Selective Dorsal Rhizotomy Procedure Research Articles

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

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. 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. 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. 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.

Unsupervised machine learning effectively clusters pediatric spastic cerebral palsy patients for determination of optimal responders to selective dorsal rhizotomy

Selective dorsal rhizotomy (SDR) can reduce the spasticity in patients with spastic cerebral palsy (SCP) and thus improve the motor function in these patients, but different levels of improvement in motor function were observed among patients after SDR. The aim of the present study was to subgroup patients and to predict the possible outcome of SDR based on the pre-operational parameters. A hundred and thirty-five pediatric patients diagnosed with SCP who underwent SDR from January 2015 to January 2021 were retrospectively reviewed. Spasticity of lower limbs, the number of target muscles, motor functions, and other clinical parameters were used as input variables for unsupervised machine learning to cluster all included patients. The postoperative motor function change is used to assess the clinical significance of clustering. After the SDR procedure, the spasticity of muscles in all patients was reduced significantly, and the motor function was promoted significantly at the follow-up duration. All patients were categorized into three subgroups by both hierarchical and K-means clustering methods. The three subgroups showed significantly different clinical characteristics except for the age at surgery, and the post-operational motor function change at the last follow-up in these three clusters was different. Three subgroups clustered by two methods could be identified as “best responders”, “good responders” and “moderate responders” based on the increasement of motor function after SDR. Clustering results achieved by hierarchical and K-means algorithms showed high consistency in subgrouping the whole group of patients. These results indicated that SDR could relieve the spasticity and promote the motor function of patients with SCP. Unsupervised machine learning methods can effectively and accurately cluster patients into different subgroups suffering from SCP based on pre-operative characteristics. Machine learning can be used for the determination of optimal responders for SDR surgery.

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.

Selective Dorsal Rhizotomy for the Treatment of Spastic Hemiplegic Cerebral Palsy.

BackgroundSelective dorsal rhizotomy (SDR) can remove spasticity in cerebral palsy (CP). Spastic hemiplegia is associated with spasticity in the upper and lower limbs on one side. Only a single report described the outcome of SDR specifically in patients with spastic hemiplegic CP. The effect of SDR on spastic hemiplegia requires further investigation.ObjectivesTo analyze the outcomes of motor functions, the quality of life, and satisfaction of patients who received SDR for the treatment of spastic hemiplegia.MethodsA total of 29 children and 1 adult who received SDR were surveyed. The survey questionnaire asked about demographic information, patient's perception of SDR, functional outcomes, SDR surgical outcomes, pain, braces/orthotics, and post-SDR treatment.ResultsOur study included 30 patients. The age at the time of surgery was 2 to 36 years. The follow-up period ranged from one to six years. Of all parents, 90% of parents reported that SDR benefited their children, and 93% stated that they would recommend the SDR procedure to other families of children with hemiplegic CP. Of all patients, 90% reported improved walking, 63% reported improved sitting, and 87% reported improved balance and posture. In daily life functioning after the SDR, 67% were more independent and confident. Moreover, 33% of patients were pain-free and 43% had reduced pain in their legs and back. In activities of daily living, 93% transferred independently from one position to another. A majority of the patients reported regular strengthening and stretching of the lower limb, and 50% of the patients played sports. A majority (73%) of patients underwent post-SDR orthopedic surgery for heel cord, hamstring, and adductor contractures. Five patients experienced numbness in the small part of the lower limb after SDR. None reported that the numbness affected their daily activities. One child required surgical repair of the cerebrospinal fluid leak.ConclusionsIn our 29 children and 1 adult with spastic hemiplegia, SDR improved motor function and daily life function. Nearly all parents of children and the one adult felt that SDR was beneficial and that they would recommend surgery to other children with spastic hemiplegia.

Selective Dorsal Rhizotomy for the Treatment of Spastic Triplegic Cerebral Palsy.

