Selective posterior rhizotomy for children with cerebral palsy: a 7-year experience

Although selective posterior rhizotomy (SPR) was pioneered as early as 1913, only over the past decade has the procedure gained popular use for the treatment of spasticity in cerebral palsy. The medical knowledge base regarding this procedure is expanding, and surgical techniques continue to be revised. We present our 7 years of experience in treating spastic cerebral palsy using SPR. The aspects of preoperative evaluation used by the multidisciplinary team to determine candidacy are outlined. The surgical procedure is detailed with a particular emphasis on the role of intraoperative nerve root stimulation to aid in selection for rootlet sectioning. Historical nerve stimulation protocols are reviewed and compared to our findings over the years. The functional goals are discussed in the context of the postoperative evaluation and therapies. Specific outcome in relation to joint range of motion, self care tasks, and ambulation is reported. The paper outlines a concise overview of our experiences and will assist the clinician in defining a protocol and expectations for SPR.     

舌咽神经痛的病因与显微手术治疗(附9例临床分析)

目的探讨舌咽神经痛的发病原因和神经根切断术治疗效果。方法对9例舌咽神经痛患者,经乙状窦后进路行桥小脑角探查并舌咽神经切断术。结果 9例患者中,6例术中探查发现有4例小脑上动脉压迫,2例神经根部蛛网膜增厚粘连者只行舌咽神经切断术。3例术中探查未见责任血管压迫和蛛网膜者增厚粘连,行舌咽神经根及迷走神经根上部1~2根丝切断术。术后疼痛症状均消失。结论舌咽神经血管压迫和蛛网膜增厚粘连可能是舌咽神经痛的发病原因,但不是唯一原因;舌咽神经根切断术疗效肯定。     

CyberKnife stereotactic radiosurgical rhizotomy for refractory trigeminal neuralgia

Stereotactic radiosurgery (SRS) has been established as an option for the treatment of trigeminal neuralgia (TN). Here, we report our experience of CyberKnife®-based (Accuray, Sunnyvale, CA, USA) stereotactic rhizotomy on medically refractory patients to determine its clinical effectiveness. Between January 2007 and December 2009, 14 selected patients underwent SRS for TN at our CyberKnife Center. Patients were evaluated for pain relief using a visual analog scale (VAS) score, time to reach pain relief (latency), duration of pain control, decrease of pain medication, occurrence of new dysesthesia, and side effects at the 3-month, 6-month, 1-year and 2-year follow-up. A literature analysis revealed that compared with other SRS systems, which can provide a high rate of pain control, CyberKnife® stereotactic rhizotomy yielded an earlier onset of pain relief in our cohort.     

Residual spasticity after selective posterior rhizotomy

The technique used in performing selective posterior rhizotomies to treat spastic cerebral palsy remains controversial. One hundred nine children who had undergone selective posterior rhizotomies were studied 6 months after their surgery. Their residual spasticity was correlated to the number of roots and whether or not abnormally responding roots were left, in order to validate the surgical technique used to treat spastic cerebral palsy at most neurosurgical centers in North America. The children were divided into three groups (group A: children who had their L2-S1 roots tested and selectively lesioned,n = 15; group B: children who had their L2-S2 roots tested and selectively lesioned,n = 62; group C: children who had their L2-S2 roots tested and whose lesioning was directed both by the response to the stimulation and mapping of the S1–S3 dorsal roots for afferent pudendal nerve activity,n = 32). Clinically significant residual spasticity was present in the gastrocnemius in 33% of the group A children, 11% of the group B children, and 6% of the group C children. We found that there was no significant increase in residual spasticity in the group C children when abnormally responding roots were not cut in order to preserve pudendal nerve activity. This study shows that the inclusion of the S2 roots decreases the amount of residual spasticity (P<0.01). It also shows that leaving abnormally responding S2 roots to preserve pudendal nerve activity does not affect the incidence of postoperative spasticity (P>0.1).     

