ECN), and contralateral VPL showed reductions in volume: 44-51% in CN, 37-48% in ECN, and 32-38% in VPL. In the affected nuclei, neurons were progressively shrunken with increasing survival time, and their packing density increased, but there was relatively little loss of neurons (10-16%). There was evidence for loss of axons of atrophic CN cells in the medial lemniscus and in the thalamus, with accompanying severe disorganization of the parts of the ventral posterior nuclei representing the normally innervated face and the deafferented upper limb. Secondary transneuronal atrophy in VPL, associated with retraction of axons of CN neurons undergoing primary transneuronal atrophy, is likely to be associated with similar withdrawal of axons from the cerebral cortex and should be a powerful influence on reorganization of somatotopic maps in the somatosensory cortex.

Differential distribution of alpha2A and alpha2C adrenergic receptor immunoreactivity in the rat spinal cord

alpha2-Adrenergic receptors (alpha2-ARs) mediate a number of physiological phenomena, including spinal analgesia. We have developed subtype-selective antisera against the C termini of the alpha2A-AR and alpha2C-AR to investigate the relative distribution and cellular source or sources of these receptor subtypes in the rat spinal cord. Immunoreactivity (IR) for both receptor subtypes was observed in the superficial layers of the dorsal horn of the spinal cord. Our results suggest that the primary localization of the alpha2A-AR in the rat spinal cord is on the terminals of capsaicin-sensitive, substance P (SP)-containing primary afferent fibers. In contrast, the majority of alpha2C-AR-IR was not of primary afferent origin, not strongly colocalized with SP-IR, and not sensitive to neonatal capsaicin treatment. Spinal alpha2C-AR-IR does not appear to colocalize with the neurokinin-1 receptor, nor is it localized on astrocytes, as evidenced by a lack of costaining with the glial marker GFAP. However, some colocalization was observed between alpha2C-AR-IR and enkephalin-IR, suggesting that the alpha2C-AR may be expressed by a subset of spinal interneurons. Interestingly, neither subtype was detected on descending noradrenergic terminals. These results indicate that the alpha2-AR subtypes investigated are likely expressed by different subpopulations of neurons and may therefore subserve different physiological functions in the spinal cord, with the alpha2A-AR being more likely to play a role in the modulation of nociceptive information.