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Abdelmageed S, Dalmage M, Mossner JM, Trierweiler R, Krater T, Raskin JS. Cervicothoracic ventral-dorsal rhizotomy for treatment of brachial hypertonia in cerebral palsy. Childs Nerv Syst 2024; 40:2835-2842. [PMID: 38958730 PMCID: PMC11322240 DOI: 10.1007/s00381-024-06479-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE Cervicothoracic ventral-dorsal rhizotomy (VDR) is a potential treatment of medically refractory hypertonia in patients who are not candidates for intrathecal baclofen, particularly in cases of severe upper limb hypertonia with limited to no function. A longitudinal cohort was identified to highlight our institutional safety and efficacy using cervicothoracic VDR for the treatment of hypertonia. METHODS Retrospective data analysis was performed for patients that underwent non-selective cervicothoracic VDR between 2022 and 2023. Non-modifiable risk factors, clinical variables, and operative characteristics were collected. RESULTS Six patients (three female) were included. Four patients underwent a bilateral C6-T1 VDR, one patient underwent a left C7-T1 VDR, and another underwent a left C6-T1 VDR. Three patients had quadriplegic mixed hypertonia, one patient had quadriplegic spasticity, one patient had triplegic mixed hypertonia, and one patient had mixed hemiplegic hypertonia. The mean difference of proximal upper extremity modified Ashworth scale (mAS) was - 1.4 ± 0.55 (p = 0.002), and - 2.2 ± 0.45 (p < 0.001) for the distal upper extremity. Both patients with independence noted quality of life improvements as well as increased ease with dressing and orthotics fits. Caregivers for the remaining four patients noted improvements in caregiving provision, mainly in dressing, orthotics fit, and ease when transferring. CONCLUSION Cervicothoracic VDR is safe and provides tone control and quality of life improvements in short-term follow-up. It can be considered for the treatment of refractory hypertonia. Larger multicenter studies with longer follow-up are necessary to further determine safety along with long-term functional benefits in these patients.
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Affiliation(s)
- Sunny Abdelmageed
- Division of Pediatric Neurosurgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital, 211 E Chicago Ave Ste 1150, Chicago, IL, 60611, USA
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mahalia Dalmage
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - James M Mossner
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Tim Krater
- Shirley Ryan Ability Lab, Chicago, IL, USA
| | - Jeffrey S Raskin
- Division of Pediatric Neurosurgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital, 211 E Chicago Ave Ste 1150, Chicago, IL, 60611, USA.
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Welborn MC, Redding G, Evers P, Nicol L, Bauer DF, Iyer RR, Poon S, Hwang S. Pre-op considerations in neuromuscular scoliosis deformity surgery: proceedings of the half day course at the 58th annual meeting of the Scoliosis Research Society. Spine Deform 2024; 12:867-876. [PMID: 38634998 DOI: 10.1007/s43390-024-00865-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/16/2024] [Indexed: 04/19/2024]
Abstract
Scoliosis is a common complication of neuromuscular disorders. These patients are frequently recalcitrant to nonoperative treatment. When treated surgically, they have the highest risk of complications of all forms of scoliosis. While recent studies have shown an improvement in the rate of complications, they still remain high ranging from 6.3 to 75% depending upon the underlying etiology and the treatment center (Mohamad et al. in J Pediatr Orthop 27:392-397, 2007; McElroy et al. in Spine, 2012; Toll et al. in J Neurosurg Pediatr 22:207-213, 2018; Cognetti et al. in Neurosurg Focus 43:E10, 2017). For those patients who are able to recover from the perioperative period without major complications, several recent studies have shown decreased long-term mortality and improved health-related quality of life in neuromuscular patients who have undergone spine fusion (Bohtz et al. in J Pediatr Orthop 31:668-673, 2011; Ahonen et al. in Neurology 101:e1787-e1792, 2023; Jain et al. in JBJS 98:1821-1828, 2016). It is critically important to optimize patients preoperatively to minimize the risk of post-operative complications and maximize long-term outcomes. In order to do so, one must familiarize themselves with the common complications and their treatment. The most common complications are pulmonary in nature. With reported rates as high as 23-29%, pre-operative