Staggered rhizotomy of anterior and posterior sacral roots for bladder reservoir function in spinal cord injury: a canine experimental study and preliminary clinical report

Objective: To report an experimental study and preliminary clinical results of staggered anterior and posterior sacral rhizotomy for restoring function of the bladder and preventing reflex incontinence in supra‐conal spinal cord injury (SCI). Methods: Ten T10 spinal cord transected mongrel dogs were divided into three groups. In group 1 (n= 2), laminectomy only was performed (control). In group 2 (n= 4), all L7‐S3 posterior roots were microsurgically cut (complete deafferentation). And in group 3 (n= 4), the L7, S1, S3 posterior roots and S2 anterior root were cut (staggered deafferentation and deefferentation). Intraoperative electrical stimulation and postoperative cystometrography (CMG) were carried out. In the clinic, three patients with spastic bladder caused by a supra conal complete SCI underwent staggered rhizotomy and were followed up for 6 years. Results: In the canine experimental study, resection of the S2 anterior root combined with L7, S1 and S3 posterior rhizotomy, stimulating the S2 posterior root (four dogs) resulted in a minimal rise in pressure in the bladder and urethra, which was only about 10% of that obtained by stimulating the S2 proximal posterior root while its anterior counterpart was intact (eight dogs, Student's t‐test, P < 0.01). The CMG study showed that groups 2 and 3 had similar volume/pressure curves; in both groups the tendency was to develop flaccid bladders. In the clinic, three cases underwent staggered rhizotomy of the anterior and posterior roots in S3 and S4. Good bladder reservoir and compliance was achieved over six years of follow‐up. Conclusion: Staggered rhizotomy of the anterior and posterior sacral roots at different spinal cord levels has the same denervation effect as a complete posterior rhizotomy, and good bladder reservoir function can be achieved by this procedure.     

神经肌电图监测在选择性脊神经后根切除术中的应用

目的:探讨神经肌电图监测在选择性脊神经后根切除术(SPR)中的应用价值。方法:对5例行SPR患者进行术中电刺激阈值及行为反应观察,对阈值较低、有反应扩散现象的神经小束予以切除。结果:5例行SPR患者,术后4例痉挛性脑性瘫痪患儿术后肌张力明显下降,痉挛获得不同程度解除,1例颈脊髓外伤后痉挛性瘫痪患者肌张力下降,痉挛减轻。5例均无感觉功能障碍、肌张力过低等并发症。结论:根据神经肌电图监测方法来施行SPR简单、可靠。它对如何确定选切比例与范围、最小化手术并发症、最大化肢体痉挛缓解起到重要作用。     

Functional Status of Patients With Cerebral Palsy According to the International Classification of Functioning, Disability and Health Model: A 20-Year Follow-Up Study After Selective Dorsal Rhizotomy

Langerak NG, Lamberts RP, Fieggen AG, Peter JC, Peacock WJ, Vaughan CL. Functional status of patients with cerebral palsy according to the International Classification of Functioning, Disability and Health Model: a 20-year follow-up study after selective dorsal rhizotomy.

Objective

To determine functional status of patients with cerebral palsy 20 years after they received selective dorsal rhizotomy (SDR).

Design

A prospective 20-year follow-up study.

Setting

Red Cross Children's Hospital (SDR operation and 1-year follow-up assessment) and at institutional or private locations nearby patients' homes (20-year follow-up assessment).

Participants

Referred sample of 14 patients with spastic diplegia (6 women, 8 men; mean age, 27y; range, 22-33y) who were preoperatively ambulant and fulfilled strict selection criteria for SDR operation in 1985.

Interventions

Patients were assessed before and 1 and 20 years after SDR.

Main Outcome Measures

Standardized assessments of function according to 2 dimensions of the International Classification of Functioning, Disability and Health (ICF) model: (1) body structure and function (muscle tone, joint stiffness, voluntary movement) and (2) activity (rolling, sitting, kneeling, crawling, standing, walking, transitions) were obtained. In addition, based on assessments and questionnaires, Gross Motor Function Classification System (GMFCS) levels were determined before and at 1 year after SDR retrospectively and currently at 20 years after SDR.

Results

One year after SDR, functional outcomes based on the 2 dimensions of the ICF model improved significantly, and these improvements were maintained at 20 years after surgery. Patients showed a shift in their GMFCS levels 1 and 20 years after SDR.

Conclusions

In line with our 20-year follow-up study with gait parameters as outcome measures, patients with spastic diplegia still show improvements in their functional status 20 years after SDR. We acknowledge the presence of possible confounding factors and a small sample size, but we argue that the improvements found in this study were caused mainly by SDR. Finally, changes in GMFCS levels suggest a possible role for this tool to detect changes after an intervention.     

痉挛性脑瘫选择性脊神经后根切断术的10年回顾（附825例随访结果分析）

目的：以随访方式对选择性脊神经后果切断术（SPR）解除脑瘫痉挛,改善功能进行疗效观察。方法：自1990年5月始采用SPR治疗的825例得到2年以上随访的脑瘫患者。病理类型：痉挛型661例,僵直型52例,混合型112例。病因：绝大多数病例为早产,产后窒息,难产,持续黄疸等。痉挛程序：Ⅲ级-Ⅴ级。下肢实用能力等情况：独立行走129例,简单介助行走143例,介助站立并有行走动作275例,双下肢交替爬行122例,上肢助力式爬行或不能爬行156例。治疗方法及其技术改进：根据术前判断下戏挛的范围并参考痉挛和下肢主要畸变施行功能性SPR;混合性脑瘫SPR同时选择部分神经节段行SAR;上肢痉挛较重,是痉挛影响手的日常生活的基本动作的脑瘫行CSPR;保留L4椎板和LR－SRR技术;部分病例应用射频技术,术后术后的康复措施应用;SPR后功能训练3－6个月后,针对固定的畸形的矫形手术。治疗结果：术后肌张力情况,Ⅰ级672例,Ⅱ级102例,Ⅲ级12例,Ⅳ级5例,Ⅴ级10例。癫痫发作频率减少或癫痫控制药物服用量减少31例,流口水减轻或消失70例。眼外斜视减轻132例。发音改善72例。腰骶段SPR上肢痉程度减轻67例。行走功能改变：在介助行走418例病例中263例变为可独立行走,爬行278例病例中91例可独立行走,52例可借助站立或行走。结论：选择性脊神经后根切断术能够长期有效地解除肢体痉挛,改善肢体功能。     

