Orthopaedic surgery after selective dorsal rhizotomy

Data were collected on orthopaedic surgical interventions during the 5 years after surgery, for 35 consecutive children undergoing selective dorsal rhizotomy. At follow-up, 15 children had been operated in the lower limb. The most frequent procedures were subtalar arthrodesis, Achilles tendon lengthening and adductor tendon lengthening. Children with walking capacity were mostly operated with foot surgery and children without walking capacity were mostly operated with hip surgery. The need for orthopaedic surgery was highest among children with walking capacity.     

The risk of spinal deformity after selective dorsal rhizotomy

To define the risk of spinal deformity after selective dorsal rhizotomy (SDR) for the treatment of spasticity due to cerebral palsy, 43 patients were reviewed before and after the procedure. The average length of follow-up was 5.3 years with a range of 2-9 years. Scoliosis was present in three patients before rhizotomy. One patient had a thoracic hyperkyphosis, and another, a lumbar hyperlordosis deformity preoperatively. Wide laminectomies were performed in 46 patients, and none had laminoplasties. Twenty-eight significant spinal deformities developed in 19 patients; 15 cases of scoliosis, seven instances of lumbar hyperlordosis, five thoracic hyperkyphosis, and one L4-5 spondylolisthesis. Five patients were placed in braces, and three patients went on to have surgical stabilization of their deformities. For the entire group, the risk of developing a structural spinal deformity was 36%, with 6% requiring stabilization at an average of 4.9 years after SDR. Older age, more severe neurologic impairment, and preexisting spinal deformity seems to increase this risk.     

Spinal deformity following selective dorsal rhizotomy

The authors performed a review of 79 patients treated by selective dorsal rhizotomy with laminoplasty, 78 of whom were ambulatory, to determine the prevalence of spinal deformities. The mean radiographic follow-up was 4.2 years, the mean clinical follow-up 5.8 years. Scoliosis (11 degrees -24 degrees ) was identified in 13 children, none of whom had a preexisting deformity. There were no significant differences between preoperative and follow-up thoracic kyphosis or lumbar lordosis, although there was a significant difference in lumbar lordosis between sitting and standing radiographs. No progressive or rigid hyperlordotic deformities were observed in the lumbar spine. Spondylolisthesis was identified in nine children (12%) (8/9 grade I), and one patient required an arthrodesis for pain. Spondylolisthesis was correlated with greater lumbar lordosis, stronger hip abductors, and increased popliteal femoral angles preoperatively, and with stronger hip flexors postoperatively. Back pain was identified in 4 of the 79 patients at last follow-up, 2 of whom had spondylolisthesis. As some cases of spondylolisthesis will remain asymptomatic, periodic radiographic follow-up is recommended.     

Anesthesia for selective dorsal rhizotomy in children

Anesthetic records for the first 71 children who underwent selective dorsal rhizotomy (SDR) at our hospital were reviewed. Anesthesia during SDR must preserve muscle contraction in response to direct electrical stimulation of the dorsal nerve rootlets. In our experience, halothane, isoflurane, and narcotics do not interfere with electrophysiologic monitoring, even though relatively large doses are required during SDR. Propofol proved to be unacceptable as an anesthetic because of severe muscle spasms during electrical stimulation of the nerve rootlets. The body temperature rises predictably during the stimulation phase of SDR and active warming measures should be avoided.     

Spinal deformity after selective dorsal rhizotomy in ambulatory patients with cerebral palsy

Thirty-four patients with ambulatory spastic diplegia (ages 10-19.8 years) who were part of a prospective study of selective dorsal rhizotomy (SDR) had standardized radiographs before and after SDR. Follow-up ranged from 5 to 11.6 years after surgery. Two different surgical approaches were used: laminectomy (14 patients) and laminoplasty (20 patients). Radiographs were measured for coronal and sagittal balance. Thirty patients had a spinal deformity at long-term follow-up compared with 10 patients before surgery. Seventeen patients (50%) developed lumbar hyperlordosis greater than 60 degrees. Six patients (18%) developed grade 1 spondylolisthesis, Scoliosis occurred de novo in eight patients (24%) and progressed by greater than 5 degrees in two patients with preoperative scoliosis. No significant differences were found between laminoplasty and laminectomy patients. None of the patients have undergone any surgical intervention for spinal deformity. There was a higher incidence of spinal deformity after SDR than in normals and an historical control population, which warrants clinical and radiographic long-term follow-up.     