optimization should be employed for these patients to minimize the risk of post-operative complications (Sharma et al. in Eur Spine J 22:1230-1249, 2013; Rumalla et al. in J Neurosurg Spine 25:500-508, 2016). The next most common cause of complications are implant related, with 13-23% of patients experiencing an implant-related complication that may require a second procedure (Toll et al. in J Neurosurg Pediatr 22:207-213, 2018; Sharma et al. in Eur Spine J 22:1230-1249, 2013) Therefore optimization of bone quality prior to surgical intervention is important to help minimize the risk of instrumentation failure. Optimization of muscle tone and spasticity may help to decrease the risk of instrumentation complications, but may also contribute to the progression of scoliosis. While only 3% of patients have neurologic complication, significant equipoise remains regarding whether or not patients should undergo prophylactic detethering procedures to minimize those risks (Sharma et al. in Eur Spine J 22:1230-1249, 2013). Although only 1.8% of complications are classified as cardiac related, they can be among the most devastating (Rumalla et al. in J Neurosurg Spine 25:500-508, 2016). Simply understanding the underlying etiology and the potential risks associated with each condition (i.e., conduction abnormalities in a patient with Rett syndrome or cardiomyopathies patients with muscular dystrophy) can be lifesaving. The following article is a summation of the half day course on neuromuscular scoliosis from the 58th annual SRS annual meeting, summarizing the recommendations from some of the world's experts on medical considerations in surgical treatment of neuromuscular scoliosis.
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Affiliation(s)
- Michelle C Welborn
- Shriners Children's Portland, 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA.
| | - Gregory Redding
- Pulmonary and Sleep Medicine Division, Seattle Children's Hospital, Room O.C. 7.730, 4800 Sand Point Way N E, Seattle, WA, 98105, USA
| | - Patrick Evers
- Doernbecher Children's Hospital, 700 SW Campus Dr, Portland, OR, 97239, USA
| | - Lindsey Nicol
- Shriners Children's Portland, 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- Doernbecher Children's Hospital, 700 SW Campus Dr, Portland, OR, 97239, USA
| | - David F Bauer
- Texas Children's Hospital, 6701 Fannin St., Suite 1230.01, Houston, TX, USA
| | - Rajiv R Iyer
- , 100 N. Mario Capecchi Drive, Suite 3850, Salt Lake City, UT, 84113, USA
| | - Selina Poon
- Shriners Children's Southern California, 909 S. Fair Oaks Ave, Pasadena, CA, 91105, USA
| | - Steven Hwang
- Shriners Children's Philadelphia, 3551 N Broad St., Philadelphia, PA, 19140, USA
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Mishra D, Barik S, Raj V, Kandwal P. A systematic review of complications following selective dorsal rhizotomy in cerebral palsy. Neurochirurgie 2023; 69:101425. [PMID: 36828056 DOI: 10.1016/j.neuchi.2023.101425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/18/2022] [Accepted: 01/05/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE The literature lacks a concise overview of complications secondary to selective dorsal rhizotomy (SDR). The aim of this study was to systematically review the literature regarding post-SDR complications, and to present them concisely. METHODS The protocol of the review was registered on Open Science Framework. Studies on SDR in cerebral palsy were included. The studies to be included used SDR for management of spasticity in patients with cerebral palsy. The long-term complications of SDR mentioned in the articles were inventoried. RESULTS Thirty studies were included for qualitative review. Twenty-one types of complication were identified. Structural complications were the commonest: scoliosis (214/1,043, 20.5%), hyperlordosis (101/552, 18.2%), spondylolysis (55/574, 9.5%) and kyphosis (67/797, 8.4%). Neurological complications comprised constipation (70/485, 14.4%), hip subluxation (3/29, 10.3%), spastic syndrome (4/47, 8.5%), sensory changes (106/1290, 8.2%) and urinary incontinence (61/1013, 6%). CONCLUSION This review should help surgeons and parents alike to know about the potential complications of SDR. Complications may affect quality of life and should be weighed. Although the majority of these complications were managed conservatively, there would still be a physical, psychological and financial burden which should be taken into account. Screening should be continued vigorously throughout skeletal growth and at reduced frequency thereafter, for timely intervention in case of structural complications.