BackgroundSpastic triplegia is a recognized subtype of cerebral palsy (CP). In the course of treating spastic triplegic children with selective dorsal rhizotomy (SDR), we found that some children who had “minimal or mild involvement” in the stronger arm improved strikingly after undergoing SDR. Some of them became independent ambulators, which was an outcome that is not usually achieved in spastic quadriplegic children. However, the literature currently contains no data on the natural clinical course and the effects of CP interventions on spastic triplegia.ObjectivesOur aim was to elucidate the clinical characteristics of spastic triplegia and the effects of SDR on functional outcomes and the quality of life after childhood SDR.MethodsThe Institutional Review Board of the Washington University School of Medicine approved this quality of life survey (number: 201908177). The subjects of this study were children and adults (ages: 3.9-23.8 years at the time of the survey completion; mean: 12.1 ± 5.1 years) with spastic triplegic CP who had undergone SDR (ages: 2.2-15.9 years; mean: 6.1 ± 3.2 years) between 2003 and 2018 at the St. Louis Children’s Hospital. The follow-up period ranged from 1-16 years (mean: 6.0 ± 4.3 years). The study included a 76-patient cohort selected from a total of 253 spastic triplegic CP patients who had undergone SDR. All 253 patients were contacted via email or postal mail soliciting their participation in the study including the survey. The cohort included all patients who responded. The survey included questions on demographic information, quality of life, perceptions of health and the SDR procedure, motor and ambulatory functions, braces and orthotics, pain issues, side effects of SDR, and post-SDR treatment.ResultsThirteen patients had presented with scissored gait, and these patients had undergone partial ventral rhizotomy (PVR) of L1-3 ventral roots immediately after the completion of SDR. Of note, 91% of 76 patients reported that SDR improved their quality of life, and 93% would recommend the procedure to other patients. After SDR, 21 more patients were able to run, 14 more played recreational sports, and 18 more could walk without using walking aids. Sixteen fewer patients used a wheelchair for long-distance walking and in crowds; 37 and 32 patients reported an improvement in the more affected arm and hand, respectively. Sixty-eight patients were able to regularly strengthened their muscles at least once a week, and 60 patients regularly stretched their legs. However, 53 patients required assistance with bathing or showering, 50 with getting dressed, and 56 with grooming or hygiene. Forty-eight patients had orthopedic surgery after SDR. Percutaneous hamstring-lengthening was the most common type of orthopedic surgery performed. Three of 13 patients who received PVR and SDR required adductor release. Six patients used medications for spasticity or dystonia. No late side effects of SDR were observed.ConclusionsOur report elucidates the clinical features of spastic triplegia before and after SDR. A distinct clinical feature was the wide variation in ambulatory functions, ranging from total independent walking to wheelchair mobility. The vast majority of patients felt that SDR improved their motor functions and quality of life. PVR also resulted in favorable outcomes, with only three of 13 patients requiring additional adductor release surgery. There were no late complications related to SDR surgery.

Functional outcomes after selective dorsal rhizotomy followed by minimally invasive tendon lengthening procedures in children with spastic cerebral palsy.

Many surgical options have been proposed to improve the ambulatory status of children with spastic cerebral palsy (CP), but none have focused on addressing both spasticity and lower extremity tendon contractures. The purpose of this study is to evaluate the results of selective dorsal rhizotomy (SDR) followed by minimally invasive tendon lengthening allowing immediate return to ambulation. Two hundred fifty-five spastic CP patients (who received SDR procedure at an average age of 6.9±2.6 years and tendon lengthening procedure at an average age of 7.2±2.5 years) were retrospectively reviewed. Patients were grouped by the gross motor function classification system (GMFCS) 1-3 and 4-5. Kaplan-Meier analysis and Cox proportional hazard model using a requirement for additional tendon lengthening as an end point were conducted. Tendon lengthening followed SDR at an average of 4.3±10.7 months. On an average of 4.9±1.2 years after tendon lengthening, GMFCS was improved in 28 and maintained in 213 patients, respectively. There was no difference of variables and joint angles between the two GMFCS groups. A repeat tendon lengthening was required in 19 patients. The Kaplan-Meier analysis showed 81% success rate. Cox proportional hazard model identified age at tendon lengthening [hazards ratio (HR), 0.53; 95% confidence interval (CI), 0.37-0.76] and duration between SDR and tendon lengthening of more than 6 months (HR, 2.96; 95% CI, 1.05-8.33) associated with need for a repeat tendon lengthening procedure. Our novel approach of SDR/tendon lengthening results in improved joint angles as well as stable or improved GMFCS. Longer follow-up is necessary to determine if this approach could prolong ambulatory ability and reduced need for more invasive orthopedic surgeries.