Intrathecal morphine for postoperative analgesia in children after selective dorsal root rhizotomy

The authors report their experience with low doses (0.007-0.015 mg/kg), moderate doses (0.016-0.025 mg/kg), and high doses (0.026-0.035 mg/kg) of intrathecal morphine for postoperative analgesia after selective dorsal root rhizotomy surgery in 50 children, aged 3 to 12 years. After closure of the dura, a single dose of preservative-free morphine was injected into the subarachnoid space, and patients were assessed for 48 hours for level of comfort and side effects. The three doses of morphine provided equivalent analgesia and similar side effects. The duration of postoperative analgesia ranged from 3 to 48 hours (mean, 12.2 +/- 9.5 h). Common side effects were limited to nausea and vomiting (42%) and mild facial pruritus. No patient experienced late respiratory depression or generalized pruritus. The authors conclude that low doses of intrathecal morphine is as effective as moderate or high doses of morphine for reducing pain in the immediate postoperative period. Intrathecal morphine provides excellent analgesia after selective dorsal rhizotomy.     

Spinal deformity after selective dorsal rhizotomy in patients with cerebral palsy.

Selective dorsal rhizotomy is used widely as a means of treating spasticity associated with cerebral palsy. Little is known regarding the effect of the procedure on the development or progression of spinal deformity. The authors reviewed six patients with progressive deformity after rhizotomy. Prerhizotomy and postrhizotomy records of physical examinations and radiographs were reviewed retrospectively in an attempt to identify risk factors for development of and/or rapid progression of, spinal deformity. Detailed preoperative and postoperative evaluation of spinal alignment should be undertaken, particularly in those patients who may be at risk of rapidly progressive deformity.     

Deformity of lumbar spine after selective dorsal rhizotomy for spastic cerebral palsy

To observe the effect of selective dorsal rhizotomy (SDR) on the deformity of the lumbar spine, a retrospective review was conducted from October 1992 to December 2002 on children who had undergone SDR in our department, and in whom preoperative and postoperative spine radiographs had been obtained. The angles of hyperlordolysis were measured. The study group comprised 219 patients, in which 61 cases were followed up and examined between May 2004 and February 2005. The mean age at surgery was 6.9 years (range 3-20 years), with a mean time to recent follow-up radiographs of 6.3 years (5-9 years). A total 219 children underwent laminectomy from L(2)-S(1). Scoliosis existed in one case, and two cases of L(5) spondylolysis were detected before surgery. One case presented lumbar hyperlordosis. After SDR, 10 cases showed distinctively abnormal walking posture of hyperlordolysis. Compared with the preoperative angle of hyperlordolysis, the angle was improved after the operation. Among them, four patients developed spondylolysis and spondylolisthesis (grade I). We also observed that one case developed lumbar kyphosis deformity. In conclusion, cerebral palsy patients may develop spinal deformity. Some cases showed distinctively abnormal walking posture of hyperlordolysis, and they developed spondylolysis and spondylolisthesis after surgery.     

Pain management for children following selective dorsal rhizotomy

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure used for treating lower extremity spasticity in patients with cerebral palsy. The purpose of this paper is to present a review of our institution’s first three years’ experience with postoperative pain and spasticity management in patients who have undergone SDR. The medical records of the 55 patients who had an SDR during the study period were reviewed. The basis of postoperative analgesia was morphine, with the majority of patients receiving continuous morphine infusions (20–40 μg · kg^?1 · hr^?1(n = 49), 60 μg · kg^?1 · hr^?1 (n = 1)). Four patients used a patient-controlled delivery system. One patient had successful analgesia with epidural morphine. Ketorolac (1 mg · kg^?1iv loading dose followed by 0.5 mg · kg^?1 iv every six hr for 48 hr) was used as an adjunct to morphine in six patients. For management of postoperative muscle spasm, an intravenous benzodiazepine was used (diazepam 0.1 mg · kg^?1 (n = 2), or midazolam infusion 10–30 μg · kg^?1· hr^?1 (n = 51)). All patients were cared for on a ward where nurses were familiar with the use of continuous opioid and benzodiazepine infusions. All patients received continuous cardiorespiratory monitoring as well as frequent nursing assessment. There were no episodes of postoperative apnoea or excessive sedation. We have found the use of continuous infusions of morphine and midazolam, along with adjunct ketorolac, to be effective in treating postoperative pain and muscle spasms following SDR.     