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Affiliation(s)
- D Mishra
- All India Institute of Medical Sciences - Bhubaneswar Orthopaedics, Bhubaneswar, India
| | - S Barik
- All India Institute of Medical Sciences - Deoghar Orthopaedics, Deoghar, Jharkhand, India.
| | - V Raj
- All India Institute of Medical Sciences - Deoghar Orthopaedics, Deoghar, Jharkhand, India
| | - P Kandwal
- All India Institute of Medical Sciences - Rishikesh Orthopaedics, Rishikesh, India
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Anastasio AT, Guisse NF, Farley KX, Rhee JM. Hospital Burdens of Patients With Cerebral Palsy Undergoing Posterior Spinal Fusion for Scoliosis. Global Spine J 2022; 12:883-889. [PMID: 33203253 PMCID: PMC9344497 DOI: 10.1177/2192568220968542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Many patients undergoing posterior spinal fusion (PSF) for scoliosis have concurrent cerebral palsy (CP), which is associated with many medical comorbidities and inherent operative risk. We aimed to quantify the contribution of CP to increased cost, length of stay (LOS), and complication rates in patients with scoliosis undergoing PSF. METHODS Using the National Inpatient Sample database, we collected data regarding patient demographics, hospital characteristics, comorbidities, in-hospital complications, and mortality. Primary outcomes included complications, hospital LOS, and total hospital costs. Multivariate regression models assessed the contribution of CP to in-hospital complications, discharge status, and mortality. Linear regression identified the contribution of a diagnosis of CP on hospital LOS and inflation-adjusted cost. RESULTS Cerebral palsy was an independent predictor of several complications. The most striking differences were seen for mortality (odds ratio [OR]: 3.40, P < .001), a postoperative requirement for total parenteral nutrition (OR: 3.16, P < .001), urinary tract infection (OR: 2.75, P < .001), surgical site infection (OR: 2.67, P < .001), and pneumonia (2.21, P < .001). Patients with CP ultimately cost an additional $13 482 (P < .001) with a 2.07-day greater LOS (P < .001) than patients without CP. CONCLUSION Most complications were seen in higher rates in the CP cohort, with higher cost and LOS in patients with CP versus those with idiopathic scoliosis (IS). Our findings represent important areas of emphasis during preoperative consultations with patients with CP and their families. Extra care in patient selection and multifaceted treatment protocols should continue to be implemented with further investigation on how to mitigate common complications.
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Affiliation(s)
| | - Ndeye F. Guisse
- Emory University, Atlanta, GA, USA
- Ndeye F. Guisse, 7 Executive Park Drive NE,
Apt 1314, Atlanta, GA 30329, USA.
| | | | - John M. Rhee
- Emory University, Atlanta, GA, USA
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
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Kakodkar P, Girgis H, Nabhan P, Chee SS, Tu A. Efficacy of Selective Dorsal Rhizotomy and Intrathecal Baclofen Pump in the Management of Spasticity. Adv Tech Stand Neurosurg 2022; 45:379-403. [PMID: 35976458 DOI: 10.1007/978-3-030-99166-1_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Neurosurgical indications and interventions provided in the management of spasticity have evolved significantly over time. Selective dorsal rhizotomy (SDR) and intrathecal baclofen (ITB) pumps have been used to improve mobility, reduce lower extremity spasticity, and increase quality of life in patients with various diagnoses. METHODS Studies describing ITB and SDR outcomes in adult and pediatric patients were identified from Medline and Embase databases. Only publications between January 1990 to January 2021 were included. Combinations of search terms 'Selective Dorsal Rhizotomy', 'Selective Posterior Rhizotomy', 'functional posterior rhizotomy', 'intrathecal baclofen pump', and 'spasticity' were used. Only studies in English language and those that included parameters for lower extremity outcome (i.e., spasticity, ambulation) were included. Only studies describing follow-up 12 months or greater were included. Case reports, reviews without primary data, or inaccessible publications were excluded. RESULTS Two hundred and ninety publications between January 1990 to January 2021 were identified. Of these, 62 fit inclusion and exclusion criteria for a total of 1291 adult and 2263 patients. Etiologies in adult and pediatric populations varied substantially with multiple sclerosis, cerebral palsy, and trauma comprising the majority of causes for spasticity in adult patients. In pediatric patients, cerebral palsy was the predominant etiology of spasticity. While outcomes after SDR and ITB varied, both are effective for long-term tone reduction. SDR appeared to have a greater effect on function compared to baseline when comparing relatively similar subgroups. The complication rates for either intervention were significant; ITB had a much greater incidence of wound and hardware adverse events, whereas SDR was associated with a not insignificant incidence of new bladder or sensory deficit. CONCLUSION ITB and SDR have demonstrated efficacy and utility for tone reduction in a variety of conditions. The selection of a specific intervention may have a variety of determining features including the etiology of spasticity, age of patient, as well as balancing benefit and complication profiles of each technique. Appropriate patient selection is essential for providing optimal patient outcomes.
