Resultados funcionales de corto plazo en rizotomía dorsal selectiva para el tratamiento de espasticidad en niños con parálisis cerebral / Short-term functional outcomes of selective dorsal rhizotomy for the treatment of spasticity in children with cerebral palsy

Introduction: selective dorsal rhizotomy (SDR) is a neurosurgical, non-reversible intervention to treat disabling spasticity in children with cerebral palsy (CP), improving their motor function and general performance. Objective: to assess functional outcomes of SDR in CP patients at Institutos teletón Chile, 6 and 12 months post-surgery. Patients and Method: Clinical records of all patients that underwent a SDR procedure between November 2010 and November 2013 were reviewed. Eighteen cases (spastic diplegia; age 7.5 +/- 2.9 years) were found, and their relevant pre-, peri- and post operative data after 6 and 12 months, were analyzed, as: clinical history, physical examination, evidence of preventricular leukomalacia (PVL), aspects related to surgery, and functional outcomes, including Gross Motor Function Measurement (GMFM)-66 and -88, Pediatric Evaluation Disability Inventory (PEDI) and gait lab (GL) using Gait Deviation Index (GDI). Results: Fifty percent of the subjects were classified as GMFCS II-III and the other 50 percent as GMFCS IV. A clinical important reduction in lower limb spasticity, particularly in triceps surae and hip flexors was observed in all patients, as well as improved muscular strength in many of them. GMFM-66 and GMFM-88 scores improved (p < 0.01). A trend towards improvement, without significant differences was observed in PEDI scores (GMFCS IV patients), and a significant improvement in GDI in ambulant patients (p < 0.015). Conclusions: SDR is a valid option to achieve long-lasting control of spasticity, 12 months after surgery, in children with spastic cerebral palsy, improving also functional capacity.

Introducción: la rizotomía dorsal selectiva (RDS) es una intervención neuro-quirúrgica irreversible para tratarla espasticidad discapacitante en niños con parálisis cerebral (PC). Su finalidad es mejorar la función motora y funcionalidad global de los pacientes. Objetivo: Evaluar los resultados funcionales de la RDS en los pacientes de Institutos teletón Chile con PC a los 6 y 12 meses postoperatorio. Pacientes y Método: Se revisan las fichas clínicas de los pacientes operados de RDS entre noviembre de 2010 y noviembre de 2013. Se encuentran 18 casos (diplejia espástica; edad 7,5 +/- 2,9 años), cuyos datos clínicos relevantes pre, peri y postoperatorios a 6 y 12 meses, fueron analizados: historia y examen físico; presencia de leucomalacia periventricular (LMPV); aspectos quirúrgicos y resultados funcionales de: Gross Motor Function Measurement (GMFM)-66 y 88, Pediatric Evaluation Disability Inventory (PEDI) y en laboratorio de marcha (LM), el Gait Deviation Index (GDI). Resultados: 50 por ciento correspondieron a pacientes GMFCS II-III y 50 por ciento a GMFCS IV. Se obtuvo importante reducción clínica de espasticidad de extremidades inferiores, especialmente plantiflexores de tobillo y flexores de cadera en todos los pacientes y en muchos un aumento de la fuerza muscular. Hubo mejoría en función motora gruesa evaluado con GMFM-66 (p < 0,001) y GMFM-88 (p < 0,001). tendencia a mejoría, sin diferencias significativas en PEDI (pacientes GMFCS IV) y mejoría significativa de GDI en pacientes ambulantes (p < 0,015). Conclusiones: La RDS es una opción válida para el control duradero de la espasticidad, a 12 meses, en niños con parálisis cerebral espástica, proporcionando además mejorías funcionales.

Development of the Hardware and Software for the Selective Dorsal Rhizotomy Using Hoffmann Reflex: A Study on the EMG Patterns Generated by Stimulation of the Spinal Nerve Roots

This experimental study was designed to develop an electromyography(EMG) machine and a program to be used during the selective dorsal rhizotomy, and to investigate the patterns of EMG waves generated by stimulation of the normal spinal nerve roots in cat. The developed machine, consisting of nerve stimulator, EMG amplifier, analogue-digital converter and computer program, functioned well during experiment without any mechanical or electrical problems. We were able to record pure H-wave(Hoffmann wave) in EMG by stimulating posterior root in most cases, although components of motor and directly conducted waves were observed only in few cases. The peak latency of H-wave, which was about half of that of the motor wave by the mean value, was consistent as a whole. H2/H1 ratio (the ratio of the second and the first H-wave), peak amplitude and the pattern of changes of the peak amplitudes with continuous sitmulation, however, varied greatly from case to case. In conclusion, the results of this experiment suggest that EMG wave patterns, generated by the stimulation of the posterior nerve roots, may not be appropriate for the determination of the nerve roots to be cut during the selective dorsal rhizotomy.

Anesthetic Management for Selective Dorsal Rhizotomy / 대한마취과학회지

Background: Cerebral palsy is due to static encephalopathy during perinatal period. Selective dorsal rhizotomy (SDR) involves selective division of posterior nerve roots to reduce spasticity and improve function in children with spastic cerebral palsy. Anesthesia during SDR must preserve muscle contraction in response to direct electrical stimulation of the dorsal nerve roots. We did this study to get the better management of anesthesia for SDR. Methods: Anesthetic records were reviewed for 16 patients who underwent SDR during January 1996 to August 1997. Demographic data; anesthetic drugs and doses; changes of vital signs and end tidal CO2; dorsal root stimulation; postoperative pain control were analysed. Results: The mean age of patients was 4.9+/-1.7 years old. The mean weight was 16.3+/-4.0 kg. The under 1 MAC concentration of isoflurane and 2~3 mcg/kg/hr fentanyl did not interfere with electrophysiologic monitoring. Esophageal temperature was increased significantly during electrical stimulation of dorsal roots. End tidal CO2 concentration had a tendency to increase after electrical stimulation too. Direct installation of 10~15 mcg/kg intrathecal morphine prior to dural closure, and postoperative 0.5 mcg/kg/hr fentanyl had a good postoperative analgesia without complication. Conclusions: Isoflurane and fentanyl during anesthesia, and intrathecal morphine with continuous infusion of fentany postoperatively are suggested a good anesthetic method for SDR.