Keyhole interlaminar dorsal rhizotomy for spastic diplegia in cerebral palsy.

Abstract

The efficiency and safety of dorsal rhizotomies for cerebral palsy lie in the accuracy of radicular identification together with selectivity of root sectioning. Two different exposures are currently in use. The first is extended laminotomy/laminectomy from the upper lumbar level to the sacrum, which allows accurate identification of all L2-S2 roots/rootlets. The second is limited laminotomy exposing the conus/cauda equina at the thoracolumbar junction; this less invasive method limits accessibility to the roots. To optimize the accuracy and selectivity while minimizing invasiveness, the authors developed a tailored interlaminar procedure targeting the radicular levels involved in the harmful components of spasticity directly and individually. Six patients with spastic diplegia at different levels of the Gross Motor Functional Classification System were selected. In each patient, two to three interlaminar spaces, preselected according to planning, were enlarged in the "keyhole" fashion, respecting the spinous processes and interspinous ligaments. Ventral root stimulation identified the radicular level. Dorsal root stimulation evaluated its implication in the hyperactive segmental circuits, helping quantify the percentage of rootlets to be cut. There were neither wound-related nor general complications. At 1 year of follow-up, X-ray examination did not reveal kyphosis or instability. In all children, the excess of spasticity was reduced. The Ashworth score decreased from 3.2 on average to 0.6 postoperatively (range: 2-4 to 0-2). Regarding the functional status at 1 year of follow-up for the three ambulatory children, the Gillette ability-to-walk score increased from 3/10 on average to 7.3/10 postoperatively (range: 2-4 to 7-8). For the three non-ambulatory children, abnormal postures, painful contractures and ease of care were much improved. Keyhole interlaminar dorsal rhizotomy (KIDr) offers direct intradural access to each of the ventral/dorsal roots, thus maximizing the reliability of anatomical mapping and allowing individual physiological testing of all targeted roots. The interlaminar approach minimizes invasiveness by respecting the posterior spine structures.