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Affiliation(s)
- Pramath Kakodkar
- School of Medicine, National University of Ireland Galway, Galway, Republic of Ireland
| | - Hidy Girgis
- Division of Neurosurgery, University of Ottawa, Ottawa, ON, Canada
| | - Perla Nabhan
- Faculty of Science, University of Ottawa, Ottawa, Canada
| | - Sharini Sam Chee
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Albert Tu
- Division of Pediatric Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
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Ravindra VM, Karas PJ, Hartnett S, Patino I, North R, Tatsui CE, Gonda D, Schwabe A, Curry DJ. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Palliative Rhizotomy: A Novel Technical Application. Oper Neurosurg (Hagerstown) 2021; 20:413-418. [PMID: 33377153 DOI: 10.1093/ons/opaa415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Spastic cerebral palsy is caused by an insult to the developing brain. Various medical and surgical procedures are used to reduce tone. OBJECTIVE To describe a novel method of magnetic resonance-guided laser interstitial thermal ablation for palliative rhizotomy. METHODS Patients treated at a single institution with percutaneous rhizotomy using magnetic resonance-guided laser interstitial thermal therapy were identified. Preoperative and postoperative Modified Ashworth Scale scores were collected as well as procedural information. RESULTS Two male children (7.8 and 19 yr, respectively) with spastic quadriparesis were treated using this technique. Neither patient experienced surgical or perioperative complications, and both were discharged from the hospital within 48 h. Each of them demonstrated improvement in his Modified Ashworth Scale score with no need for retreatment for spasticity at last follow-up. CONCLUSION These 2 cases illustrate a novel technique for treating spasticity in the setting of cerebral palsy. Further study of this technique in additional patients, and comparison with traditional methods of surgical tone reduction, are warranted.
