Effects of selective dorsal rhizotomy for spastic diplegia on hip migration in cerebral palsy

Multidimensional Outcomes of Selective Dorsal Rhizotomy for Children With Spastic Cerebral Palsy: Single-Level Laminectomy vs Multiple-Level Laminotomy Techniques

BACKGROUND

Selective dorsal rhizotomy (SDR) reduces lower limb spasticity, improves gait patterns, and restores normal physical and social activity in children with spastic cerebral palsy. Single-level laminectomy (SLL) and multiple-level laminotomy (MLL) are 2 surgical approaches for SDR with limited clinical data comparing their postoperative outcomes.

OBJECTIVE

To compare the differences in multidimensional outcomes after SDR between SLL and MLL for children with spastic cerebral palsy.

METHODS

We retrospectively reviewed children who underwent SDR in our hospital from 1997 to 2016. The multidimensional outcomes in spasticity, joint range of motions, gait kinetics, gross motor activities, functional outcomes, and urological outcomes were assessed 1 year postoperatively. Hip dysplasia and scoliosis rate were compared as long-term outcomes.

RESULTS

Sixty children underwent SDR, including 34 SLL patients and 26 MLL patients. Most improvements in multidimensional outcomes were comparable between SLL and MLL. Patients in the SLL group had larger improvements in ankle dorsiflexion in the midstance phase (SLL 7.59° ± 11.48° vs MLL 0.29° ± 11.30°, P = .027). The rate of scoliosis was similar between the 2 surgical approaches (SLL 12.1% vs MLL 15.4%, P = .722).

CONCLUSION

SDR for children with spastic cerebral palsy could provide physical, functional, and urological improvements. SLL achieved a higher degree of improvement in ankle dorsiflexion in the midstance phase. The rate of scoliosis was not significantly increased by multiple-level laminotomy.

A pediatric physiatrist's approach to neuromuscular hip dysplasia in cerebral palsy

Cerebral palsy (CP) encompasses a group of disorders pertaining to abnormalities in movement, tone, and/or posture due to a nonprogressive lesion to an immature brain. Hip dysplasia is the second most common orthopedic deformity seen in CP, and its severity can range from a hip at risk for subluxation to full hip dislocation with degenerative changes. The purpose of this article is to review the hip pathologies that occur in CP focusing on their pathogenesis, physical exam findings, impact on function, and conservative treatment. Through a review of the medical literature, it is demonstrated that early, aggressive, and comprehensive care led by a pediatric physiatrist is essential to mitigate progression to complete hip dislocation and preserve range of motion, prevent contracture, and promote maximum functional ability in all children with CP.

Intraoperative neurophysiological monitoring in selective dorsal rhizotomy (SDR)

For decades, intraoperative neurophysiological monitoring (IONM) has been used to guide selective dorsal rhizotomy (SDR) for the treatment of spastic cerebral palsy (CP). Electromyography (EMG) interpretation methods, which are the core of IONM, have never been fully discussed and addressed, and their importance and necessity in SDR have been questioned for years. However, outcomes of CP patients who have undergone IONM-guided SDR have been favorable, and surgery-related complications are extremely minimal. In this paper, we review the history of evolving EMG interpretation methods as well as their neuroelectrophysiological basis.

Intrathecal baclofen versus selective dorsal rhizotomy for children with cerebral palsy who are nonambulant: a systematic review

OBJECTIVE

Cerebral palsy (CP) is the most common childhood physical disability. Historically, children with hypertonia who are nonambulatory (Gross Motor Function Classification System [GMFCS] level IV or V) were considered candidates for intrathecal baclofen (ITB) therapy to facilitate care and mitigate discomfort. Selective dorsal rhizotomy (SDR) was often reserved for ambulant children to improve gait. Recently, case series have suggested SDR as an alternative to ITB in selected children functioning at GMFCS level IV/V. The objective for this study was to systematically review the evidence for ITB and SDR in GMFCS level IV or V children.

