Systematic review on use and efficacy of selective dorsal rhizotomy (SDR) for the management of spasticity in non-pediatric patients

Nerve-Targeted Surgical Treatments for Spasticity: A Narrative Review

Spasticity is a potentially debilitating symptom of various acquired and congenital neurologic pathologies that, without adequate treatment, may lead to long-term disability, compromise functional independence, and negatively impact mental health. Several conservative as well as non-nerve targeted surgical strategies have been developed for the treatment of spasticity, but these may be associated with significant drawbacks, such as adverse side effects to medication, device dependence on intrathecal baclofen pumps, and inadequate relief with tendon-based procedures. In these circumstances, patients may benefit from nerve-targeted surgical interventions such as (i) selective dorsal rhizotomy, (ii) hyperselective neurectomy, and (iii) nerve transfer. When selecting the appropriate surgical approach, preoperative patient characteristics, as well as the risks and benefits of nerve-targeted surgical intervention, must be carefully evaluated. Here, we review the current evidence on the efficacy of these nerve-targeted surgical approaches for treating spasticity across various congenital and acquired neurologic pathologies.

Mapping the focus of research conducted with adults with cerebral palsy: an overview of systematic reviews

PURPOSE

To map research conducted with adults with cerebral palsy (CP) to the International Classification of Functioning, Disability and Health (ICF) to understand the array of research available, identify key clinical messages and inform future research.

MATERIALS AND METHODS

An overview of systematic reviews was conducted. Comprehensive searches (to December 2021) were conducted in PsycINFO, Web of Science, MEDLINE, CINAHL, Cochrane, JBI, and EMBASE. Eligible studies were systematic reviews that included primary studies of adults with CP. Included reviews were assessed for study quality and mapped to the ICF components and chapters. A narrative synthesis of commonly reported outcomes within the component/s and chapter/s was conducted.

RESULTS

All 24 included reviews were published since 2010. Thirteen focused on body functions: movement related functions and cardiovascular and respiratory systems. Although nine reviews focused on gait and mobility, considerable overlap of included studies limited the volume of evidence and variability in review quality limited generalisability of findings.

CONCLUSIONS

Research involving adults with CP is growing; however, this overview of reviews found a predominant focus on mobility and gait. Future research, informed by consumer priorities, is needed to address a broader range of key health and participation outcomes.Implications for rehabilitationFitness, mobility, and gait were the most common research topics found in these systematic reviews suggesting a narrow research focus in adults with CP.There are significant gaps in our knowledge to inform clinical messages for practice about broad long-term outcomes of CP and how best to support their activity performance and participation.There is very limited evidence with which to guide and support rehabilitation professionals working in this field.

Treatment of spasticity

Spasticity is characterized by an enhanced size and reduced threshold for activation of stretch reflexes and is associated with "positive signs" such as clonus and spasms, as well as "negative features" such as paresis and a loss of automatic postural responses. Spasticity develops over time after a lesion and can be associated with reduced speed of movement, cocontraction, abnormal synergies, and pain. Spasticity is caused by a combination of damage to descending tracts, reductions in inhibitory activity within spinal cord circuits, and adaptive changes within motoneurons. Increased tone, hypertonia, can also be caused by changes in passive stiffness due to, for example, increase in connective tissue and reduction in muscle fascicle length. Understanding the cause of hypertonia is important for determining the management strategy as nonneural, passive causes of stiffness will be more amenable to physical rather than pharmacological interventions. The management of spasticity is determined by the views and goals of the patient, family, and carers, which should be integral to the multidisciplinary assessment. An assessment, and treatment, of trigger factors such as infection and skin breakdown should be made especially in people with a recent change in tone. The choice of management strategies for an individual will vary depending on the severity of spasticity, the distribution of spasticity (i.e., whether it affects multiple muscle groups or is more prominent in one or two groups), the type of lesion, and the potential for recovery. Management options include physical therapy, oral agents; focal therapies such as botulinum injections; and peripheral nerve blocks. Intrathecal baclofen can lead to a reduction in required oral antispasticity medications. When spasticity is severe intrathecal phenol may be an option. Surgical interventions, largely used in the pediatric population, include muscle transfers and lengthening and selective dorsal root rhizotomy.

A Cadaver Feasibility Study of Extradural Contralateral C7 Ventral Root Transfer Technique for Treating Upper Extremity Paralysis

STUDY DESIGN

A total of 6 formalin-fixed cadavers were included in the cadaver feasibility study.

OBJECTIVE

The aim was to ascertain the anatomical feasibility of extradural contralateral C7 ventral root transfer technique by cervical posterior.

SUMMARY OF BACKGROUND DATA

Upper limb spastic hemiplegia is a common sequela after stroke. In our previous study, the authors established a method by transferring contralateral C7 dorsal and ventral roots to the corresponding C7 dorsal and ventral roots on the affected side in the cervical posterior.

METHODS

In the present study, six formalin-fixed cadavers were dissected to confirm the anatomical feasibility. Experimental anastomosis in cadavers was conducted. The pertinent lengths of the extradural nerve roots were measured. The tissue structures surrounding regions between the extradural CC7 nerve roots and the vertebral artery were observed. The cervical magnetic resonance imaging scans of 60 adults were used to measure the distance between the donor and recipient nerves.

RESULTS

Experimental anastomosis showed that the distance between the donor and recipient nerves was approximately 1 cm; the short segment of the sural nerve needed bridging. The distance between both exit sites of the exit of the extradural dura mater was 33.57±1.55 mm. The length of the extradural CC7 ventral root was 22.00±0.98 mm. The ventral distance (vd) and the dorsal distance (dd) in males were 23.98±1.72 mm and 30.85±2.22 mm ( P <0.05), while those in females were 23.28±1.51 mm and 30.03±2.16 mm, respectively. C7 vertebral transverse process, ligaments, and other soft tissues were observed between the vertebral artery and the extradural C7 nerve root.

CONCLUSION

Under the premise of less trauma, our study shows that the extradural contralateral C7 ventral root transfer technique, in theory, yields better surgical results, including better recovery of motor function and complete preservation of sensory function.

LEVEL OF EVIDENCE

5.

A novel treatment for malignant spasticity: the therapeutic use of stereotactic radiosurgery (SRS)

Spasticity is a clinical condition secondary to central nervous system damage, which impairs patients' mobility and quality of life. Stereotactic radiosurgery (SRS) to the spinal roots responsible of the spasms might represent a non-invasive therapy. The present are the preliminary results of the first clinical use of this novel technique.