Selective posterior rhizotomy and intrathecal baclofen for the treatment of spasticity

Reducing opioid usage: a pilot study comparing postoperative selective dorsal rhizotomy protocols

OBJECTIVE

Selective dorsal rhizotomy (SDR) is a surgical procedure used to treat spasticity in children with spastic cerebral palsy. Currently, there is a lack of work examining the efficacy of optimizing pain management protocols after single-level laminectomy for SDR. This pilot study aimed to compare the clinical outcomes of SDR completed with a traditional pain management protocol versus one designed for opioid dosage reduction.

METHODS

The Texas Comprehensive Spasticity Center prospective database was queried for all patients who underwent SDR between 2015 and 2018. Demographic, surgical, and postoperative data for all patients who underwent SDR were collected from medical records. The study was designed as a retrospective study between the patient-controlled analgesia (PCA) and dexmedetomidine infusion (INF) groups with 80% power to detect a 50% difference at a significance level of 0.05. Patients in the INF group received perioperative gabapentin, intraoperative dexmedetomidine infusion, and scheduled acetaminophen and NSAIDs postoperatively.

RESULTS

Medication administration records, pain scores, and therapy notes were collected for 30 patients. Patients who underwent SDR between June 2015 and the end of December 2017 received traditional pain management (PCA group, n = 14). Patients who underwent SDR between January 2018 and the end of December 2018 received modified pain management (INF group, n = 16). No patients were lost to follow-up. Differences in age, weight, height, preoperative Gross Motor Function Classification System scores, operative duration, hospital length of stay, and sex distribution were not statistically different between the 2 groups (p > 0.05). Analysis of analgesic medication doses demonstrated that the INF group required fewer doses and lower amounts of opioids overall, and also fewer NSAIDs than the PCA group. When converted to the morphine milligram equivalent, the patients in the INF group used fewer doses and lower amounts of opioids overall than the PCA group. These differences were either statistically significant (p < 0.05) or trending toward significance (p < 0.10). Both groups participated in physical and occupational therapy similarly postoperatively (p > 0.05). Pain scores were comparable between the groups (p > 0.05) despite patients in the INF group requiring fewer opioids.

CONCLUSIONS

Infusion with dexmedetomidine during SDR surgery combined with perioperative gabapentin and scheduled acetaminophen and NSAIDs postoperatively resulted in similar pain scores to traditional pain management with opioids. In addition, this pilot study demonstrated that patients who received the INF pain management protocol required reduced opioid dosages and were able to participate in therapy similarly to the control PCA group.

Intrathecal baclofen for treating spasticity in children with cerebral palsy

BACKGROUND

Cerebral palsy is a disorder of movement and posture arising from a non-progressive lesion in the developing brain. Spasticity, a disorder of increased muscle tone, is the most common motor difficulty and is associated with activity limitation to varying degrees in mobility and self care.Oral baclofen, a gamma-aminobutyric acid (GABA) agonist, has been used in oral form to treat spasticity for some time, but it has a variable effect on spasticity and the dose is limited by the unwanted effect of excessive sedation. Intrathecal baclofen produces higher local concentrations in cerebrospinal fluid at a fraction of the equivalent oral dose and avoids this excessive sedation.

OBJECTIVES

To determine whether intrathecal baclofen is an effective treatment for spasticity in children with cerebral palsy.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, EMBASE and CINAHL databases, handsearched recent conference proceedings, and communicated with researchers in the field and pharmaceutical and drug delivery system companies.

SELECTION CRITERIA

We included studies which compared the effect of intrathecal baclofen treatment on spasticity, gross motor function or other areas of function with controls.

DATA COLLECTION AND ANALYSIS

Two authors selected studies, two authors extracted data and two authors assessed the methodological quality of included studies.

