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Selective Dorsal Rhizotomy for Spasticity Periprocedural Care

  • Author: Richard CE Anderson, MD; Chief Editor: Kim J Burchiel, MD, FACS  more...
 
Updated: Sep 20, 2015
 

Patient Education & Consent

It is essential for the family and interdisciplinary health care team to understand and agree upon the goals of surgical intervention in spasticity. With the correct patient selection and postoperative rehabilitation, children with spasticity can experience marked improvements in lower extremity function, range of motion, and global function following selective dorsal rhizotomy (SDR). With an irreversible procedure such as SDR, however, expectations should be clearly defined and realistic outcomes delineated.

The ability to participate in a rigorous postoperative physical therapy program is essential and must be discussed with families and caregivers in advance.[11]

Patient Instructions

All patients undergo general anesthesia so are required to be kept on nil per os (NPO; nothing by mouth) from midnight the night before surgery. Patients are sometimes instructed to use a special cleansing soap the night prior and morning of surgery in order to minimize the risk of surgical infection. Patients may expect to be kept flat in bed the first day or two postoperatively in order to minimize the risk of cerebrospinal fluid leakage.

Elements of Informed Consent

Patients must be aware the goal of surgery is reduction of motor tone, which has various functional implications based on the patient’s age, functional status, strength, and ability to engage in postoperative physical therapy. They must be aware that the consequences of rootlet transection are irreversible. The patient should also be informed of the risk of cerebrospinal fluid leak from an intradural operation.

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Pre-Procedure Planning

Preoperative MRI and intraoperative ultrasonography are helpful to determine if additional bone removal is needed to achieve adequate exposure around the conus.

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Equipment

Preoperative neurophysiologic monitoring electrodes are placed after intubation. Needle electrodes are typically placed in the adductor magnus (longus or brevis) (L2-4), vastus lateralis (L2-4), anterior tibialis (L4, L5), bicep femoris (L5, S1), gastrocnemius (S1, S2), and external anal sphincter muscles (S2-S4) in preparation for intraoperative electromyography (EMG).

Ultrasonography is used to ensure adequate bone removal

An operating microscope is used for the intradural portion of the case.

Rhizotomy stimulating electrodes and routine microinstruments should be made available.

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Anesthesia

The anesthetic regimen is critical to intraoperative evaluation by the neurophysiologist and physiotherapy team. Premedication with a short-acting benzodiazepine and induction agents such as sevoflurane and remifentanil are frequently used. Subsequently, propofol, benzodiazepines, and paralytics are avoided because of the alteration of EMG activity.

Anesthesia is often maintained with fentanyl, nitrous oxide, and sevoflurane.

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Positioning

The patient is placed in a prone position, with soft supports under the chest and hips, and appropriate padding of the knees, feet, and arms. The patient’s head is placed in a soft foam head-holder with the breathing tube to the side. The patient’s arms are typically placed at 90° at the shoulder and elbows, in a cephalad direction, in order to allow the surgeon access to the lumbosacral spine and anesthesiologist better access to lines. In smaller children, the arms may be left at the side of the hips in anatomical position, if desired.

If manual palpation of muscle groups is performed intraoperatively to assess response during nerve rootlet stimulation, the patient’s feet should be close to the bottom of the bed to allow adequate access for the therapists under the operative drapes.

If a traditional SDR is performed, a five- or six-level laminoplasty is typically done to expose the entire cauda equina. If a SDR centered at the conus is performed, fluoroscopy is used to localize L1. Preoperative MRI and intraoperative ultrasonography are helpful to determine if additional bone removal is needed to achieve adequate exposure around the conus.

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Monitoring & Follow-up

Initial management includes transfer to the PICU and then to the neurosurgical ward with intravenous and then oral pain medications, as needed.

Antibiotics are continued for 24 hours, and steroids for 72 hours postoperatively.

The patient may be kept flat for 1-3 days postoperatively to promote healing and to reduce the risk of cerebrospinal fluid leak.

Recovery from surgery typically takes 2-3 days.

Immediately after surgery, patients typically have a significant reduction in spasticity, often unmasking underlying muscle weakness.[13] Pudendal monitoring, in an attempt to avoid such complications, is practiced by many institutions.[14] Although studies have proposed an increased incidence of scoliosis and hip subluxation following SDR, the common finding of these conditions in patients with spasticity who have not undergone SDR leave the role of SDR in the causation of these conditions unclear.[21, 22]

Long-term monitoring

Several studies have documented positive outcomes from SDR. Muscle tone, flexibility, gait pattern, functional positioning, and the functional ability of the child have all been documented as improving following SDR.[19, 23] Of note, SDR did not eliminate the need for further orthopedic surgery in approximately half of patients requiring further tendon-lengthening procedures. The need for subsequent orthopedic procedures has also been reported in other studies; however, it is likely that these procedures would have been necessary regardless of SDR.[24]

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Contributor Information and Disclosures
Author

Richard CE Anderson, MD Assistant Professor of Neurosurgery and Pediatric Neurosurgery, Columbia University Medical Center, Columbia University College of Physicians and Surgeons; Director, Pediatric Neurosurgery, St Joseph's Children's Hospital

Richard CE Anderson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, Congress of Neurological Surgeons, American Association of Neurological Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Paul R Gigante, MD Resident Physician in Neurological Surgery, Columbia University College of Physicians and Surgeons

Paul R Gigante, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery

Disclosure: Nothing to disclose.