METHODS

Medline, Embase, Web of Science, and Cochrane databases were systematically searched. Articles were screened using the following inclusion criteria: 1) peer-reviewed articles reporting outcomes after SDR or ITB; 2) outcomes reported using a quantifiable scale or standardized outcome measure; 3) patients were < 19 years old at the time of operation; 4) patients had a diagnosis of CP; 5) patients were GMFCS level IV/V or results were reported based on GMFCS status and included some GMFCS level IV/V patients; 6) article and/or abstract in English; and 7) primary indication for surgery was hypertonia. Included studies were assessed with the Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) tool.

RESULTS

Twenty-seven studies met inclusion criteria. The most commonly reported outcomes were spasticity (on the Mean Ashworth Scale) and gross motor function (using the Gross Motor Function Measure), although other outcomes including frequency of orthopedic procedures and complications were also reported. There is evidence from case series that suggests that both ITB and SDR can lower spasticity and improve gross motor function in this nonambulatory population. Complication rates are decidedly higher after ITB due in part to the ongoing risk of device-related complications. The heterogeneity among study design, patient selection, outcome selection, and follow-up periods was extremely high, preventing meta-analysis. There are no comparative studies, and meaningful health-related quality of life outcomes such as care and comfort are lacking. This review is limited by the high risk of bias among included studies. Studies of SDR or ITB that did not clearly describe patients as being GMFCS level IV/V or nonambulatory were excluded.

CONCLUSIONS

There is a lack of evidence comparing the outcomes of ITB and SDR in the nonambulatory CP population. This could be overcome with standardized prospective studies using more robust methodology and relevant outcome measures.

Evidence Supporting Selective Dorsal Rhizotomy for Treatment of Spastic Cerebral Palsy

The objective of this review is to analyze the evidence supporting selective dorsal rhizotomy (SDR) for the treatment of spastic cerebral palsy (CP). We reviewed 85 outcome studies from 12 countries between 1990 and 2017. The published results are overwhelmingly supportive of SDR, and 39 studies form a basis for this review. Also included is some of the clinical experience of the senior author.

The results show that SDR plus postoperative physiotherapy (PT) improved gait, functional independence, and self-care in children with spastic diplegia. In adults with a follow-up of 20 to 28 years, the early improvements after childhood SDR were sustained and improved quality of life. Furthermore, majority of the adults who underwent SDR as children would recommend SDR to others. On the clinical side, while SDRs through multilevel laminectomies or laminoplasty were associated with spinal deformities (i.e., scoliosis, hyperlordosis, kyphosis, spondylolisthesis, spondylolysis, and nonhealing of laminoplasty), SDRs through a single level laminectomy prevented SDR-related spinal problems. The outcomes of SDR specific to spastic quadriplegia require further investigation because of the relatively small patient population with quadriplegia. Lastly, we found that SDR can prevent or reverse premature aging in adolescents and adults with spastic diplegia. In conclusion, the evidence supporting the efficacy of SDR is strong, and SDR is a well-established option for spasticity management in spastic CP.

Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children

BACKGROUND

Selective dorsal rhizotomy (SDR) has been established as an effective surgical treatment for spastic diplegia. The applicability of SDR to the full spectrum of spastic cerebral palsy and the durability of its therapeutic effects remain under investigation. There are currently limited data in the literature regarding efficacy and outcomes following SDR in Gross Motor Function Classification System (GMFCS) IV and V patients. Intrathecal baclofen has traditionally been the surgical treatment of choice for these patients. When utilised primarily as a treatment for the relief of spasticity, it is proposed that SDR represents a rational and effective treatment option for this patient group. We report our outcomes of SDR performed on children with severe cerebral palsy (GMFCS grade IV and V). The commensurate improvement in upper as well as lower limb spasticity is highlighted. Apparent benefit to urological function following SDR in this patient group is also discussed.

METHOD

A retrospective review of prospectively collected data for 54 paediatric patients with severe cerebral palsy (GMFCS IV-V) who received SDR plus specialised physiotherapy. Mean age was 10.2 years (range, 3.0-19.5). SDR guided by electrophysiological monitoring was performed by a single experienced neurosurgeon. All subjects received equivalent physiotherapy. The primary outcome measure was change to the degree of spasticity following SDR. Spasticity of upper and lower limb muscle groups were quantified and standardised using the Ashworth score. Measures were collected at baseline and at 2-, 8- and 14-month postoperative intervals. In addition, baseline and 6-month postoperative urological function was also evaluated as a secondary outcome measure.