MAIN RESULTS

Six studies met the inclusion criteria. The data obtained were unsuitable for the conduct of a meta-analysis; we have completed a qualitative summary.All studies were found to have high or unclear risk of bias in some aspects of their methodology.Five of the six studies reported data collected in the randomised controlled phase of the study. A sixth study did not report sufficient results to determine the effect of intrathecal baclofen versus placebo. Of these five studies, four were conducted using lumbar puncture or other short-term means of delivering intrathecal baclofen. One study assessed the effectiveness of implantable intrathecal baclofen pumps over six months.The four short-term studies demonstrated that intrathecal baclofen therapy reduces spasticity in children with cerebral palsy. However, two of these studies utilised inappropriate techniques for statistical analysis of results. The single longer-term study demonstrated minimal reduction in spasticity with the use of intrathecal baclofen therapy.One of the short-term studies and the longer term study showed improvement in comfort and ease of care. The longer term study found a small improvement in gross motor function and also in some domains of health-related quality of life.Some caution is required in interpreting the findings of the all the studies in the review due to methodological issues. In particular, there was a high risk of bias in the methodology of the longer term study due to the lack of placebo use in the control group and the absence of blinding to the intervention after randomisation for both participants and investigators.

AUTHORS' CONCLUSIONS

There is some limited short-term evidence that intrathecal baclofen is an effective therapy for reducing spasticity in children with cerebral palsy. The effect of intrathecal baclofen on long-term spasticity outcomes is less certain.The validity of the evidence for the effectiveness of intrathecal baclofen in treating spasticity in children with cerebral palsy from the studies in the review is constrained by the small sample sizes of the studies and methodological issues in some studies.Spasticity is a impairment in the domain of body structure and function. Consideration must also be given to the broader context in determining whether intrathecal baclofen therapy is effective. The aim of therapy may be, for example, to improve gross motor function, to increase participation at a social role level, to improve comfort, to improve the ease of care by others or to improve the overall quality of life of the individual. Intrathecal baclofen may improve gross motor function in children with cerebral palsy, but more reliable evidence is needed to determine this.There is some evidence that intrathecal baclofen improves ease of care and the comfort and quality of life of the individuals receiving it, but again small sample sizes and methodological issues in the studies mean that these results should be interpreted with caution.Further evidence of the effectiveness of intrathecal baclofen for treating spasticity, increasing gross motor function and improving comfort, ease of care and quality of life is needed from other investigators in order to validate these results.The short duration of the controlled studies included in this review did not allow for the exploration of questions regarding whether the subsequent need for orthopaedic surgery in children receiving intrathecal baclofen therapy is altered, or the safety and the economic implications of intrathecal baclofen treatment when long-term therapy is administered via an implanted device. Controlled studies are not the most appropriate study design to address these questions, cohort studies may be more appropriate.

Neurosurgical Management of Childhood Spasticity: Functional Posterior Rhizotomy and Intrathecal Baclofen Infusion Therapy

A paradigm shift is currently ongoing in the treatment of spasticity in childhood in Japan. Functional posterior rhizotomy (FPR), which was first introduced to Japan in 1996, is best indicated for children with spastic cerebral palsy, regardless of the clinical severity of spasticity. Surgery is generally carried out in the cauda equina, where the posterior root is separated from the anterior one, and neurophysiological procedures are used to judge which nerve root/rootlet should be cut. The outcome of FPR is favorable for reducing spasticity in the long-term follow-up. Intrathecal baclofen (ITB) treatment for childhood spasticity was approved in 2007 in Japan and the number of children undergoing ITB pump implantation has been gradually increasing. ITB treatment is best indicated for children with severe spasticity, especially those with dystonia, regardless of the pathological background. Since it is a surgery performed to implant foreign bodies, special attention should be paid to avoid perioperative complications such as CSF leakage, meningitis, and mechanical failure. Severely disabled children with spasticity would benefit most from ITB treatment. We would especially like to emphasize the importance of a strategic approach to the treatment of childhood spasticity. The first step is to reduce spasticity by FPR, ITB, and botulinum toxin injection. The second step is to aim for functional improvement after controlling spasticity. Traditional orthopedic surgery and neuro-rehabilitation form the second step of treatment. The combination of these treatments that allows them to complement each other is the key to a successful treatment of childhood spasticity.

Clinical outcomes after selective dorsal rhizotomy in an adult population

OBJECT

Selective dorsal rhizotomy (SDR) is a highly effective and well-established surgical tool for correction of lower-extremity spasticity in children with spastic diplegia caused by cerebral palsy (CP). Although the literature demonstrates considerable immediate and long-term functional benefits in children treated with SDR, the effects of SDR on adults with spastic diplegia have not been thoroughly investigated. The purpose of this retrospective study was to examine the objective and subjective clinical outcomes of SDR on an adult population.

