Functional Outcome of Adulthood Selective Dorsal Rhizotomy for Spastic Diplegia

Abstract

ObjectiveThe medical evidence supporting the efficacy of selective dorsal rhizotomy (SDR) on children with spastic diplegia is strong. However, the outcome of SDR on adults with spastic diplegia remains undetermined. The aim is to study the effectiveness and morbidities of SDR performed on adults for the treatment of spastic diplegia. MethodsPatients who received SDR in adulthood for the treatment of spastic diplegia were surveyed. The survey questionnaire addressed the living situation, education level, employment, health outcomes, postoperative changes of symptoms, changes in ambulatory function, adverse effects of SDR and orthopedic surgery after SDR. ResultsThe study included 64 adults, who received SDR for spastic diplegia. The age at the time of surgery was between 18 and 50 years. The age at the time of the survey was between 20 and 52 years. The follow-up period ranged from one to 28 years. The study participants reported post-SDR improvements of the quality of walking in 91%, standing in 81%, sitting in 57%, balance while walking 75%, ability to exercise in 88%, endurance in 77%, and recreational sports in 43%. Muscle and joint pain present before surgery improved in 64% after surgery. Concerning the level of ambulatory function, all patients who walked independently in all environments maintained the same level of ambulatory function. Eighteen percent of the patients who walked independently in some environments improved to the independent walking in all environments. All patients who walked with an assistive device before SDR maintained the assistive walking after SDR. Concerning adverse effects of SDR, 50% (32 of 64 patients) developed numbness in the various parts of the legs. Two patients reported a complete loss of sensation in parts of the legs, and one patient reported numbness and constant pain in the bilateral lower extremities. Ten patients (16%) reported recurrent spasticity after SDR, and three patients (5%) reported ankle clonus, which is an objective sign of spasticity. Tendon lengthening surgery after SDR was needed in 27% and hip and knee surgery in 2% and 6%, respectively. ConclusionsThe great majority of our 64 patients, who received adulthood SDR for spastic diplegia, improved the quality of ambulation and abated signs of early aging. Numbness and diminished sensation in the lower extremity was the most common adverse effect of the adulthood SDR.

Selective Dorsal Rhizotomy for the Treatment of Spastic Hemiplegic Cerebral Palsy

“…In our experience, early aging often begins around 10 years of age in childhood and at any age in adulthood. Most significantly, the eventual outcome of the early aging process is the loss of the ability to walk in late adulthood [ 13 ].…”

Intraoperative neurophysiological monitoring in selective dorsal rhizotomy (SDR)

“…could guide the selection of dorsal roots (rootlets) that are thought to be more closely associated with spasticity just beneath the conus level, which means the selection could be fully achieved without the need to identify the level of those nerve roots (rootlets). The use of Park's method could allow SDR to be performed via a single-level approach, particularly in cases with moderate or severe spasticity [2][3][4][5][6][7][8]. In an attempt to find a universally applicable EMG interpretation scheme that could be applied to all kinds of spastic CP cases (including mild ones), Browd developed a new rhizotomy protocol in 2016 [10].…”

“…Studies have shown that different anesthetics can affect intraoperative electrophysiological outcomes [16][17][18], including changes in threshold, latency to stimulus, and EMG response patterns. Because, to date, there is no proven anesthetic protocol used specifically for SDR, clinical practitioners have either just applied those protocols conducted in other neurosurgical procedures requiring IONM or simply developed their own [2][3][4][5][6][7][8][9][10][11][12][13].…”

“…Since Fasano's setup, intraoperative electrical stimulation has typically included both singlepulse stimulation and train stimulation. Singlepulse stimulation, which contains a constant current with a duration that varies from 0.05 to 0.5 ms and an intensity starting at 0.01 mA [2][3][4][5][6][7][8][9][10][11][12][13], is used mainly (1) to differentiate dorsal roots from ventral ones, (2) to identify those rootlets associated with the sphincter, and (3) to determine the electrical intensity for the following train stimulation. In both Browd's and our team's setups, single-pulse stimulation was also used to determine whether such rootlet stimulation initially evokes EMG responses in those target muscles.…”

“…The word "selective" refers to the intraoperative selection and dissection of the afferent nerve rootlets in the spinal cord that are considered to be more involved in spasticity, decreasing the afferent signaling to the motor neurons in the anterior horn of the spinal cord, so as to achieve a reduction in muscle tone after surgery. At present, some centers that perform SDR use intraoperative neurophysiological monitoring (IONM) to assist or even fully guide the operation [2][3][4][5][6][7][8][9][10][11][12][13]. Because the role of IONM in SDR has never been fully discussed, its importance and necessity have been long questioned.…”