RESULTS

The mean lower limb Ashworth score at baseline was 3.2 (range, 0-4). Following SDR, significant reduction in lower limb spasticity scores was observed at 2 months and maintained at 8 and 14 months postoperatively (Wilcoxon rank, p < 0.001). The mean reduction at 2, 8 and 14 months was 3.0, 3.2 and 3.2 points respectively (range, 1-4), confirming a sustained improvement of spasticity over a 1-year period of follow-up. Significant reduction in upper limb spasticity scores following SDR was also observed (mean, 2.9; Wilcoxon rank, p < 0.001). Overall, the improvement to upper and lower limb tone following SDR-generally to post-treatment Ashworth scores of 0-was clinically and statistically significant in GMFCS IV and V patients. Urological assessment identified pre-existing bladder dysfunction in 70% and 90% of GMFCS IV and V patients respectively. Following SDR, improvement in urinary continence was observed in 71% of affected GMFCS IV and 42.8% of GMFCS V patients. No serious postoperative complications were identified.

CONCLUSIONS

We conclude that SDR is safe and-in combination with physiotherapy-effectively reduces spasticity in GMFCS grade IV and V patients. Our series suggests that spastic quadriplegia is effectively managed with significant improvements in upper limb spasticity that are commensurate with those observed in lower limb muscle groups. These gains are furthermore sustained more than a year postoperatively. In light of these findings, we propose that SDR constitutes an effective treatment option for GMFCS IV and V patients and a rational alternative to intrathecal baclofen.

Prevention of hip displacement in children with cerebral palsy: a systematic review

AIM

To conduct a systematic review and evaluate the quality of evidence for interventions to prevent hip displacement in children with cerebral palsy (CP).

METHOD

A systematic review was performed using American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Searches were completed in seven electronic databases. Studies were included if participants had CP and the effectiveness of the intervention was reported using a radiological measure. Results of orthopaedic surgical interventions were excluded.

RESULTS

Twenty-four studies fulfilled the inclusion criteria (4 botulinum neurotoxin A; 2 botulinum neurotoxin A and bracing; 1 complementary and alternative medicine; 1 intrathecal baclofen; 1 obturator nerve block; 8 positioning; 7 selective dorsal rhizotomy). There was significant variability in treatment dosages, participant characteristics, and duration of follow-up among the studies. Overall, the level of evidence was low. No intervention in this review demonstrated a large treatment effect on hip displacement.

INTERPRETATION

The level and quality of evidence for all interventions aimed at slowing or preventing hip displacement is low. There is currently insufficient evidence to support or refute the use of the identified interventions to prevent hip displacement or dislocation in children and young people with CP.

WHAT THIS PAPER ADDS

High-quality evidence on prevention of hip displacement is lacking. No recommendations can be made for preventing hip displacement in children with cerebral palsy because of poor-quality evidence. High-quality, prospective, longitudinal studies investigating the impact of interventions on hip displacement are required.

Australian hip surveillance guidelines for children with cerebral palsy: 5-year review

AIM

To ensure hip surveillance guidelines reflect current evidence of factors influencing hip displacement in children with cerebral palsy (CP).

METHOD

A three-step review process was undertaken: (1) systematic literature review, (2) analysis of hip surveillance databases, and (3) national survey of orthopaedic surgeons managing hip displacement in children with CP.

RESULTS

Fifteen articles were included in the systematic review. Quantitative analysis was not possible. Qualitative review indicated hip surveillance programmes have decreased the incidence of hip dislocation in populations with CP. The Gross Motor Function Classification System was confirmed as the best indicator of risk for displacement, and evidence was found of hip displacement occurring at younger ages and in young adulthood. Femoral geometry, pelvic obliquity, and scoliosis were linked to progression of hip displacement. A combined data pool of 3366 children from Australian hip surveillance databases supported the effectiveness of the 2008 Consensus Statement to identify hip displacement early. The survey of orthopaedic surgeons supported findings of the systematic review and database analyses.

INTERPRETATION

This review rationalized changes to the revised and renamed Australian Hip Surveillance Guidelines for Children with Cerebral Palsy 2014, informing frequency of radiographic examination in lower risk groups and continuation of surveillance into adulthood for adolescents with identified risk factors.