Long-term benefits from selective dorsal rhizotomy in a young patient with cerebral palsy

Abstract Introduction Spasticity is considered to be one of the most important factors hampering functional abilities among patients with a cerebral palsy (CP). Aim The aim of the study was to present results of the selective dorsal rhizotomy (SDR) procedure combined with the physiotherapy process in a 3 year follow-up study, presented from a functional and structural perspective. Case study After the diagnosis of CP in the form of spastic diplegia, the 2-years-old patient (GMFCS 4) was directed for a comprehensive rehabilitation. After clinical examination and family consultation, spasticity was found to be important factor limiting patient functional abilities. Results and discussion The patient was directed to SDR operation. The patient was evaluated four times: before the SDR, and then 1, 2 and 3 years after the SDR surgery. The spasticity was assessed using the modified Tardieu scale. A functional assessment was done using the gross motor function measure (GMFM) scale, 6-min walk test and functional assessment questionnaire (FAQ-10). A muscle tension remained decreased throughout the 3 years of the follow up period. The achieved reduction in muscle tone was accompanied by a change in a range of motion, an improvement in GMFM total score result, an increased distance in 6-min walk test and in the FAQ-10 questionnaire. Conclusions SDR procedure combined with comprehensive rehabilitation programs leads to short- and long-term reduction in the spasticity of a 5-year-old boy with a spastic diplegia. Decreased level of spasticity was accompanied by an increased gross motor functioning and mobility.

Does decreased spasticity improve gait in children with cp after selective dorsal rhizotomy?

Main topics: Analysis of gait and motor disorders, Outcomes after clinical intervention Introduction and aim: Selective dorsal rhizotomy (SDR) is a neurosurgical procedure aimed to reduce spasticity and thereby increase functionality in children with spastic cerebral palsy (CP). Although it is described that spasticity is clearly diminished after SDR, there is less evidence that gait and functionality is improved [1]. This may be related to the finding that strength has a higher correlation with function [2]. The aim of this study was to evaluate spasticity, strength and gait, one year after SDR. Patients/materials and methods: Forty-two children with spastic diplegic CP underwent an SDR between 2001 and 2013 and received 3D lower limb gait analyses, including kinematics, kinetics, EMGandaclinical examinationprior toandoneyearpost (range 11–17 months) SDR. The Gait Profile Score (GPS), the Movement Analysis Profiles (MAPs) and seven clinically important kinematic parameters were calculated. Paired T-test was used to investigate whether there were significant differences between pre and post SDRcondition.Difference scores (DS)were calculatedbetweenpost and pre condition to be able to correlate the changes after SDR to the pre SDR condition. Comparison of Modified Ashworth Scale (MAS) and strength measurements pre versus post SDR condition was done by means of the Wilcoxon signed rank test. Correlation between MAS, strength, the amount of rootlets cut (%RC) and pre SDR gait was studied using the Pearson Correlation Coefficient. A subgroup of 22 patients also received a second follow-up 3D gait analysis two years after SDR (range 23–36 months). The same gait parameters were compared between pre, one year post and two year post SDR. Results: The GPS showed no significant difference between pre and post SDR condition. Taking into account the MCID of the GPS (1.6◦ [3]) there was an improvement in 27% of the children. 50% showed no change and 23% had a higher GPS. At the knee, theMAPS showed significant less deviation (p<0.001) due to improved knee extension at initial contact (IC) and midstance and increased flexion in swing. The ankle motion tended to be less deviated from normal, however not significant. The ankle position at IC was significantly better after SDR.MAPS of the pelvis and hip in the sagittal plane showed significant increased pathology after SDR. Correlation between DS and pre SDR condition showed low to moderate correlations for all MAPs indicating that there was more improvement in more affected children. These correlations were higher in the coronal and transverse plane compared to the sagittal plane. MAS and strength respectively decreased (p=0.000) and increased (p=0.001) for all observed muscles post SDR. Correlation between strength and GPS showed low but significant correlations for hip extensors (r=−0.412), hip abductors (r=−0.460) and dorsiflexors (r=−0.499). Between MAS and GPS, there were only low correlations for the hip flexors (r=0.317), hip adductors (r=0.414) and the totalMAS score (r=0.409). Lowcorrelationwas also foundbetween %RC and the pre GPS (r=0.314). In the subgroup of 22 patients, there were no significant differences between one and two year post SDR. Discussion and conclusions: One year after SDR, gait significantly improved at the knee and ankle. However, due to increased pelvic anterior tilt and hip flexion therewas no overall reduction of the gait deviation, as expressed by GPS. The second follow-up one year later showed no reversal of this pattern.We observed only low correlations between spasticity and gait, which is in accordance to previous studies [1,2] and may explain why the reduced spasticity does not result in an overall improved gait pattern. While psoas spasticity decreased and hip extensors strength increased, the pathological pelvic anterior tilt remained. These findings, especially at the proximal levels, may be related to possible loss of sensory control after SDR due to the afferent rootlets that were cut. This imbalance in treatment response between proximal and distal levels may be tackled by amore careful SDR procedure when rootlets of the proximalmuscles are involved and by targeted rehabilitation preand post SDR on hip and pelvis.