右美托咪定用于小儿脑瘫选择性脊神经后根切断术麻醉的研究

目的观察右美托咪定用于4,JL脑瘫选择性脊神经后根切断术麻醉的效果。方法选择30例行选择性脊神经后根切断术的患儿,随机分为右美托咪定组和对照组,每组15例,右美托咪定组于术中按0．2μg·kg^-1·h^-1持续泵人右美托咪定。两组术中麻醉维持按瑞芬太尼0．1～0．3μg·kg^-1·min^-1、丙泊酚2—6mg·kg^-1·h^-1持续泵人。记录两组不同时段SBP、HR、BIS、PETcO：,记录术中电刺激进行肌电（EMG）监测时患儿体动发生例数、术后躁动例数。结果右美托咪定组EMG监测时HR低于对照组,术中EMG监测时体动例数（0）及术后躁动例数（6．7％）少于对照组（13．3％,13．3％）。结论右美托咪定用于小儿脑瘫选择性脊神经后根切断术的麻醉维持,可使患儿术中生命体征更平稳,减少术后躁动发生。     

The location of GABAB receptor binding sites in mammalian spinal cord

GABAB binding sites in rat spinal cord have been detected by receptor autoradiography using 3H-GABA in the presence of isoguvacine. The sites could be demonstrated throughout the spinal cord grey matter. The maximum concentration of GABAB sites occurred in lamina II with substantial amounts in other laminae of the dorsal horn. Much lower levels were detected in the ventral horn. Unilateral rhizotomy reduced the number of GABAB sites in the dorsal horn without affecting levels in the ventral horn. The greatest reduction occurred in lamina II with 18% loss 2 days after surgery, 23% after 4 days, 25% after 6 days, and 48% after 15 days. The change after 15 days was comparable to that produced 4 months after neonatal capsaicin administration (50 mg/kg). The only apparent difference between rhizotomy and capsaicin treatment occurred in lamina IV, where rhizotomy produced a greater reduction than capsaicin. 3H-Neurotensin binding in sections from the same animals was unaltered after rhizotomy, indicating a lack of change in the populations of neurons containing neurotensin-binding sites. This would support the view that up to 50% of GABAB binding sites are located on nerve terminals. The greater reduction in lamina IV after rhizotomy would suggest that GABAB sites may be present on large-diameter afferent fibres that terminate in this region as well as on smaller-diameter C and A delta fibres.     

Selective posterior rhizotomy for the treatment of spasticity: a review

The use of sensory rhizotomy has long been used for the treatment of spasticity. This review outlines the historical development of this treatment, the current surgical technique, and its physiologic rationale. Patient selection, postoperative treatment, and complications are also discussed.     

Key role of the dorsal root ganglion in neuropathic tactile hypersensibility.

Cutting spinal nerves just distal to the dorsal root ganglion (DRG) triggers, with rapid onset, massive spontaneous ectopic discharge in axotomized afferent A-neurons, and at the same time induces tactile allodynia in the partially denervated hindlimb. We show that secondary transection of the dorsal root (rhizotomy) of the axotomized DRG, or suppression of the ectopia with topically applied local anesthetics, eliminates or attenuates the allodynia. Dorsal rhizotomy alone does not trigger allodynia. These observations support the hypothesis that ectopic firing in DRG A-neurons induces central sensitization which leads to tactile allodynia. The question of how activity in afferent A-neurons, which are not normally nociceptive, might induce allodynia is discussed in light of the current literature.     

Selective dorsal rhizotomy versus orthopedic surgery: a multidimensional assessment of outcome efficacy

OBJECTIVE: To compare the efficacy of selective dorsal rhizotomy (SDR) and orthopedic surgery using multidimensional (National Center for Medical Rehabilitation Research disablement framework) outcome measures. DESIGN: Prospective outcome study. SETTING: Pediatric orthopedic hospital. PARTICIPANTS: Twenty-five children with spastic diplegia. Eighteen participants (mean age, 71.3 mo) chose SDR. Seven participants (mean age, 78.6 mo) chose orthopedic surgery. INTERVENTIONS: Children were evaluated 2 days before surgical intervention and at 6 months, 1 year, and 2 years postsurgically. MAIN OUTCOME MEASURES: The Gross Motor Performance Measure, the Gross Motor Function Measure, and the Pediatric Evaluation of Disability Inventory. RESULTS: The SDR group improved significantly in quality of movement attributes 6 months postsurgically; however, gross motor skills (standing; walking, running, and jumping) gains were seen 2 years postsurgically. The orthopedic group improved significantly in select quality of movement attributes 6 months postsurgically and in standing skills within the first postsurgical year. Self-care skills, mobility, and social function gains were seen earlier and with greater frequency in the SDR group. CONCLUSIONS: Both surgical interventions demonstrated multidimensional benefits for ambulatory children with spastic diplegia. The results suggest that qualitative changes in movement, achieved by spasticity reduction, have a greater effect on the enhancement of functional skill proficiency, thus independence, than recognized.