有限度选择性脊神经后根切断术联合内收肌松解改善下肢痉挛型脑性瘫痪儿童的运动能力

背景选择性脊神经后根切断术(selectiveposterior rhizotomy,SPR)作为痉挛型脑性瘫痪解除痉挛和改善功能的有效手段已被逐渐公认和推广,但标准的SPR手术后脊柱失稳、肌力减退等并发症已成为人们观注的课题.有限度的选择性脊神经后根切断术(limitedselective posterior rhizotomy,LSPR)联合内收肌松解术有效解除下肢痉挛畸形同时,在减少上述并发症方面有良好效果.目的探讨LSPR联合内收肌松解术治疗下肢痉挛型脑性瘫痪对解除下肢痉挛畸形、改善步态、提高患者运动能力的作用.设计以痉挛性脑性瘫痪患儿为研究对象的自身前后对照、随访性观察.单位大连医科大学附属第一医院骨科病房.对象病例来源于2001-01/2002-12吉林大学第一医院骨科病房住院治疗的痉挛性脑性瘫痪患儿.双下肢表现为不同程度的剪刀步态、屈膝及尖足行走.腱反射亢进,踝阵挛阳性18例,Babinski征阳性15例.所有患者躯干与四肢均有较好的运动功能,均能独立行走、下蹲或在单手或双手扶持下行走,无固定的软组织挛缩畸形.干预本组患者均采用选择性L5、S1脊神经后根切断术,同时联合双侧内收肌松解术治疗.术后评定患者下肢肌张力、肌力、膝及跟腱反射、病理症及踝阵挛变化;腰椎、骨盆X射线片及物理检查了解畸形改变;根据手术前后立姿、步姿、下蹲起立等评分,评价运动功能改善情况.随访方法通过查阅原始病历,回院复查及书信联系,填写表格并详细记录,了解手术前后运动功能、肌张力、肌力、膝及跟腱反射、踝阵挛等改变.主要观察指标痉挛性脑性瘫痪患儿有限度的选择性脊神经后根切断术治疗前后痉挛解除和下肢功能评分情况.结果本组30例均获随访,随访时间6个月～3年,平均11个月.所有患者的痉挛程度较术前有明显降低,平均下降2.5级.术后步态明显改善,剪刀步态及尖足消失,屈膝改善,足跟可着地行走.踝阵挛及病理反射消失率100%,12例术前膝腱反射亢进的患者,术后膝反射减弱.术后双下肢无肌力减退及感觉的永久性缺失.术后随访2年以上的9例摄腰椎及骨盆X线片未见畸形出现.同时8例术前有上肢痉挛或流涎、语言障碍的患者术后上述症状也不同程度缓解.患者手术后立姿(4.25±0.91)、步姿(3.92±0.65)、蹲、立姿势变换能力(4.02±0.74)较术前明显改善,差异均有显著性意义(t=2.04～2.98,P＜0.05～0.01).结论LSPR结合内收肌松解术,在减少手术创伤的同时,可有效的解除脑性瘫痪患者下肢痉挛畸形,提高其运动能力.

Limited selective posterior rhizotomy combined with adductor tenotomy for the improvement of motor ability of children with spastic lower limbs in cerebral palsy

BACKGROUND: Selective posterior rhizotomy has been extensively acknowledged as an effective method of relieving lower limb spasticity in cerebral palsy. However, the postoperative complications such as reduced muscle strength and imbalance of the spine are of concern among surgeons and therapists. The combination of limited selective posterior rhizotomy (LSPR) with adductor tenotomy can decrease these complications without compromising the treatment effects.OBJECTIVE: To investigate the effects of combination therapy of LSPR with adductor tenotomy on lower limb spasticity, gait and movement of the patients.DESIGN: A self-controlled trial and observational follow-up taking children with cerebral palsy as the subjects.SETTING: Orthopedic Department of First Hospital Affiliated to Dalian Medical University.PARTICIPANTS: Thirty children patients with cerebral palsy treated in the Orthopedics Department of the First Affiliated Hospital of Jilin University from January 2001 to December 2002 were recruited in this trial. They presented scissors gait, flexed knee and tiptoeing of different degree. There were 18 cases of brisk tendon reflex and ankle clonus, and 15 cases of positive Babinski' s sign. All the patients had no immobile soft tissue contracture and could either accomplish walking and crouching independently or walk with arms on assistant devices.INTERVENTIONS: The patients received LSPR of L5 and S1 dorsal roots together with bilateral adductor tenotomy. Muscle tone and strength, knee and Achilles tendon reflexes, ankle clonus and pathologic signs were recorded before and after operation. X-ray examination on lumbar spine and pelvic was also taken for detection of deformity. The patients' movements were assessed according to their standing and walking postures, standing and crouching movements before operation and on follow-up. During follow-up all the mentioned indices were recorded by reference to the original case history, hospital reexamination and correspondence with the patients.MAIN OUTCOME MEASURES: The amelioration in lower limb spasticity and grading of lower limb()movements.RESULTS: During the follow-up for six months to three years(the mean of 11 months), the patients' lower limb spasticity was decreased by 2. 5 grades. The gait was also improved with disappeared scissors gait and tiptoeing, knee flexion was improved and the patients could walk with heels on the ground. All ankle clonus and pathologic reflexes disappeared. The brisk knee reflex in 12 patients became sluggish after operation. There was no decrease in lower limb strength or permanent hypesthesia. X-ray examination of lumbar spine and pelvic showed no deformity in 9 patients after over 2-year follow-up. The upper limb spasticity, salivation and aphasia in 8 patients were also ameliorated. The grading for postoperative standing, walking and crouching-standing alternation[(4.25±0.91), (3.92±0.65) and(4.02±0.74)] wasimproved(t=2.04-2.98, P ＜0.05-0.01).CONCLUSION: The combination of LSPR with adductor tenotomy can effectively ameliorate lower limb spasticity and movement with decreased operative damage.