Changes in hip geometry after selective dorsal rhizotomy in children with cerebral palsy

PURPOSE

Hip development in children with spastic cerebral palsy (CP) may be different in comparison to that of typical developing children due to impaired motor function and altered lever arms. Selective dorsal rhizotomy (SDR) is known to reduce spasticity. It is postulated that it also improves mobility. Its influence on hip development is unclear. The aim of this study is to evaluate changes in hip geometry before and after selective dorsal rhizotomy.

METHODS

Conventional radiographs (Rippstein I and II) of 33 ambulatory children aged 2.67 to 11.75 years who underwent SDR were analysed pre- and postoperatively at a mean of 18 months (range 12-29 months). Migration percentage, acetabular index, and anteversion were evaluated. The reduction of spasticity was measured with the modified Ashworth scale. A priori power analysis was performed. As data was normally distributed statistical analysis was performed applying the t-test for paired variables.

RESULTS

Radiographic parameters concerning hip geometry improved significantly after SDR. The spasticity of adductors and hamstrings was significantly reduced through SDR from on average 1.7 to 0.8 on the modified Ashworth scale (p<0.001). The acetabular index decreased from 19° to 17° (p = 0.001), the migration percentage improved from 24% to 21% (p<0.001). Anteversion was also significantly reduced from 41° to 38° (p<0.001). Function improved significantly from 80% to 85% when measured with the GMFM-88 (p<0.001).

CONCLUSIONS

The results confirm that SDR improves hip geometry as well as function in ambulatory CP children. Long-term studies need to show whether this radiographic improvement has clinical relevance with regard to pain and function.

Recurrence of hip instability after reconstructive surgery in patients with cerebral palsy

BACKGROUND

Hip instability can cause major problems in children with cerebral palsy, although good outcomes of hip reconstructive surgery for hip instability have been reported. In the present study, we investigated the recurrence of hip instability after reconstructive surgery and the factors influencing this recurrence in patients with cerebral palsy.

METHODS

We examined consecutive patients with hip instability related to cerebral palsy who had undergone hip reconstructive surgery including femoral varus derotational osteotomy. The neck-shaft angle, head-shaft angle, and migration percentage were measured at each postoperative follow-up evaluation. For each Gross Motor Function Classification System (GMFCS) level, annual changes in radiographic indices were adjusted for multiple factors with use of a linear mixed model, with sex as the fixed effect and laterality and each subject as the random effects.

RESULTS

A total of 144 hips (seventy-six patients) were included in this study, and 845 radiographs were evaluated. The GMFCS level was II or III for twelve patients, IV for thirty, and V for thirty-four. The neck-shaft angle showed no significant change in the patients with GMFCS level II or III (p = 0.425), IV (p = 0.106), or V (p = 0.972). The head-shaft angle showed a significant change in those with GMFCS level IV (p = 0.008) but not in those with level II or III (p = 0.201) or V (p = 0.591). The migration percentage did not change significantly in patients with GMFCS level II or III (p = 0.742), but it increased significantly by 2.0% per year (p < 0.001) in patients with GMFCS level IV and by 3.5% per year (p = 0.003) in those with level V.

CONCLUSIONS

Periodic monitoring and follow-up for the recurrence of hip instability is important in patients with cerebral palsy and a GMFCS level of IV or V.

Intraoperative neurophysiological monitoring in pediatric neurosurgery

The use of intraoperative neurophysiological monitoring (IONM) in pediatric neurosurgery is not new; however, its application to a wider range of procedures is a relatively new development. The purpose of this article is to review the physiology underlying the commonly employed IONM modalities and to describe their application to a subset of pediatric neurosurgical procedures.

Hip Development after Selective Dorsal Rhizotomy in Patients with Cerebral Palsy

Objective

The effects of selective dorsal rhizotomy (SDR) on the hip development in children with spastic cerebral palsy (CP) are not well defined. The present study was performed to determine the effects of SDR and other associated clinical and radiological factors on the outcome of hip development after SDR.

