Gait before and 10 years after rhizotomy in children with cerebral palsy spasticity

Abstract

<jats:p>Selective dorsal rhizotomy is a neurosurgical procedure performed for the relief of spasticity in children with cerebral palsy, but its long-term functional efficacy is still unknown. The authors sought to address this issue by means of an objective, prospective study in which quantitative gait analysis was used. Eleven children with spastic diplegia (mean age at initial surgery 7.8 years) were evaluated preoperatively in 1985 and then at 1, 3, and at least 10 years after surgery. For comparison, 12 age-matched normal individuals were also studied. Retroreflective targets were placed over the hip, knee, and ankle joints, and each individual's gait was videotaped. The video data were subsequently entered into a computer for extraction and analysis of the gait parameters. An analysis of variance yielded a significant time effect (p &lt; 0.05), and post hoc comparisons revealed differences before and after surgery and with respect to the normal control subjects. The knee and hip ranges of motion (59š and 44š, respectively, for controls) were significantly restricted prior to surgery (41š and 41š, respectively), but were within normal limits after 10 years (52š and 45š, respectively). The knee and hip midrange values (31š and 3š, respectively, for controls), indicative of posture, were significantly elevated preoperatively (42š and 15š) and increased sharply at 1 year (56š and 18š), but by 10 years they had decreased to within normal limits (36š and 9š). Step length and velocity improved postoperatively but were not within the normal range after 10 years. Ten years after surgery our patients not only had increased ranges of motion, they also used that movement about a normal midrange point. Selective dorsal rhizotomy is an effective method for alleviating spasticity; furthermore, the authors provide evidence to show that lasting functional benefits, as measured by improved gait, can also be obtained.</jats:p>

Reduction in upper-extremity tone after lumbar selective dorsal rhizotomy in children with spastic cerebral palsy

“…16 Clinical studies have demonstrated that SDR results in short-and long-term improvement in lower-extremity tone and can lead to improved mobility, improved lower-limb function, decreased need for orthopedic surgical interventions, and an increased level of self-care for children with spastic diplegia and spastic quadriplegia. 2,5,7,8,10,12,15,18,19 Although nerve rootlet transection is limited to the lumbosacral rootlets in SDR, early anecdotal reports in the 1980s suggested the unexpected observation of improvements above the level of the lower extremities, termed "suprasegmental effects." Over the next decade, a number of small case series emerged describing improvement in upper-extremity function or tone following SDR, but only described qualitative improvement or quantitative improvement in select upper-extremity muscle groups.…”

“…4 The advancement of intraoperative electrophysiological monitoring allowed for the development and popularization of the selective dorsal rhizotomy (SDR) in the 1980s. 13,14,17,18 Selective dorsal rhizotomy involves a selective transection of lower-extremity sensory nerve rootlets based on EMG data and manual palpation of muscle groups indicating excessive levels of diffuse excitatory input when Ia afferent nerve fibers are stimulated. 16 Clinical studies have demonstrated that SDR results in short-and long-term improvement in lower-extremity tone and can lead to improved mobility, improved lower-limb function, decreased need for orthopedic surgical interventions, and an increased level of self-care for children with spastic diplegia and spastic quadriplegia.…”

Role of dorsal rhizotomy in spinal cord injury–induced spasticity

“…4,7,9,18 Three randomized controlled trials and other nonrandomized prospective studies have provided strong evidence that SDR decreases lower-extremity spasticity in children with spastic diplegia. 4,17 Additional studies have demonstrated maintenance of the postoperative benefits in the long term.…”

A review of orthopedic surgeries after selective dorsal rhizotomy

“…In a 1998 review, Subramanian, et al, 17 showed with moderate certainty that the rate of orthopedic surgery after SDR is approximately 65%. In our three studies, we only found such high rates of orthopedic surgery in children with quadriplegia who underwent SDR at an older age (6-14 years) and who all needed assistance walking at follow-up evaluation.…”