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Affiliation(s)
- Vijay M Ravindra
- Division of Pediatric Neurosurgery, Texas Children's Hospital Baylor College of Medicine, Houston, Texas.,Division of Pediatric Neurosurgery, Rady Children's Hospital, University of California San Diego, San Diego, California
| | - Patrick J Karas
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sara Hartnett
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Ilana Patino
- Division of Pediatric Neurosurgery, Texas Children's Hospital Baylor College of Medicine, Houston, Texas
| | - Robert North
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Claudio E Tatsui
- Department of Neurosurgery, Division of Surgery, MD Anderson Cancer Center, Houston, Texas
| | - David Gonda
- Division of Pediatric Neurosurgery, Rady Children's Hospital, University of California San Diego, San Diego, California
| | - Aloysia Schwabe
- Department of Physical Medicine and Rehabilitation Medicine, Baylor College of Medicine, Section of Pediatric Physical Medicine and Rehabilitation, Texas Children's Hospital, Houston, Texas
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Texas Children's Hospital Baylor College of Medicine, Houston, Texas.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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De Vloo P, Huttunen TJ, Forte D, Jankovic I, Lee A, Hair M, Cawker S, Chugh D, Carr L, Crowe BHA, Pitt M, Aquilina K. Intraoperative electrophysiology during single-level selective dorsal rhizotomy: technique, stimulation threshold, and response data in a series of 145 patients. J Neurosurg Pediatr 2020; 25:597-606. [PMID: 32109863 DOI: 10.3171/2019.12.peds19372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Selective dorsal rhizotomy (SDR) is effective at permanently reducing spasticity in children with spastic cerebral palsy. The value of intraoperative neurophysiological monitoring in this procedure remains controversial, and its robustness has been questioned. This study describes the authors' institutional electrophysiological technique (based on the technique of Park et al.), intraoperative findings, robustness, value to the procedure, and occurrence of new motor or sphincter deficits. METHODS The authors analyzed electrophysiological data of all children who underwent SDR at their center between September 2013 and February 2019. All patients underwent bilateral SDR through a single-level laminotomy at the conus and with transection of about 60% of the L2-S2 afferent rootlets (guided by intraoperative electrophysiology) and about 50% of L1 afferent roots (nonselectively). RESULTS One hundred forty-five patients underwent SDR (64% male, mean age 6 years and 7 months, range 2 years and 9 months to 14 years and 10 months). Dorsal roots were distinguished from ventral roots anatomically and electrophysiologically, by assessing responses on free-running electromyography (EMG) and determining stimulation thresholds (≥ 0.2 mA in all dorsal rootlets). Root level was determined anatomically and electrophysiologically by assessing electromyographic response to stimulation. Median stimulation threshold was lower in sacral compared to lumbar roots (p < 0.001), and 16% higher on the first operated (right) side (p = 0.023), but unrelated to age, sex, or functional status. Similarly, responses to tetanic stimulation were consistent: 87% were graded 3+ or 4+, with similar distributions between sides. This was also unrelated to age, sex, and functional status. The L2-S2 rootlets were divided (median 60%, range 50%-67%), guided by response to tetanic stimulation at threshold amplitude. No new motor or sphincter deficits were observed, suggesting sparing of ventral roots and sphincteric innervation, respectively. CONCLUSIONS This electrophysiological technique appears robust and reproducible, allowing reliable identification of afferent nerve roots, definition of root levels, and guidance for rootlet division. Only a direct comparative study will establish whether intraoperative electrophysiology during SDR minimizes risk of new motor or sphincter worsening and/or maximizes functional outcome.
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Affiliation(s)
- Philippe De Vloo
- Departments of1Neurosurgery
- 2Department of Neurosurgery, University Hospitals Leuven, Belgium
| | | | | | | | | | | | - Stephanie Cawker
- 4Neurodisability, Great Ormond Street Hospital for Children, London, United Kingdom; and
| | - Deepti Chugh
- 4Neurodisability, Great Ormond Street Hospital for Children, London, United Kingdom; and
| | - Lucinda Carr
- 4Neurodisability, Great Ormond Street Hospital for Children, London, United Kingdom; and
| | - Belinda H A Crowe
- 4Neurodisability, Great Ormond Street Hospital for Children, London, United Kingdom; and
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Tedroff K, Hägglund G, Miller F. Long-term effects of selective dorsal rhizotomy in children with cerebral palsy: a systematic review. Dev Med Child Neurol 2020; 62:554-562. [PMID: 31342516 PMCID: PMC7187377 DOI: 10.1111/dmcn.14320] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 12/22/2022]
Abstract
AIM To evaluate the long-term effects of selective dorsal rhizotomy (SDR) 10 years or more after the procedure and complications observed any time after SDR in children with cerebral palsy (CP). METHOD Embase, PubMed, and the Cochrane Library were searched from their individual dates of inception through 1st June 2018 for full-text original articles in English that described long-term follow-up after SDR in children with CP. The authors independently screened publications to determine whether they met inclusion criteria; thereafter all authors extracted data on patient characteristics, the proportion of the original cohort being followed-up, and the reported outcomes. RESULTS Of the 199 studies identified, 16 were included in this evaluation: 14 were case series and two studies reported a retrospectively assigned comparison group. Evidence concerning function was limited by study design differences, clinical variability, loss to follow-up, and heterogeneity across trials. INTERPRETATION At 10 years or more follow-up, available studies generate low-level evidence with considerable bias. No functional improvement of SDR over routine therapy is documented. Furthermore, the long-term effects of SDR with respect to spasticity reduction is unclear, with many studies reporting a high amount of add-on spasticity treatment. More long-term follow-up using robust scientific protocols is required before it can be decided whether the use of SDR as routine therapy for children with CP is to be recommended or not. WHAT THIS PAPER ADDS Ten years after selective dorsal rhizotomy, available studies supply inconclusive evidence on functional outcomes. The long-term effect on spasticity is uncertain, studies reported a substantial need for add-on treatment. Short- and long-term complications seem frequent but are not reported in a consistent manner.