Methods

The study included 53 patients who were skeletally immature at the time of SDR. Between 2003 and 2010, they underwent SDR at our institute. The age ranged from 4 to 15 years old. Their preoperative hip status was divided into two groups: normal and abnormal. The final outcome of the hip was considered good if the centre-edge angle of Wiberg (CEA) at last follow-up was more than 20 degrees without the need for orthopaedic intervention. Thirty-seven patients satisfied the inclusion criteria for statistical analysis.

Results

Seventeen patients were in the “Normal pre-op” group. In all patients (except for two patients), the hip status remained normal after the SDR. Twenty patients were in the “Abnormal pre-op” group. In this group, only two patients returned to normal hips, whereas 11 patients required orthopaedic hip surgery within 5 years after the SDR. The remaining seven patients had hip subluxation, but not to the extent of hip dislocation. The preoperative hip radiological measurements and functional status were positively correlated with the postoperative hip status. The preoperative radiological measurements showed superior predictive value when other covariance were considered. No difference of outcome existed in regard to the different surgical approaches of SDR.

Conclusion

Selective dorsal rhizotomy has a neutral effect on hip development. The preoperative hip radiological measurement is the most important predictive factor to determine hip status after SDR. Good collaboration between neurosurgeons and paediatric orthopaedists is essential for the best management of these patients.

Reliability of hip migration index in children with cerebral palsy: the classic and modified methods

Objective

To determine reliability and clinical use of two methods of migration index (MI) in CP patients with or without hip dysplasia.

Method

The materials included radiographs of 200 hips of children with cerebral palsy. Conventional anteroposterior radiographs of the pelvis were taken with the child in the supine position with standardized methods. Two rehabilitation doctors measured the migration index using two methods. In the classic method, the lateral margin of the acetabular roof was used as a landmark and in the modified method the lateral margin of the sourcil was used as a landmark. Each rater measured the migration index at three separate times with a time interval of at least one week. Intraclass correlation (ICC) was used to test the inter- and intra-rater reliability.

Results

MI shows excellent intra-rater reliability in both the classic and modified methods, but the inter-rater reliability was higher in the classic method than in the modified method. When categorized according to the sourcil classification, inter-rater reliability was higher in the normal sourcil type and lower in the dysplastic sourcil types.

Conclusion

Generally, the classic method showed higher reliability than the modified method, even though the reliability of the MI measurement was relatively high with both methods.

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.

Selective dorsal rhizotomy for spastic cerebral palsy: a review

OBJECTIVE

The purpose of this report is to review the historical development, current operative techniques, selection criteria, outcomes, and complications of selective dorsal rhizotomy (SDR) for treatment of spastic cerebral palsy (CP).

MATERIALS AND METHODS

This review is based on a review of literature and personal observations.

RESULTS

SDR has evolved from the 1960s onwards into a standard neurosurgical procedure for spastic CP. There is much variation in the operative technique among surgeons with respect to the level of exposure, electrophysiological guidance, and extent of rhizotomies. Appropriate selection of patients for SDR requires determination that spasticity, not dystonia, is the major disabling hypertonia and that the lower limbs are maximally involved. Positive outcomes have been well demonstrated in the impairment, functional limitations, and disability dimensions, as per the National Center for Medical Rehabilitation Research Model of Dimensions of the Disabling Process. Complications have been relatively few.

CONCLUSIONS

SDR is the procedure of choice for treatment of spasticity in spastic diplegic CP and in selected children with spastic quadriplegic CP. Optimal selection and outcomes are achieved using a multidisciplinary approach.

Selection of treatment modalities in children with spastic cerebral palsy

The purpose of this report was to outline the various options currently used for treatment of spastic cerebral palsy (CP) and to discuss factors involved in selecting the appropriate treatment modalities for the individual child. In a review of the literature and his personal observations, the author presents an outline of treatment options and the criteria for using each. Therapeutic options include the following: physiotherapy; occupational therapy; oral spasmolytic and antidystonic drugs; botulinum toxin injections; orthopedic procedures; continuous infusion of intrathecal baclofen (ITB); selective dorsal rhizotomy (SDR); and selective peripheral neurotomy. The most commonly used neurosurgical procedures are ITB pump placement and SDR, and these are discussed in the most detail. The author's personal schema for assessment of the child to determine the nature of the hypertonia, the impact of the hypertonia, and the appropriate therapeutic intervention is presented. There are factors that help guide the optimal treatment modalities for the child with spastic CP. The treatment of these children is optimized in the setting of a multidisciplinary team.