Barbara CS Hamilton Columbia University College of Physicians and Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Kim J Burchiel, MD, FACS John Raaf Professor and Chairman, Department of Neurological Surgery, Professor, Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University School of Medicine; Attending Neurosurgeon, Section of Neurosurgery, Portland Veterans Affairs Medical Center; Attending Neurosurgeon, Shriners Hospital for Children

Kim J Burchiel, MD, FACS is a member of the following medical societies: American Academy of Pain Medicine, American Association of Neurological Surgeons, American College of Surgeons, American Pain Society, International Association for the Study of Pain, Oregon Medical Association, Society of Neurological Surgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

References
  1. Arens LJ, Peacock WJ, Peter J. Selective posterior rhizotomy: a long-term follow-up study. Childs Nerv Syst. 1989 Jun. 5(3):148-52. [Medline].

  2. Kim HS, Steinbok P, Wickenheiser D. Predictors of poor outcome after selective dorsal rhizotomy in treatment of spastic cerebral palsy. Childs Nerv Syst. 2006 Jan. 22(1):60-6. [Medline].

  3. Delgado MR, Hirtz D, Aisen M, Ashwal S, Fehlings DL, et al. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2010 Jan 26. 74(4):336-43. [Medline]. [Full Text].

  4. Hoving MA, van Raak EP, Spincemaille GH, Palmans LJ, Becher JG, Vles JS. Efficacy of intrathecal baclofen therapy in children with intractable spastic cerebral palsy: a randomised controlled trial. Eur J Paediatr Neurol. 2009 May. 13(3):240-6. [Medline].

  5. Albright AL. Intrathecal baclofen in cerebral palsy movement disorders. J Child Neurol. 1996 Nov. 11 Suppl 1:S29-35. [Medline].

  6. Foerster. Resection of the Posterior Spinal Nerve-roots in the Treatment of Gastric Crises and Spastic Paralysis. Proc R Soc Med. 1911. 4:226-46. [Medline]. [Full Text].

  7. Foester O. On the indications and results of the excision of posterior spinal nerve roots in men. Surg Gynecol Obstet. May 1913;16:464-474.

  8. Fasano VA, Barolat-Romana G, Ivaldi A, Sguazzi A. [Functional posterior radiculotomy, in the treatment of cerebral spasticity. peroperative electric stimulation of posterior roots and its use in the choice of the roots to be sectioned]. Neurochirurgie. 1976. 22(1):23-34. [Medline].

  9. Sindou M, Quoex C, Baleydier C. Fiber organization at the posterior spinal cord-rootlet junction in man. J Comp Neurol. 1974 Jan 1. 153(1):15-26. [Medline].

  10. Peacock WJ, Eastman RW. The neurosurgical management of spasticity. S Afr Med J. 1981 Nov 28. 60(22):849-50. [Medline].

  11. Steinbok P. Selective dorsal rhizotomy for spastic cerebral palsy: a review. Childs Nerv Syst. 2007 Sep. 23(9):981-90. [Medline].

  12. Gutknecht SM, Schwartz MH, Munger ME. Ambulatory children with cerebral palsy do not exhibit unhealthy weight gain following selective dorsal rhizotomy. Dev Med Child Neurol. 2015 Apr 27. [Medline].

  13. Steinbok P, Schrag C. Complications after selective posterior rhizotomy for spasticity in children with cerebral palsy. Pediatr Neurosurg. 1998 Jun. 28(6):300-13. [Medline].

  14. Abbott R. Complications with selective posterior rhizotomy. Pediatr Neurosurg. 1992. 18(1):43-7. [Medline].

  15. McFall J, Stewart C, Kidgell V, Postans N, Jarvis S, Freeman R, et al. Changes in gait which occur before and during the adolescent growth spurt in children treated by selective dorsal rhizotomy. Gait Posture. 2015 Jun 29. [Medline].

  16. Josenby AL, Wagner P, Jarnlo GB, Westbom L, Nordmark E. Functional performance in self-care and mobility after selective dorsal rhizotomy: a 10-year practice-based follow-up study. Dev Med Child Neurol. 2015 Mar. 57 (3):286-93. [Medline].

  17. McLaughlin JF, Bjornson KF, Astley SJ, Graubert C, Hays RM, Roberts TS, et al. Selective dorsal rhizotomy: efficacy and safety in an investigator-masked randomized clinical trial. Dev Med Child Neurol. 1998 Apr. 40(4):220-32. [Medline].