Complications after Selective Posterior Rhizotomy for Spasticity in Children with Cerebral Palsy

Selective dorsal rhizotomy (SDR) has been shown to be an effective treatment for the spasticity of cerebral palsy, but few studies have addressed specifically the side effects of the procedure. A retrospective study was performed to determine the frequency and nature of complications in 158 children who had undergone SDR at British Columbia’s Children’s Hospital from 1987 to 1996. Intraoperative, preoperative (immediate postoperative until discharge at approximately 7 days) and postdischarge complications occurred in 3.8, 43.6 and 30% of patients, respectively. The most common intraoperative complication was aspiration pneumonia, which was experienced by 2 patients (1.3%). Perioperatively, sensory changes were found in 8.9% of the children, and transient urinary retention in 4.4%. Complications after discharge included back pain starting more than 6 months after surgery in 10.8%, sensory changes in 13.9%, and neurogenic bladder or bowel problems in 12.7%. Persistent sensory changes occurred in 3.8%, were not important functionally, and tended to occur in patients with the largest amount of dorsal root tissue cut. In 8 patients (5.1%), bladder and/or bowel dysfunction attributed to the SDR was present at the latest follow-up, although in only 2 patients (1.3%) this dysfunction was a definite complication of the rhizotomy. The use of pudendal monitoring and/or cutting less than 50% of the S2 roots may have been associated with a lower incidence of long-term sphincter dysfunction. Data about the nature and frequency of complications may result in further modifications to the SDR procedure, and is critical for counseling about SDR and alternative options available for treatment of the child with spastic cerebral palsy.

An experimental study of reflex variability in selective dorsal rhizotomy.

Significant problems regarding the measurement technique currently used to choose nerve roots for sectioning in the selective dorsal rhizotomy procedure have recently been reported. To better understand the source of these problems, a series of six experiments was performed in which the selective rhizotomy technique was applied to cats that were either intact, decerebrate, or spinalized. Measurements were made before and after partial rhizotomy. In decerebrate preparations, large, spontaneous changes in reflex threshold were observed over short periods of time, especially after partial rhizotomy was performed, and threshold changes greater than 1000% could be observed over 10-minute periods. Using constant-current stimulation of the dorsal root at threshold, the response of each ipsilateral leg muscle demonstrated frequent changes, and changes coincided with the variability in threshold estimation. In addition, very low thresholds were measured (0.1 to 0.25 mA) in half (3 of 6) of these experiments, these measurements being well below the currents customarily used for intraoperative decision making. Stimulation at twice threshold was found to consistently increase the pathological quality of the responses observed. Although intact animals never displayed contralateral responses when stimulated at threshold, such contralateral responses could readily be elicited at twice threshold. These laboratory results raise further doubts regarding the reliability of the measurement techniques now widely used for selective dorsal rhizotomy.

Intraoperative Monitoring in Selective Dorsal Rhizotomy

The method used in the intraoperative portion of the selective dorsal rhizotomy procedure for the selection of abnormal circuits within the central nervous system of children with spasticity due to cerebral palsy is described. The decision to transect dorsal rootlets is made on the basis of electrophysiological, behavioral and medical criteria. In 100 cases the average number of rootlets transected was 64%. Of the total stimulated, 23.3% exhibited normal electrophysiological and behavioral responses. Decision making regarding the preservation or transection of the remaining 12.7% of the segments is described. This information is presented in an effort to increase understanding of this particular portion of the procedure and to encourage standardization of the procedure between centers in the future.