坐骨神经切断后GDNF mRNA在两侧断端的表达变化

目的探讨大鼠坐骨神经切断后,GDNFmRNA在两侧断端的表达变化及其意义。方法切断SD大鼠左侧坐骨神经,在不同时间、应用半定量RT-PCR方法观察两侧断端GDNFmRNA的表达变化。结果坐骨神经切断前,GDNFmRNA在两侧坐骨神经微量表达,坐骨神经切断后远断端表达逐渐增加(1、7、14、28d分别增加20%、60%、85%、90%),近断端表达逐渐减少(1、7、14、28d分别减少10%、38%、45%、52%)。结论坐骨神经切断后断端GDNFmRNA表达变化是由于“胞体-轴突-靶器官”轴中断造成的。此结论为应用外源性GDNF治疗脊髓损伤提供了理论依据。     

高选择性脊神经后根切断对SD大鼠膀胱和阴茎勃起功能的影响

目的：探讨高选择性切断脊神经后根小束对SD大鼠膀胱和阴茎勃起功能的影响。方法：清洁级成年雄性SD大鼠40只,体重300~350 g,其中10只电刺激L6和S1后根,观察膀胱内压（intravesical pressure, IVP）和海绵体内压（intracavernous pressure, ICP）的变化以确定膀胱和海绵体的主要神经传导支;另外30只随机分成A、B两组,每组各15只,A组高选择性切断S1后根传导膀胱逼尿肌的小束,B组高选择性切断S1后根传导阴茎海绵体的小束,观察并记录切断前后IVP和ICP的变化情况。结果：分别电刺激L6和S1后根,IVP变化的差异不显著（P=0.972）,ICP变化的差异显著,电刺激L6后根的ICP升高值为（6.88±2.76）cmH₂O(1 cmH₂O=0.098 kPa),电刺激S1后根的ICP升高值为（13.05±8.41）cmH₂O(P<0.01)。分别电刺激S1左右两侧引起IVP和ICP的变化差异无统计学意义（P值分别为0.623和0.828）。A组S1后根小束切断前后电刺激下IVP的变化差异有统计学意义,切断前的IVP升高值为（14.37±4.89）cmH₂O,切断后的IVP升高值为（3.25±1.29）cmH₂O(P<0.001),而ICP的变化差异无统计学意义（P=0.153）;B组S1后根小束切断前后电刺激下ICP的变化差异有统计学意义,切断前的ICP升高值为（11.97±4.41）cmH₂O,切断后的ICP升高值为（2.68±1.01）cmH₂O(P<0.001),而IVP的变化差异无统计学意义（P=0.162）。结论：通过显微解剖及电刺激可以区别SD大鼠S1后根主要传导膀胱逼尿肌或阴茎海绵体的不同小束,高选择性切断后可以分别改变膀胱内压和海绵体内压,或可为临床治疗脊髓损伤后痉挛性膀胱同时最大限度保留反射性阴茎勃起功能提供实验基础。     

