Selective Dorsal Rhizotomy For Treatment Research Articles

Selective Dorsal Rhizotomy for Treatment of Hereditary Spastic Paraplegia-Associated Spasticity in 37 Patients.

BackgroundA limited number of publications have described a reduction of spasticity associated with hereditary spastic paraplegia (HSP) after selective dorsal rhizotomy (SDR). Typically, the SDR procedure is performed on patients with spastic cerebral palsy to remove spasticity and to help these patients with ambulatory function. Whether SDR has similar effects on HSP patients, requires further investigation. Thus, we are providing a personal experience of the effects of SDR on this specific cohort of patients.ObjectivesTo examine the safety of SDR, changes in spasticity, and ambulatory function after SDR on patients with HSP.MethodsThe Institutional Review Board of Washington University School of Medicine approved this study (#201704003). A total of 37 children and adults received SDR for the treatment of HSP-associated spasticity between 1988 and 2021. SDR was performed through an L1 laminectomy, as we previously described in an earlier publication. The patients took part in the follow-up examination either in-person or by email. The follow-up focused on the patients’ motor functions (primarily ambulation), adverse effects of SDR, and orthopedic treatments after SDR.ResultsOf the total 37 patients who participated in this study, 46% were female and 54% were male. The age range of when HSP was diagnosed was one month to 34 years. Six of the patients’ diagnoses were made, based on the family history of HSP in six patients and the remaining 31 patients’ diagnoses were confirmed by genetic tests. The most common genetic mutations were SPG4 and SPG3A. Of the patients with positive genetic tests, 40% had no family history of HSP. SDR was performed at the age of 2 to 45 years (mean: 14.7 years). The follow-up period ranged from 0 to 33 years (mean: 3.8 years). One patient developed a spinal fluid leak requiring surgical repair. Two patients reported mild numbness in parts of the lower limbs. Spasticity was removed in 33 patients (89%). Four patients (11%) experienced a return in spasticity. Regarding ambulatory function, 11% of patients reported a decline in function. Two patients walked independently before surgery but declined, requiring a wheelchair eight years and seven years, respectively, after surgery for each patient. In contrast, 16% saw an improvement in ambulatory function, improving from walking with a walker to walking independently. The remaining 73% of patients maintained their level of ambulation. These two groups of patients showed improvement in other motor functions and independence. ConclusionsThe present analysis suggests the potential role of SDR in the management of spasticity in HSP patients. We found no sign of SDR being a direct cause of deleterious effects on patients with HSP.

Effect of selective dorsal rhizotomy for treatment of spasticity related to cerebral palsy - report on one-year postoperative results in the Polish population

Aim: Selective dorsal rhizotomy (SDR) is a form of surgical treatment that reduces tone in lower extremities by selective sectioning of lumbosacral dorsal roots fibers. However, the method occasionally still arouses some controversies. Since it was introduced in Poland, relatively recently, the discussion on its efficacy is even more vivid. To address this issue we present the analysis of patients treated with SDR in our institution. Material and methods: Out of 96 operated patients 76 were eligible for the study and 30 of them showed up for one-year follow up and were finally analyzed. Modified Ashworth Scale (MAS) was used to measure spasticity and the Gross Motor Function Measure (GMFM) to asses gross motor functioning of the patients. Results: For spasticity of different muscles measured by MAS there were significant differences between pre-treatment and post- -treatment (p < 0.05, after Holm-Bonferroni correction; effect size 1.26 < d> 2.32). Furthermore, for gross motor functioning measured by GMFM, there was significant difference between both time points treatment (d = 0.68). Conclusions: To our knowledge this is the first report on results of SDR for cerebral palsy treatment in Polish population. The treatment significantly diminished spasticity and improved gross motor functioning on the long term basis. This should provide reassurance to parents considering the procedure and influence the discussion on including SDR in the group of neurosurgical procedures founded by health system authorities in Polandneurodegenerative and metabolic diseases are suspected, genetic testing is performed. Despite the progress that has been made in treating some ataxia disorders in recent years, with few exceptions, for most of patients the therapy of choice is symptomatic and supportive treatment.

Evidence Supporting Selective Dorsal Rhizotomy for Treatment of Spastic Cerebral Palsy.

The objective of this review is to analyze the evidence supporting selective dorsal rhizotomy (SDR) for the treatment of spastic cerebral palsy (CP). We reviewed 85 outcome studies from 12 countries between 1990 and 2017. The published results are overwhelmingly supportive of SDR, and 39 studies form a basis for this review. Also included is some of the clinical experience of the senior author.The results show that SDR plus postoperative physiotherapy (PT) improved gait, functional independence, and self-care in children with spastic diplegia. In adults with a follow-up of 20 to 28 years, the early improvements after childhood SDR were sustained and improved quality of life. Furthermore, majority of the adults who underwent SDR as children would recommend SDR to others. On the clinical side, while SDRs through multilevel laminectomies or laminoplasty were associated with spinal deformities (i.e., scoliosis, hyperlordosis, kyphosis, spondylolisthesis, spondylolysis, and nonhealing of laminoplasty), SDRs through a single level laminectomy prevented SDR-related spinal problems. The outcomes of SDR specific to spastic quadriplegia require further investigation because of the relatively small patient population with quadriplegia. Lastly, we found that SDR can prevent or reverse premature aging in adolescents and adults with spastic diplegia. In conclusion, the evidence supporting the efficacy of SDR is strong, and SDR is a well-established option for spasticity management in spastic CP.

Mapping dermatomes during selective dorsal rhizotomy: case report and review of the literature

Background Studies suggest that the pattern of dermatomal segmental innervation in any given patient, may differ from the classic dermatomal maps first described in the 1890s. Such variability may limit the effectiveness of selective dorsal rhizotomy for treatment of neurogenic pain. Case description A 46-year-old male presented with a 27-year history of intractable pain in his left arm after being shot during the Vietnam War; multiple surgical and medical therapeutic modalities failed to produce durable pain relief. The patient underwent selective dorsal rhizotomy, with intraoperative dermatomal and mixed somatosensory evoked potential recordings. Pre- and postrhizotomy recordings were compared, effectively mapping this patient’s dermatomal pattern. At 4 years’ follow-up, the patient remains pain free. Conclusion Intraoperative monitoring of somatosensory evoked potentials during dorsal rhizotomy for neurogenic pain can be used to establish the degree to which an individual’s pattern of segmental innervation conforms to the traditionally described dermatomes.

Commentary

BACKGROUND Studies suggest that the pattern of dermatomal segmental innervation in any given patient, may differ from the classic dermatomal maps first described in the 1890s. Such variability may limit the effectiveness of selective dorsal rhizotomy for treatment of neurogenic pain. CASE DESCRIPTION A 46-year-old male presented with a 27-year history of intractable pain in his left arm after being shot during the Vietnam War; multiple surgical and medical therapeutic modalities failed to produce durable pain relief. The patient underwent selective dorsal rhizotomy, with intraoperative dermatomal and mixed somatosensory evoked potential recordings. Pre- and postrhizotomy recordings were compared, effectively mapping this patient's dermatomal pattern. At 4 years' follow-up, the patient remains pain free. CONCLUSION Intraoperative monitoring of somatosensory evoked potentials during dorsal rhizotomy for neurogenic pain can be used to establish the degree to which an individual's pattern of segmental innervation conforms to the traditionally described dermatomes.