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Affiliation(s)
- Kristina Tedroff
- Neuropaediatric Unit, Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Gunnar Hägglund
- Department of Clinical Sciences Lund, OrthopaedicsLund UniversityLundSweden
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Warsi NM, Tailor J, Coulter IC, Shakil H, Workewych A, Haldenby R, Breitbart S, Strantzas S, Vandenberk M, Dewan MC, Ibrahim GM. Selective dorsal rhizotomy: an illustrated review of operative techniques. J Neurosurg Pediatr 2020; 25:540-547. [PMID: 32032949 DOI: 10.3171/2019.12.peds19629] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 12/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Selective dorsal rhizotomy (SDR) is a procedure primarily performed to improve function in a subset of children with limitations related to spasticity. There is substantial variability in operative techniques among centers and surgeons. Here, the authors provide a technical review of operative approaches for SDR. METHODS Ovid MEDLINE, Embase, and PubMed databases were queried in accordance with PRISMA guidelines. All studies included described a novel surgical technique. The technical nuances of each approach were extracted, including extent of exposure, bone removal, and selection of appropriate nerve roots. The operative approach preferred at the authors' institution (the "2 × 3 exposure") is also detailed. RESULTS Five full-text papers were identified from a total of 380 articles. Operative approaches to SDR varied significantly with regard to level of exposure, extent of laminectomy, and identification of nerve roots. The largest exposure involved a multilevel laminectomy, while the smallest exposure involved a keyhole interlaminar approach. At the Hospital for Sick Children, the authors utilize a two-level laminoplasty at the level of the conus medullaris. The benefits and disadvantages of the spectrum of techniques are discussed, and illustrative figures are provided. CONCLUSIONS Surgical approaches to SDR vary considerably and are detailed and illustrated in this review as a guide for neurosurgeons. Future studies should address the long-term impact of these techniques on functional outcomes and complications such as spinal deformity.
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Affiliation(s)
- Nebras M Warsi
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 2Division of Neurosurgery, Hospital for Sick Children
| | | | - Ian C Coulter
- 2Division of Neurosurgery, Hospital for Sick Children
| | - Husain Shakil
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
| | | | - Renée Haldenby
- 4Department of Pediatrics, University of Toronto, Ontario, Canada
| | | | | | | | | | - George M Ibrahim
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 2Division of Neurosurgery, Hospital for Sick Children
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Davidson B, Schoen N, Sedighim S, Haldenby R, Dalziel B, Breitbart S, Fehlings D, Milo-Manson G, Narayanan UG, Drake JM, Ibrahim GM. Intrathecal baclofen versus selective dorsal rhizotomy for children with cerebral palsy who are nonambulant: a systematic review. J Neurosurg Pediatr 2020; 25:69-77. [PMID: 31628286 DOI: 10.3171/2019.8.peds19282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | - Nathan Schoen
- 2University of Miami, Miller School of Medicine, Miami, Florida
| | - Shaina Sedighim
- 2University of Miami, Miller School of Medicine, Miami, Florida
| | - Renée Haldenby
- 3Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Blythe Dalziel
- 3Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Sara Breitbart
- 4Division of Orthopaedics, Hospital for Sick Children, University of Toronto; and
| | - Darcy Fehlings
- 3Department of Pediatrics, University of Toronto, Ontario, Canada
| | | | - Unni G Narayanan
- 4Division of Orthopaedics, Hospital for Sick Children, University of Toronto; and
| | - James M Drake
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Hospital for Sick Children, Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, University of Toronto, Ontario, Canada
| | - George M Ibrahim
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Hospital for Sick Children, Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, University of Toronto, Ontario, Canada