Cerebral palsy

Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis.

Treatment of spastic diplegia in patients with cerebral palsy: Part II

This review article describes the evaluation, treatment options, and expected outcomes for many of the common deformities of the lower extremities in patients with cerebral palsy. The evaluation tools including gait analysis will be applied to each specific deformity. Dynamic components are addressed with spasticity management and appropriate muscle and tendon procedures. The static components are treated with bony procedures, including various osteotomies and arthrodesis, incorporating biomechanical principles.

Functional performance following selective posterior rhizotomy: long-term results determined using a validated evaluative measure

Object. Selective posterior rhizotomy (SPR) may result in considerable benefit for children with spastic cerebral palsy. To date, however, there have been few studies in which validated functional outcome measures have been used to report surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine long-term functional performance outcomes in patients who underwent lumbosacral dorsal rhizotomy performed using intraoperative electrophysiological monitoring.

Methods. The study population was composed of children with debilitating spasticity who underwent SPR and were evaluated by a multidisciplinary team preoperatively and at 6 months and 1 year postoperatively. Quantitative standardized assessments of activities of daily living (ADL) were obtained using the Pediatric Evaluation of Disability Inventory (PEDI). Of 57 patients who met the entry criteria for the study, 41 completed the 3-year assessments and 30 completed the 5-year assessments.

Statistical analysis demonstrated significant improvement in the mobility and self-care domains of the functional skills dimension at 1 year after SPR. The preoperative and 1-, 3-, and 5-year postoperative scaled scores for the mobility domain were 56, 64, 77.2, and 77.8, respectively. The scaled score for the self-care domain increased from 59 presurgery to 67.9, 81.6, and 82.4 at the 1-, 3-, and 5-year postoperative assessments, respectively.

Conclusions. The results of this study support the presence of significant improvements in functional performance, based on PEDI scores obtained 1 year after SPR. The improvements persisted at the 3- and 5-year follow-up examinations. The authors conclude that SPR performed using intraoperative stimulation is valuable in the augmentation of motor function and self-care skills essential to the performance of ADL.

Long-term functional outcome after selective posterior rhizotomy

OBJECT

Selective posterior rhizotomy (SPR) is a well-recognized treatment for children with spastic cerebral palsy (CP). Few investigators have used quantitative outcome measures to assess the surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine the long-term functional outcome of children who had undergone selective dorsal rhizotomy accompanied by intraoperative electrophysiological monitoring.

METHODS

The study population was composed of children with spastic CP who underwent SPR and were evaluated by a multidisciplinary team preoperatively, and at 6 months and 1 year postoperatively. Quantitative standardized assessments of lower-limb spasticity, passive range of motion, muscle strength, and ambulatory function were obtained. Of the 93 patients who met the entry criteria for the study, 71 completed the 3-year and 50 completed the 5-year assessments, respectively. Statistical analysis demonstrated significant improvements in spasticity, range of motion, and functional muscle strength at 1 year after SPR. The preoperative, 1-, 3-, and 5-year values for the global score of the Gross Motor Function Measure were 64.6, 70.8, 80, and 85.6, respectively. The greatest improvement occurred in the dimensions reflecting lower-extremity motor function, where the mean change was 10.1% at 1 year, 19.9% at 3 years, and 34.4% at the 5-year follow-up review in comparison with the baseline value. This was associated with a lasting improvement in alignment and postural stability during developmental positions, as well as increased ability to perform difficult transitional movements.

CONCLUSIONS

The results of this study support the presence of significant improvements in lower-limb functional motor outcome 1 year after SPR, and the improvements persist at 3 and 5 years. The authors conclude that SPR in conjunction with intraoperative stimulation is valuable for permanently alleviating lower-limb spasticity while augmenting motor function.

Selective posterior rhizotomy for lower extremity spasticity: how much and which of the posterior rootlets should be cut?