  18. McLaughlin J, Bjornson K, Temkin N, Steinbok P, Wright V, Reiner A, et al. Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol. 2002 Jan. 44(1):17-25. [Medline].

  19. Kan P, Gooch J, Amini A, Ploeger D, Grams B, Oberg W, et al. Surgical treatment of spasticity in children: comparison of selective dorsal rhizotomy and intrathecal baclofen pump implantation. Childs Nerv Syst. 2008 Feb. 24(2):239-43. [Medline].

  20. Steinbok P, Reiner AM, Beauchamp R, Armstrong RW, Cochrane DD, Kestle J. A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy. Dev Med Child Neurol. 1997 Mar. 39(3):178-84. [Medline].

  21. Greene WB, Dietz FR, Goldberg MJ, Gross RH, Miller F, Sussman MD. Rapid progression of hip subluxation in cerebral palsy after selective posterior rhizotomy. J Pediatr Orthop. 1991 Jul-Aug. 11(4):494-7. [Medline].

  22. Mooney JF 3rd, Millis MB. Spinal deformity after selective dorsal rhizotomy in patients with cerebral palsy. Clin Orthop Relat Res. 1999 Jul. 48-52. [Medline].

  23. Langerak NG, Lamberts RP, Fieggen AG, Peter JC, van der Merwe L, Peacock WJ, et al. A prospective gait analysis study in patients with diplegic cerebral palsy 20 years after selective dorsal rhizotomy. J Neurosurg Pediatr. 2008 Mar. 1(3):180-6. [Medline].

  24. Carroll KL, Moore KR, Stevens PM. Orthopedic procedures after rhizotomy. J Pediatr Orthop. 1998 Jan-Feb. 18(1):69-74. [Medline].

  25. Park TS, Owen JH. Surgical management of spastic diplegia in cerebral palsy. N Engl J Med. 1992 Mar 12. 326(11):745-9. [Medline].

 
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Schematic drawings representing the excitatory and inhibitory influences on the spinal cord alpha motor neuron, which innervates the muscle fibers. (A) Normal physiology with a balance of inhibitory influence from descending neurons and excitatory influence from the sensory spinal reflex arc. (B) In children with spasticity, injury to the upper motor neuron results in a decrease in the descending inhibitory influence, leaving a hyperactive spinal cord reflex arc. By cutting some of the dorsal rootlets, selective dorsal rhizotomy can help restore balance to the alpha motor neuron by reducing the amount of excitatory influence on the alpha motor neuron. Courtesy of Tae S Park, MD.
After the conus is clearly identified, a single laminectomyis done entirely with a Midas Rex craniotome. At least 5 mm of thecaudal conus should be exposed. The laminectomy extends laterallyclose to the facet joint. Courtesy of Tae S Park, MD.
After the dural incision, an operatingmicroscope is brought into the field. The L-1 and L-2 spinal roots areidentified at the corresponding intervertebral foramina, and the filumterminale in the midline is found. Courtesy of Tae S Park, MD.
The L-2 dorsal root and the dorsal rootsmedial to the L-2 root are retracted medially to separate the L2-S2 dorsalroots from the ventral roots. The thin S3-5 spinal roots exiting fromthe conus are identified. A cotton patty is placed over the ventralroots and lower sacral roots. Courtesy of Tae S Park, MD.
A 5 mm Silastic sheet is placed underthe L2-S2 dorsal roots, after which the sugeon again inspects the L-2 dorsal root at the foraminal exit, the lateral surface of the conusbetween the dorsal and ventral roots, and the lower sacral roots near the filum terminale. The Inspection ensures placement of only the the L2-S2 dorsal roots on top of the Silastic sheet. Courtesy of Tae S Park, MD.
The L-2 dorsal root is easily identified. In an attempt to identify the L3-S2 dorsal roots, all the dorsal roots are spread over the Silastic sheet and grouped into presumed individual dorsal roots. Then the innervation pattern of each dorsal root is examined with electromyographic (EMG) responses to electrical stimulation with a threshold voltage. Courtesy of Tae S Park, MD.
With a Scheer needle, each dorsal root is subdivided into three to five rootlet fascicles, which are subjected to EMG testing. Courtesy of Tae S Park, MD.
Stimulation of an L-2 rootlet fascicle elicits an unsustained discharge to a train of titanic stimuli. Courtesy of Tae S Park, MD.
The rootlet is thus spared from sectioning and placed behind the Silastic sheet. Courtesy of Tae S Park, MD.
Stimulation of a rootlet is thus sectioned. Courtesy of Tae S Park, MD.
The rootlets spared from sectioning are under the Silastic sheet, and the roots to be tested are on top of the Silastic sheet. Note the EMG testing and sectioning of the dorsal roots are performed caudal to the conus. Courtesy of Tae S Park, MD.
 
 
 
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