腰骶段选择性脊神经后根切断术治疗脑瘫性下肢痉挛状态手术并发症

目的：探讨腰骶段选择性脊神经后根部分切断术（selective posterior rhizotomy,SPR）治疗脑瘫性下肢痉挛状态手术并发症的防治。方法：回顾性分析2000年1月至2012年9月经腰骶段SPR治疗并随访1年以上的2 593例脑瘫性下肢痉挛状态患者的临床资料,分析术后并发症发生情况。结果：围手术期并发症情况：呼吸系统并发症包括支气管痉挛5例（0.19%）、吸入性肺炎4例（0.15%）;消化系统并发症包括腹胀145例（5.6%）、肠绞痛80例（3.1%）;泌尿系统并发症包括暂时性膀胱功能障碍54例（2.1%）、泌尿系感染6例（0.23%）;周围神经系统并发症包括下肢无力327例（12.6%）、下肢感觉障碍140例（5.4%）;中枢神经系统并发症包括头痛112例（4.32%）、癫痫发作4例（0.15%）,无椎管内或颅内感染、椎管内血肿或颅内出血等;一般手术并发症包括腰背部疼痛1 382例（53.3%）、切口感染延迟愈合5例（0.19%）、脑脊液漏8例（0.31%)。随访1年以上中远期并发症发生率：下肢运动能力下降7.33%（190/2 593）,下肢感觉障碍5.59%（145/2 593）,大小便障碍0.04%（1/2 593）,脊柱侧弯7.23%（31/429）,胸椎后凸4.2%（18/429）,腰椎滑脱10.49%（45/429）,长期腰背痛9.72%（252/2 593）,未见性功能障碍。结论：腰骶段SPR是治疗脑瘫性下肢痉挛状态的安全的手术方法,选择合适病例、术中精细操作、术中神经电生理监测、加强围手术期管理及术后正规康复训练可有效降低术后并发症的发生率。     

Dorsal rhizotomy in cerebral palsy: How root sectioning is influenced by intraoperative neuromonitoring?

Introduction and objectiveDorsal rhizotomy is a controversial procedure for treating spasticity in children with cerebral palsy, particularly regarding the influence of intraoperative neuromonitoring (ION). The objective of this study was to evaluate the influence of ION in adjusting root sectioning compared the preoperative program established by the multidisciplinary team.Material and methodsTwenty-four consecutive children with spastic diplegia or quadriplegia, operated on between 2017 and 2020 in the University Hospital of Nancy, France, were studied. All underwent the same procedure: Keyhole Intralaminar Dorsal rhizotomy (KIDr) with enlarged multilevel interlaminar openings to access all roots from L2 to S2. The Ventral Root (VR) was stimulated to map radicular myotomes, and the Dorsal Root (DR) to test excitability of the segmental circuitry. Muscle responses were observed independently by the physiotherapist and by EMG-recordings. The study compared final root sectioning per radicular level and per side after ION versus the preoperative program determined by the multidisciplinary team.ResultsION resulted in significant differences in final percentage root sectioning (P < 0.05), with a decrease for L2 and L3 and an increase for L5. ION modified the symmetry of sectioning, with 32% instead of 5% in preoperative program. Only 5 children showed change in GMFC score 6 months after surgery.ConclusionThe use of ION during dorsal rhizotomy led to important modifications of root sectioning during surgery, which justifies individual control of each root, level by level and side by side, to optimize the therapeutic effect.     

Muscle responses to radicular stimulation during lumbo-sacral dorsal rhizotomy for spastic diplegia: Insights to myotome innervation

ObjectiveMost of knowledge on muscle radicular innervation was from explorations in root/spinal cord pathologies. Direct and individual access to each of the lumbar-sacral -ventral and dorsal- nerve roots during dorsal rhizotomy for spastic diplegia allows precise study of the corresponding muscle innervation. Authors report the lumbo-sacral segmental myotomal organization obtained from recordings of muscle responses to root stimulation in a 20-children prospective series.MethodsSeven key-muscles in each lower limb and anal sphincter were Electromyography (EMG)-recorded and clinically observed by physiotherapist during L2-to-S2 dorsal rhizotomy. Ventral roots (VR), for topographical mapping, and dorsal roots (DR), for segmental excitability testing, were stimulated, just above threshold for eliciting muscular response.ResultsIn 70% of the muscles studied, VR innervation was pluri-radicular, from 2-to-4 roots, with 1 or 2 roots being dominant at each level. Overlapping was important. Muscle responses to DR stimulation were 1.75 times more extended compared to VR stimulation. Inter-individual variability was important.ConclusionsAccuracy of root identification and stimulation with the used method brings some more precise information to radicular functional anatomy.SignificanceThose neurophysiological findings plead for performing Intra-Operative Neuromonitoring when dealing with surgery in the lumbar-sacral roots.