BACKGROUND

It is well known that selective posterior rhizotomy is effective for relieving spasticity associated with cerebral palsy. However, there is significant variation between surgeons in terms of how much and which of the posterior rootlets should be cut for the improvement of ambulatory function without causing adverse effects.

METHODS

The study population was composed of 200 CP patients who underwent SPR more than 1 year before this study. The children were divided into 4 groups (Group A had their L1-S2 roots cut, Group B had the L2-S2 roots cut, Group C had the L2-S1 roots cut, and Group D had the L2-S1 roots and the unilateral S2 root cut). We assessed lower limb spasticity, passive range of motion, ambulatory function, and gait pattern in each group.

RESULTS

Inclusion of L1 and S2 in the lesioning process of SPR was more effective at relieving spasticity in terms of hip adduction and ankle dorsiflexion respectively and improving ambulatory function (p < 0.01). Although lesioning of S2 carried a greater risk of urinary dysfunction, resection of less than 50% of S2 significantly improved ambulatory function without urinary complications (p < 0.01). Unilateral lesioning of S2 was an alternative option in selected cases with different amounts of spasticity in the ankles for the same purpose.

CONCLUSIONS

We propose that L1 and S2 roots should be included in the lesioning process of SPR for effective improvement of gross motor function, but that resection of these roots should be less than 50% to prevent complications.

Advances in prevention and treatment of cerebral palsy

In recent years there have been a number of advances in understanding of predisposing and protective factors in the development of cerebral palsy in infants. Multiple gestation births, maternal infection, and maternal and fetal thrombophilic conditions all predispose to the development of CP in the infant. Opportunities for prevention of CP may develop from an improved understanding of these factors and their mechanisms of operation. Similar progress has been made in the evaluation of treatments for CP and the effects of these treatments on the individual's impairment, function, and disability. Selective posterior rhizotomy and Botulinum toxin A are now widely used in the treatment of spasticity. The challenge remains to determine how effectively these promising interventions can alter long-term function and quality of life outcomes in children and adults with CP.

Intrathecal baclofen infusion and subsequent orthopedic surgery in patients with spastic cerebral palsy

Intrathecal baclofen infusion (IBI) is an effective treatment for spasticity secondary to cerebral palsy (CP).

OBJECT

To assess the need for orthopedic surgery of the lower extremities in such cases, the authors retrospectively reviewed the outcome in 48 patients with spastic CP who were treated with IBI.

METHODS

Pumps were placed in 40 patients (84%) suffering from spastic quadriplegia and eight patients (16%) with spastic diplegia. The patients' ages ranged from 5 to 43 years (mean 15 years). The mean follow-up period was 53 months (range 24-94 months). The mean baclofen dosage was 306 microg/day (range 25-1350 microg/day). At the time of pump placement, subsequent orthopedic surgery was planned in 28 patients (58%); however, only 10 (21%) underwent surgery after IBI therapy. In all 10 cases, the surgical procedure was planned at the time of initial evaluation for IBI therapy. In the remaining 18 patients, who did not subsequently undergo their planned orthopedic operation, it was believed that their lower-extremity spasticity had improved to the degree that intervention was no longer indicated. In addition, although six patients had undergone multiple orthopedic operations before their spasticity was treated, no patient required more than one operation after IBI treatment for spasticity.

CONCLUSIONS

The authors conclude that IBI for treatment of spastic CP reduces the need for subsequent orthopedic surgery for the effects of lower-extremity spasticity. In patients with spastic CP and lower-extremity contractures, spasticity should be treated before orthopedic procedures are performed.

Intrathecal baclofen infusion and subsequent orthopedic surgery in patients with spastic cerebral palsy