METHODS

We reviewed the charts of 21 consecutive adult patients who underwent SDR for treatment of CP-related spastic diplegia between the years of 1989 and 2007. All patients were treated by a single surgeon (T.S.P.) and underwent formal pre- and postoperative physical therapy assessments to examine joint range of motion (ROM), gross motor function measure (GMFM), and muscle tone. The majority of patients (15/21) exhibited preoperative ambulatory independence without an assistive device. Postoperative assessments were performed at 4 months, but most patients (11/21) had longer follow-up periods (mean, 17.6 ± 30.2 months). All patients were assessed with a telephone survey to estimate pre- and postoperative function with the Katz and Lawton Activities of Daily Living (ADL) Scale.

RESULTS

After SDR surgery, patients experienced significant improvements in lower-extremity passive joint ROM (namely, decreases in hamstring and gastrocnemius tightness) as well as in GMFM crawling and kneeling scores. In addition, spasticity in all measured lower-extremity muscle groups was decreased as compared with preoperative levels. On the basis of our patient self-assessments conducted via telephone, each patient demonstrated subjective improvements in ambulatory ability, spasticity, coordination, joint ROM, pain, overall quality of life, and independence. Also, the Lawton total instrumental ADL scale scores were subjectively improved from preoperative levels. We documented no complications, including postoperative sensory deficits, in any of our patients.

CONCLUSIONS

Our experience suggests that SDR can be an effective treatment for CP-related spastic diplegia in ambulatory adults who are unresponsive to medical therapy and should be considered as a therapeutic option in carefully selected patients. Although our study represents the largest series of adult patients with spastic diplegia to date treated with SDR, the data collected will need to be validated in a larger, prospective clinical trial.

[Neuromodulation of spasticity in children by intrathecal baclofen]

INTRODUCTION

Treatment with intrathecal baclofen (ITB) is an important part of the complex therapy of patients with cerebral spasticity aiming to improve the motoric functions and to reduce pain intensity.

MATERIAL AND METHODS

ITB was started in the Orthopaedic Hospital in Speising in 1999. From 1999 to 2006 a total of 15 children aged 3 to 16 years old were selected for this special treatment.

RESULTS

The average degree of spasticity according to Ashworth (scale 1-5) could be reduced by ITB from 4.38 to 3.0, the time spent sitting could be increased from 3.3 to 5.8h per day and the pain intensity (VAS 1-10) could be reduced from 4.2 to 0.6. The time necessary for nursing treatment was shortened from 7.5 to 3.4 (VAS 1-10). Also improved was the emotional situation, the ability to swallow, the posture of the head and the concentration ability.

CONCLUSION

ITB provides neuromodulation even in pediatric patients with complex neuromotoric spasticity.

Selective dorsal rhizotomies in the treatment of spasticity related to cerebral palsy

RATIONALE

Selective dorsal rhizotomy (SDR) is a surgical technique developed over the past decades to manage patients diagnosed with cerebral palsy suffering from spastic diplegia. It involves selectively lesioning sensory rootlets in an effort to maintain a balance between elimination of spasticity and preservation of function. Several recent long-term outcome studies have been published. In addition, shorter follow-up randomized controlled studies have compared the outcome of patients having undergone physiotherapy alone with those that received physiotherapy after selective dorsal rhizotomy.

MATERIALS AND METHODS

In this account, we will discuss the rationale and outcome after SDR. The outcome is addressed in terms of the gross motor function measurement scale (GMFM), degree of elimination of spasticity, strength enhancement, range of motion, fine motor skills, activity of daily living, spastic hip, necessity for postoperative orthopedic procedures, bladder and sphincteric function, and finally possible early or late complications associated with the procedure.

CONCLUSION

We conclude that SDR is a safe procedure, which offers durable and significant functional gains to properly selected children with spasticity related to cerebral palsy.

Experience with external pump trial prior to implantation for intrathecal baclofen in ambulatory patients with spastic cerebral palsy

OBJECTIVES

To evaluate effectiveness and safety of intrathecal baclofen administration (ITB) testing with continuous infusion via an external pump before the implantation of an internal one in ambulatory spastic patients with cerebral palsy (CP).