A 2-year follow-up of outcomes following orthopedic surgery or selective dorsal rhizotomy in children with spastic diplegia

The purpose of this study was to prospectively compare the effect of orthopedic surgery (OS) and selective dorsal rhizotomy (SDR) on muscle tone, range of motion, gait and energy efficiency in ambulatory children with spastic diplegia. Twenty-five children with a diagnosis of spastic diplegia, with a mean age of 73 months, were evaluated prior to surgery and 1 and 2 years postoperatively; however, only the preoperative and 2-year postoperative data are reported here. Eighteen children received SDR and seven received OS. Children were evaluated with the Ashworth scale for muscle tone, passive range of motion (PROM), gait analysis and oxygen consumption for energy cost. Significant improvements were seen in PROM, muscle tone, gait kinematics and oxygen cost regardless of surgical intervention. Although OS and SDR interventions influence motor function through different mechanisms, the gait and energy outcomes 2 years following OS or SDR are similar.     

Nerve rootlets to be sectioned for spasticity resolution in selective dorsal rhizotomy

BACKGROUND: The goal of this study is to confirm the efficacy of the protocol for selective dorsal rhizotomy (SDR). In this protocol, rootlets to be sectioned are selected by palpable responses elicited by intraoperative electrical stimulation, without detailed electromyographic classifications. METHODS: Thirty-six children with spasticity due to cerebral palsy underwent SDR according to our protocol. Priority was given to sectioning rootlets that showed palpable clonic or bilateral responses, which were considered abnormal, over sectioning rootlets that merely had hyperactive responses to intraoperative stimulation. The results of intraoperative monitoring and sectioning amount were analyzed by physical evaluation. RESULTS: Significant improvements were obtained in passive range of motion and muscle tone of the lower extremities. The total percentages of rootlets with abnormal and hyperactive responses at L3 and S1 were bilaterally correlated with preoperative spasticity of the hip adductors and the plantar flexors, respectively. When rootlets with hyperactive responses were excluded from the correlation analysis, no bilateral correlation was observed. From the correlation analyses between the improvement in the physical evaluation and the amount of nerve sectioned, it was concluded that a greater improvement in muscle tone in all examined muscles, except the hamstrings, could be obtained if larger amounts of nerve roots were sectioned. CONCLUSION: The number of rootlets with palpable abnormal and hyperactive responses elicited by intraoperative stimulation reflects the preoperative spasticity of multiple muscles. This implies that only selecting rootlets with palpable responses can be reliable. Because more sectioning leads to better spasticity resolution, our protocol should be reviewed to increase the percentage of rootlets sectioned with hyperactive responses, especially for innervated levels of severely affected muscles.     

A systematic review of complications following selective dorsal rhizotomy in cerebral palsy

PurposeThe literature lacks a concise overview of complications secondary to selective dorsal rhizotomy (SDR). The aim of this study was to systematically review the literature regarding post-SDR complications, and to present them concisely.MethodsThe protocol of the review was registered on Open Science Framework. Studies on SDR in cerebral palsy were included. The studies to be included used SDR for management of spasticity in patients with cerebral palsy. The long-term complications of SDR mentioned in the articles were inventoried.ResultsThirty studies were included for qualitative review. Twenty-one types of complication were identified. Structural complications were the commonest: scoliosis (214/1,043, 20.5%), hyperlordosis (101/552, 18.2%), spondylolysis (55/574, 9.5%) and kyphosis (67/797, 8.4%). Neurological complications comprised constipation (70/485, 14.4%), hip subluxation (3/29, 10.3%), spastic syndrome (4/47, 8.5%), sensory changes (106/1290, 8.2%) and urinary incontinence (61/1013, 6%).ConclusionThis review should help surgeons and parents alike to know about the potential complications of SDR. Complications may affect quality of life and should be weighed. Although the majority of these complications were managed conservatively, there would still be a physical, psychological and financial burden which should be taken into account. Screening should be continued vigorously throughout skeletal growth and at reduced frequency thereafter, for timely intervention in case of structural complications.     