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Lewis J, Bear N, Baker F, Fowler A, Lee O, McLennan K, Richardson E, Scheinberg A, Smith N, Thomason P, Tidemann A, Wynter M, Paget S. Australian children undergoing selective dorsal rhizotomy: protocol for a national registry of multidimensional outcomes. BMJ Open 2019; 9:e025093. [PMID: 31048430 PMCID: PMC6502035 DOI: 10.1136/bmjopen-2018-025093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Selective dorsal rhizotomy (SDR) is a neurosurgical intervention intended to permanently reduce spasticity in the lower limbs and improve mobility in selected children with cerebral palsy (CP). Despite SDR having been performed worldwide for the past 30 years, there is moderate quality of evidence that SDR is effective in reducing spasticity with low to very low evidence of its effectiveness in improving gait, function and participation, using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Published studies have described outcomes for groups that differ in selection, surgical technique and postoperative rehabilitation making it difficult for clinicians to use this information to advise families on best management. There is substantial community interest in SDR. A small number of children with CP undergo SDR in Australia each year and some families seek the intervention at international sites. Capturing clinical outcomes and adverse event (AE) data for Australian children undergoing SDR will provide clinicians with information to help guide families considering SDR. METHODS AND ANALYSIS The Australian SDR Research Registry is a national registry of multidimensional outcomes for Australian children undergoing SDR in an Australian or overseas centre. Data will be collected for up to 10 years following the surgery, to include surgery and admission details, surgical and long-term AEs, and outcome measures across the body structure and functions, activity and participation domains of the International Classification of Functioning, Disability and Health. Data will be collected at baseline, during inpatient admission and at 1, 2, 5 and 10 years post. The aim of collecting these data is to improve understanding of short-, medium- and long-term outcomes and adverse effects of the intervention. ETHICS AND DISSEMINATION This study was approved by the individual Human Research and Ethics committees at the five Australian tertiary hospitals involved. Results will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12618000985280; Pre-results.
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Affiliation(s)
- Jennifer Lewis
- The Children’s Hospital at Westmead, Kids Rehab, Sydney, New South Wales, Australia
| | - Natasha Bear
- Child and Adolescent Health Service Western Australia, Perth, Western Australia, Australia
| | - Felicity Baker
- Rehabilitation Department, Women’s and Children’s Hospital Adelaide Women’s and Babies Division, North Adelaide, South Australia, Australia
| | - Adam Fowler
- Department of Neurosurgery, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Olivia Lee
- Victorian Paediatric Rehabilitation Service, Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
| | - Kim McLennan
- Lady Cilento Children’s Hospital, South Brisbane, Queensland, Australia
| | - Emma Richardson
- Department of Paediatric Rehabilitation, Princess Margaret Hospital for Children, Perth, Australia
| | - Adam Scheinberg
- Victorian Paediatric Rehabilitation Service, Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
- University of Melbourne Melbourne Medical School, Melbourne, Victoria, Australia
| | - Nadine Smith
- Department of Paediatric Rehabilitation, Princess Margaret Hospital for Children, Perth, Australia
| | - Pam Thomason
- Hugh Williamson Gait Analysis Laboratory, Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
| | - Andrew Tidemann
- Paediatric Rehabilitation Department, Women’s and Children’s Hospital Adelaide, North Adelaide, Australia
| | - Meredith Wynter
- Lady Cilento Children’s Hospital, South Brisbane, Queensland, Australia
| | - Simon Paget
- Kids Rehab, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- University of Sydney, Sydney Medical School, Sydney, New South Wales, Australia
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12
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VanderHave KL, Cho RH, Kelly DM. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2019; 101:289-295. [PMID: 30801367 DOI: 10.2106/jbjs.18.01078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Robert H Cho
- Shriners for Children Medical Center, Pasadena, California
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