PATIENTS AND METHODS

Seven CP patients (3 diplegic, 4 quadriplegic - 18.4+/-7.0 years) with a progressive decrease in walking ability were included. Assessments included: Ashworth's scale, Observational Gait Scale (OGS), and GMFM-66.

RESULTS

During the ITB test (45-150 microg/24h), spasticity decreased by more than two points on Ashworth's scale (p<0.001) and walking ability improved (median OGS increased from 7 to 9, p<or=0.05). After implantation of an internal Synchromed pump (dosage 66-160 microg/24h), mean GMFM-66 increased from 49.9+/-7.3 to 54.5+/-7.7 (p<0.05) and median OGS from 7 to 10 (p<0.05). Two nonambulatory patients recovered some walking ability following implantation of the pump. Adverse effects included one case of chemical meningitis during the test and two temporary CSF leaks.

CONCLUSIONS

Tests of ITB using a continuous infusion by an external pump allowed precise evaluation of the effects of different ITB doses on walking ability, enabling prediction of how the patient would respond to an internal pump. All patients showed ambulatory improvement with ITB.

Use of Intrathecal Baclofen in a Child With Spastic Paraparesis Related to Human Immunodeficiency Virus Infection: A Case Report

This case report describes a 2-year treatment course of a 6-year-old with spastic paraparesis due to human immunodeficiency virus (HIV) encephalopathy. She continued to develop worsening musculoskeletal problems and a decline in mobility despite aggressive antispasticity interventions. In addition to meeting the usual clinical criteria for treatment with continuous intrathecal baclofen (ITB), she was believed to be an appropriate candidate for ITB because of adequate treatment of her HIV infection and associated overall low risk of mortality. For over 12 months, she has been successfully treated with ITB and has not developed any complications related to her HIV infection. To my knowledge, this is the first reported successful treatment of spasticity with ITB in a patient with stable HIV infection.

Functional posterior rhizotomy for severely disabled children with mixed type cerebral palsy

The authors evaluated the impact of functional posterior rhizotomy (FPR) for children with severely disabled mixed type cerebral palsy (CP). Three quadriplegic children at the age of 3, 4, and 10 years underwent FPR. They were classified as mixed type CP based on the clinical presentation of marked spasticity with dystonic posture. Preoperative Ashworth score of the lower extremity was 3.5, 4.5, 4.8 respectively. Two children showed prominent opisthotonus and all showed severe subluxation of the hip joint. Advanced scoliosis was associated in two children. FPR was performed from L2 to S1 in one child, L2 to S2 in one and L2 to S1/S2 in one based on the result of pudendal mapping. Rootlet cutting rate ranged from 66 to 75%. Postoperatively, Ashworth score dropped to 1.4, 1.2, 1.3, respectively. Functional improvement of the upper extremity and urination were confirmed in two children. Hip subluxation was reduced in one child and remained stable in two. A one-year follow-up review confirmed no relapse of spasticity among them. FPR achieved highly satisfactory surgical effects in children with severe mixed type CP. Although long-term follow-up is mandatory since there was a report of relapsed spasticity after FPR in this particular population of CP, FPR could be a choice of surgery in severely disabled children with mixed type CP.

Impact of selective posterior rhizotomy on fine motor skills. Long-term results using a validated evaluative measure

Suprasegmental effects following selective posterior rhizotomy have been frequently reported. However, few studies have used validated functional outcome measures to report the surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine the long-term impact of lumbosacral dorsal rhizotomy on fine motor skills. The study population comprised children with debilitating spasticity who underwent SPR and were evaluated by a multidisciplinary team preoperatively, at 6 months and 1 year postoperatively. Quantitative standardized assessments of upper extremity function were obtained using the fine motor skills section of the Peabody Developmental Motor Scales (PDMS) test. Of 70 patients who met the entry criteria for the study, 45 and 25 completed the 3- and 5-year assessments, respectively. Statistical analysis demonstrated significant improvements in grasping, hand use, eye-hand coordination, and manual dexterity at 1 year after SPR. More importantly, all improvements were maintained at 3 and 5 years following SPR. This study supports that significant improvements in upper extremity fine motor function using the PDMS evaluative measure are present after SPR and that these suprasegmental benefits are durable.