Long-term functional outcome after selective posterior rhizotomy

OBJECT: Selective posterior rhizotomy (SPR) is a well-recognized treatment for children with spastic cerebral palsy (CP). Few investigators have used quantitative outcome measures to assess the surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine the long-term functional outcome of children who had undergone selective dorsal rhizotomy accompanied by intraoperative electrophysiological monitoring. METHODS: The study population was composed of children with spastic CP who underwent SPR and were evaluated by a multidisciplinary team preoperatively, and at 6 months and 1 year postoperatively. Quantitative standardized assessments of lower-limb spasticity, passive range of motion, muscle strength, and ambulatory function were obtained. Of the 93 patients who met the entry criteria for the study, 71 completed the 3-year and 50 completed the 5-year assessments, respectively. Statistical analysis demonstrated significant improvements in spasticity, range of motion, and functional muscle strength at 1 year after SPR. The preoperative, 1-, 3-, and 5-year values for the global score of the Gross Motor Function Measure were 64.6, 70.8, 80, and 85.6, respectively. The greatest improvement occurred in the dimensions reflecting lower-extremity motor function, where the mean change was 10.1% at 1 year, 19.9% at 3 years, and 34.4% at the 5-year follow-up review in comparison with the baseline value. This was associated with a lasting improvement in alignment and postural stability during developmental positions, as well as increased ability to perform difficult transitional movements. CONCLUSIONS: The results of this study support the presence of significant improvements in lower-limb functional motor outcome 1 year after SPR, and the improvements persist at 3 and 5 years. The authors conclude that SPR in conjunction with intraoperative stimulation is valuable for permanently alleviating lower-limb spasticity while augmenting motor function.     

Functional outcomes following selective posterior rhizotomy in children with cerebral palsy

The recent increase in popularity of selective posterior rhizotomy demands objective documentation of surgical outcome. For this reason, the authors have analyzed the status of 25 children with spastic cerebral palsy before and after rhizotomy to determine the effects of this therapy on muscle tone, range of movement, and motor function. Postoperative tests showed a reduction in muscle tone compared with preoperative assessments. Range of motion in the lower extremities was significantly increased and improvements in functional gross motor skills were noted. An increase in range of motion in the knees and thighs during gait was detected in 18 ambulatory patients studied with computerized two-dimensional motion analysis. Preliminary findings indicate that selective posterior rhizotomy reduced spasticity, thereby increasing range of motion and contributing to improvements in active functional mobility.     

Morphine with or without a local anaesthetic for postoperative intrathecal pain treatment after selective dorsal rhizotomy in children

Selective dorsal rhizotomy is a surgical procedure with a selective division of posterior spinal nerve rootlets to treat spasticity in children. The extensive surgical procedure with multilevel laminectomies and the nerve root manipulation result in intense pain postoperatively. Two intrathecal (IT) regimes of pain treatment were compared in these children, concerning their pain relief and possible side-effects. In a prospective study, 12 children (3-6 years of age) with six in each group, received either intermittent IT morphine (5 microg x kg(-1) four times a day) or continuous infusion of a mixture of bupivacaine (40 microg x kg(-1) x h(-1)) and morphine (0.6 microg x kg(-1) x h(-1)). Pain score was lower in the bupivacaine/morphine group (0.2 +/- 1.1) compared to intermittent morphine (2 +/- 2.4) on a scale from 0 to 6 (P less than or = 0.0001). Bupivacaine/morphine resulted in a lower, but not significant, difference in pruritus and lower muscle spasm. Haemodynamic and ventilatory parameters did not differ between the groups. Intrathecal continuous infusion of bupivacaine and morphine was superior to intermittent morphine in the treatment of pain after selective dorsal rhizotomy operations.     