Intrathecal baclofen infusion (IBI) is an effective treatment for spasticity secondary to cerebral palsy (CP). The authors retrospectively reviewed the need for orthopedic surgery of the lower extremities in 48 patients with spastic CP who were treated with IBI. Forty pumps were placed in patients suffering from spastic quadriplegia (84%) and eight (16%) in patients with spastic diplegia. The patients' ages ranged from 5 to 43 years (mean 15 years). The mean follow-up period was 53 months (range 22-94 months). The mean baclofen dosage was 306 μg/day (range 25-1350 μg/day). At the time of pump placement, subsequent orthopedic surgery was planned in 28 patients (58%); however, only 10 (21%) underwent orthopedic surgery after IBI therapy. In all 10 cases, the surgical procedure was planned at the time of initial evaluation for IBI therapy. In the remaining 18 patients, who did not subsequently undergo their planned orthopedic operation, it was believed that their lower-extremity spasticity had improved to the degree that orthopedic intervention was no longer indicated. In addition, although six patients had undergone multiple orthopedic operations before their spasticity was treated, no patient required more than one orthopedic operation after IBI treatment for their spasticity. The authors conclude that IBI for treatment of spastic CP reduces the need for subsequent orthopedic surgery for the effects of lower-extremity spasticity. In patients with spastic CP and lower-extremity contractures, spasticity should be treated before orthopedic procedures are performed.

Selective dorsal rhizotomy and rates of orthopedic surgery in children with spastic cerebral palsy

If the spasticity of cerebral palsy (CP) is reduced in children at a young age by selective dorsal rhizotomy, the incidence of lower-extremity deformities requiring orthopedic surgery may be reduced; however, this has never been investigated in detail. The authors examined the effects of selective dorsal rhizotomy on rates of lower-extremity orthopedic surgery in 178 children with CP. Age at selective dorsal rhizotomy ranged from 2 to 19.3 years (mean 5.5 years) with follow-up intervals ranging from 24 to 70 months (mean 44 months). Spastic CP was classified as quadriplegia (33%), diplegia (65%), and hemiplegia (2%). To assess the effects of early versus late rhizotomy on rates of orthopedic surgery, patients were grouped as follows: Group I underwent rhizotomy between 2 and 4 years of age (54 patients), and Group II underwent rhizotomy between 5 and 19 years of age (124 patients). Comparison of Kaplan-Meier plots of lifetime orthopedic surgery rates revealed that Group II underwent orthopedic surgery at a higher rate than Group I (p = 0.037). Analysis by procedure type revealed higher orthopedic surgery rates in Group II than Group I for heel cord releases (p = 0.0025), adductor releases (p = 0.018), and hamstring releases (p = 0.02). Orthopedic surgery rates were no higher for Group II compared to Group I for ankle/foot operations (p = 0.023), femoral osteotomy (p = 0.25), iliopsoas releases (p = 0.35), and "other" operations (p = 0.013). The data indicate that early rhizotomy reduces the need for orthopedic surgery for heel cord, hamstring, and adductor releases.

Changes in hip migration after selective dorsal rhizotomy for spastic quadriplegia in cerebral palsy

Selective dorsal rhizotomy is increasingly used for management of spastic quadriplegic cerebral palsy but rates of hip stability following the operation have not been reported. Determining hip stability by radiographic measurement of lateral migration of the femoral head beyond a lateral edge of the acetabulum after dorsal rhizotomy allows an objective assessment of the outcome of the operation. This prospective study examined the effect of selective dorsal rhizotomy on lateral migration of the femoral head in 45 children with spastic quadriplegic cerebral palsy. The children ranged in age from 2 to 9 years (average 5 years 1 month) and were grouped according to their ages with 23 children in the 2- to 4-year-old group and 22 children in the 5- to 9-year-old group. Postoperative follow up ranged from 7 to 50 months (average 20 months). The Reimers migration percentage (MP), a measure of the lateral migration of the femoral head, was calculated from anteroposterior hip radiographs taken prior to the operation and at the last follow-up examination. Of the 90 hips involved, 9% improved, 80% remained unchanged, and 11% worsened, yielding a radiographic stability rate of 89%. The hips with postrhizotomy worsening of the MP had an average preoperative MP of 14% (range 9% to 38%) and an average postoperative increase in MP of 18% (range 11% to 37%). Of the 45 children, four subsequently underwent unilateral derotational femoral osteotomies for persistent or worsening hip subluxation. There was a significant tendency for the MP to worsen in patients with lower prerhizotomy MP values (chi 2 = 20.74, df = 4, p = 0.001), but the age of patients and their ambulatory status at the time of rhizotomy had no bearing on postoperative hip stability. The data indicate that selective dorsal rhizotomy prevents progressive lateral migration of the femoral head in the majority of children who undergo the operation for spastic quadriplegia.