Pre- and Postoperative Gait Analysis and Video for Selective Dorsal Rhizotomy in Spastic Diplegia: 2-Dimensional Operative Video

Abstract

Severe lower limb spasticity can hinder motor tasks and negatively impacts the quality of life in patients with cerebral palsy. Selective dorsal rhizotomy is a well-established neurosurgical intervention aimed at reducing muscle spasticity in patients with such neuromuscular conditions. Long-term outcomes of selective dorsal rhizotomy have been promising among the authors’ institutional series of patients. In this case, we demonstrate the use of L1-S1 osteoplastic laminoplasty and L1-S1 selective dorsal rhizotomy in a 5-year-old male patient with cerebral palsy and spastic lower extremity diplegia. Favorable selection criteria for this case included disabling lower extremity diplegia, young age, good core strength, no cognitive delay, and strong rehabilitation potential. The patient's preoperative functional status was noncommunity ambulator (Gross Motor Function Classification System Level III) with walker use and good dynamic balance. Prior to the procedure, he demonstrated an overall decreased muscle strength in bilateral lower extremities with bilateral hamstring spasticity (Ashworth 3) and bilateral heel cord spasticity (Ashworth 4). Rhizotomy was performed with identification and selective sectioning of dorsal nerve roots with abnormal stimulation patterns. Fibers with unsustained discharge of appropriate muscles were identified and spared. No intraoperative or postoperative complications were encountered. The patient had minimal back pain and surgical morbidity postoperatively. Following the procedure and highly structured inpatient and outpatient rehabilitation therapies, the patient exhibited significant improvement in gait velocity (84%) and gait cadence (66%) at 5 months. Additionally, the patient demonstrated greater independence of activities of daily living and improvements in mobility by Pediatric Evaluation Disability Index. Patient consent was obtained from the parent.

Commentary: Pre- and Postoperative Gait Analysis and Video for Selective Dorsal Rhizotomy in Spastic Diplegia: 2-Dimensional Operative Video

“…Authors also provide excision of the filum terminale to prevent any future tethering. 1 Intraoperative neuromonitoring, which shows an abnormal firing pattern/most robust response, at the same level as done by the authors, can improve the success of surgery. 7 The authors present a series of patients in their institution who show improvement in velocity and cadence after SDR, which is being followed up until 4 mo after surgery.…”

“…In this surgical video, the authors provide a systematic procedure that explains step by step selective dorsal rhizotomy (SDR) for patients with leg spasticity. 1 Patient evaluation before surgery is described by the authors briefly, including the patient selection characteristics. The walking condition of the patient before surgery is also shown in this video with spastic gait, which can affect the gait balance of the patient.…”

“…The walking condition of the patient before surgery is also shown in this video with spastic gait, which can affect the gait balance of the patient. 1 The authors use the Gross Motor Function Classification System (GMFCS) scale categorized into 5 different levels. The patient in the video walking using a hand-held mobility device explains that the patient had Level III of GMFCS scale.…”

“…The patient in the video walking using a hand-held mobility device explains that the patient had Level III of GMFCS scale. 1,2 SDR was first introduced by Foerster in 1913 for children with cerebral palsy and having diplegia; the milestone began with more selective root cutting by Gros and Fasano. SDR is performed by cutting 30%-50% of dorsal roots along L1 and S1 either by monitoring the clinical response of muscle by electrical stimulation at the dorsal roots or by using electromyograph during intraoperative monitoring.…”

“…The patients can walk better without using a hand-held mobility device and without any complication. 1 Patient selection is very important. Evaluation should be done comprehensively by a medical team member in order to have the best outcome for management of cerebral palsy children with spasticity.…”