Postoperative continuous intrathecal pain treatment in children after selective dorsal rhizotomy with bupivacaine and two different morphine doses

BACKGROUND: Children undergoing selective dorsal rhizotomy (SDR) experience severe pain postoperatively; a pain related to both the extensive surgical exposure with multilevel laminectomy and nerve root manipulation. We sought to define an optimal dose of continuous intrathecal (IT) morphine and bupivacaine to treat this severe pain. The aim of this study was to compare two different concentrations of morphine in a fixed dose of bupivacaine with regard to the analgesic effect and survey if they differed in side effects. METHODS: Twenty-six children, aged 2.7-7.4 years undergoing SDR were included in this study. Postoperatively 11 children received a continuous infusion of morphine 0.4 microg x kg(-1) x h(-1) and bupivacaine 40 microg x kg(-1) x h(-1) (low-dose group) and 15, a continuous infusion of morphine 0.6 microg x kg(-1) x h(-1) and bupivacaine 40 microg x kg(-1) x h(-1) (high-dose group). The Behavioral Observational Pain Scale (BOPS) was used to evaluate pain. RESULTS: Better pain relief was obtained in the high-dose group seen in lower BOPS score compared with the low-dose group [P = 0.03, Fisher's permutation test and P = 0.06 Wilcoxon-Mann-Whitney (WMW) test]. The low-dose group received seven times as much ketobemidone 0.43 +/- 0.54 mg x kg(-1) 48 h(-1) compared with 0.06 +/- 0.09 mg x kg(-1) 48 h(-1) in the high-dose group (P = 0.0005 Fisher's permutation test, P = 0.0017 WMW test). There was no statistical difference in pruritus and postoperative nausea and vomiting between the groups. Respiratory and hemodynamic depression was not found. CONCLUSION: This study shows that, compared with low-dose, the higher dose of continuous IT morphine combined with bupivacaine, significantly reduce pain score and postoperative intravenous analgesic requirements without increasing adverse effects.     

The role of selective dorsal rhizotomy in the management of post-traumatic spasticity: systematic review

Neurosurgical Review - There is a huge burden of patients suffering from trauma-induced disabling spasticity the world over. There are surprisingly few modalities of treatment with a sustained,...     

An acute pain service improves postoperative pain management for children undergoing selective dorsal rhizotomy

Background: A continuous epidural infusion of morphine is the pain treatment modality for children undergoing selective dorsal rhizotomy (SDR) in our institution. The aim of the study was to evaluate the impact of having an organized acute pain service (APS) on postoperative pain management of these children. Methods: We conducted a retrospective cohort study using anesthetic records and the APS database to compare the postoperative pain management of children undergoing SDR before and after the introduction of the APS at the Montreal Children’s Hospital in April 2001. Ninety‐two consecutive children who had their surgery between January 1997 and July 2006 were included. We collected data regarding postoperative pain, opioid‐induced side effects, complications (sedation, desaturations < 92%), and hospital length of stay. Results: Pain scores were documented more frequently after the implementation of the APS (61% vs 48.5%). Sedation scores were documented only after the implementation of the APS. Postoperative desaturation was significantly more frequent in the pre‐APS group compared to the APS group (45.5% vs 6.8%, P < 0.001). Despite the fact that the epidural catheter was in place for the same duration for both groups [median of 3 days (3–3 25–75%ile)], the duration of hospitalization was 1 day shorter in the APS group compared to the pre‐APS group [median of 5 (5–5 25–75%ile) vs 6 (5–6 25–75%ile) days, P < 0.001]. Conclusions: Although we recognize that it is possible that there were changes in care not related specifically to the introduction of a dedicated APS that occurred in our institution that resulted in improvements in general postoperative care and in length of stay, our study did show that having an organized APS allowed to significantly decrease the incidence of postoperative oxygen desaturation and to decrease the hospital length of stay by 1 day.