Dorsal Longitudinal T-Myelotomy (Bischof II Technique): A Useful, Antiquated Procedure for the Treatment of Intractable Spastic Paraplegia.

OBJECTIVE: Dorsal longitudinal T-myelotomy is a long-established operation to treat severe spastic paraplegia. The present study aimed to report this surgical technique and investigate the efficacy of T-myelotomy for spasticity relief. METHODS: All cases undergoing T-myelotomy for treatment of intractable spastic paraplegia during 2009-2017 were included. The severity of spasticity was evaluated with the Modified Ashworth Scale, Penn Spasm Frequency Scale, Adductor Tone Rating Scale, degree of passive range of motion, and occurrence of abdominal muscle spasms. Other clinical assessments included deep tendon reflex assessed by the National Institute of Neurological Disorders and Stroke scale, Babinski sign, healing of decubitus ulcers, and ambulatory status. RESULTS: Fourteen patients with a mean age of 39.3 ± 13.4 years were included. The 7 patients with abdominal muscle spasms before surgery had no spasms after surgery. The Babinski sign was absent in all cases after surgery. Unhealed pressure ulcers in all 9 cases were healed after surgery. All 4 patients with a preoperative bed-bound condition were able to ambulate with a wheelchair. A statistically significant improvement in mean Modified Ashworth Scale score, degree of passive range of motion, and National Institute of Neurological Disorders and Stroke scale score was found in the subgroup and overall analyses. There was also a statistically significant improvement in the Penn Spasm Frequency Scale and Adductor Tone Rating Scale scores. CONCLUSIONS: Dorsal longitudinal T-myelotomy remains an effective option for the treatment of intractable spastic paraplegia. It is suitable for, and may be an alternative to, intrathecal baclofen therapy for patients with complete spinal cord lesion or patients without hope of regaining motor function.

Comparison of efficacy between dorsal root entry zone lesioning and selective dorsal rhizotomy for spasticity of cerebral origin.

BACKGROUND: Severe spasticity adversely affects patient functional status and caregiving. No previous study has compared efficacy between dorsal root entry zone lesioning (DREZL) and selective dorsal rhizotomy (SDR) for reduction of spasticity. This study aimed to investigate the efficacy of DREZL and SDR for attenuating spasticity, and to compare efficacy between these two methods. METHODS: All patients who underwent DREZL, SDR, or both for treatment of intractable spasticity caused by cerebral pathology at Siriraj Hospital during 2009 to 2016 were recruited. Severity of spasticity was assessed using Modified Ashworth Scale (MAS) and Adductor Tone Rating Scale (ATRS). Ambulatory status was also evaluated. RESULTS: Fifteen patients (13 males) with a mean age of 30.3 ± 17.5 years were included. Eight, six, and one patient underwent DREZL, SDR, and combined cervical DREZL and lumbosacral SDR, respectively. Eight of ten patients with preoperative bed-bound status had postoperative improvement in ambulatory status. Spasticity was significantly reduced in the DREZL group (p < 0.001), the SDR group (p < 0.001), and in overall analysis (p < 0.001). SDR was effective in both pediatric and adult spasticity patients. A significantly greater reduction in spasticity as assessed by MAS score (p < 0.001) and ATRS score (p = 0.015) was found in the DREZL group. Transient lower limb weakness was found in a patient who underwent SDR. CONCLUSIONS: DREZL is more effective for reducing spasticity, but is more destructive than SDR. DREZL should be preferred for bed-ridden patients, and SDR for ambulatory patients. Both operations are helpful for improving ambulatory status. Gait improvement was observed only in patients who underwent SDR. Adult patients with spasticity of cerebral origin benefit from SDR.

Progression-Free Survival and Factors Associated with Postoperative Recurrence in 126 Patients with Atypical Intracranial Meningioma.

OBJECTIVE: Atypical meningioma has a higher recurrence rate than benign meningioma. The mainstay of treatment is surgery with or without radiation therapy (RT). The objective of this study was to investigate progression-free survival (PFS) and factors associated with postoperative recurrence in patients with atypical meningioma. METHODS: Patients with diagnoses of atypical menigioma who underwent surgery at Siriraj Hospital during the 2004 to 2014 study period were included. Features potentially associated with PFS and tumor recurrence from clinical records, operative records, and neuroimaging studies were evaluated and analyzed. RESULTS: One hundred twenty-six patients (mean age, 55 years) were included. The median PFS was 55 months. The 5-year and 10-year PFS rates were 72.5% and 32%, respectively. The median follow-up duration was 52 months. In multivariate analysis, tumor location (convexity, parasagittal/falcine, intraventricular, skull base) (P = 0.003), and pial invasion (hazard ratio [HR]: 2.02; P = 0.045) were significantly associated with tumor recurrence. Postoperative RT was associated with reduction in tumor recurrence in both univariate (odds ratio: 0.48; P = 0.039) and multivariate analysis (HR: 0.42; P = 0.005). CONCLUSIONS: Tumor location and pial invasion were significantly correlated with increased incidence of tumor recurrence, and postoperative RT was found to be significantly associated with decreased tumor progression and recurrence.

The therapeutic effects of ablative neurosurgical procedures on the spinal cord for intractable spinal spasticity.

STUDY DESIGN: This research is a retrospective study. OBJECTIVE: To study the therapeutic effects of operative procedures, including dorsal longitudinal myelotomy (DLM) and dorsal root entry zone lesion (DREZL) on spasticity and associated aspects. SETTING: Tertiary university hospital in Bangkok, Thailand. METHODS: Eighteen patients with refractory spasticity of spinal origin who underwent the operations were recruited. Clinical parameters for evaluating severity of spasticity and ambulatory status were compared between before and after surgery, and between surgeries. RESULTS: A statistically significant reduction of spasticity as measured by the Modified Ashworth Scale (MAS), Adductor Tone Rating Scale (ATRS) and Penn Spasm Frequency Scale (PSFS) was found after surgeries and in the overall analysis (p < 0.05). Chronic pressure ulcers disappeared postoperatively in 11 cases. All of 7 bed-ridden subjects experienced improvement in their ambulatory status postoperatively. DLM was found to be more effective than DREZL in reduction of spasticity. CONCLUSION: Ablative neurosurgery on the spinal cord is still valuable in situations when intrathecal baclofen is unavailable. These operations are potentially effective in the treatment of intractable spasticity of spinal origin.

Surgical outcomes of microsurgical selective peripheral neurotomy for intractable limb spasticity.

BACKGROUND: The authors frequently employed selective peripheral neurotomy (SPN) as the primary treatment of severe intractable focal and multifocal spastic hypertonia. We occasionally operated SPN in diffuse spastic disorders. OBJECTIVE: To study surgical outcome of SPN in terms of severity of spasticity and functional condition. METHODS: Patients harboring refractory harmful spasticity of various origins were enrolled into the present study. They were clinically evaluated by using the Modified Ashworth Scale (MAS), passive range of motion (PROM) and functional status. These variables were compared between pre- and postsurgery by using the paired t test and the Wilcoxon signed-rank matched-pairs test. RESULTS: One hundred and forty-one SPNs were accomplished in 33 patients. Overall mean pre- and postoperative MAS and PROM were 3.0 and 0.7 (p < 0.001) and 78.3 and 102.3° (p < 0.001), respectively. Analysis of individual SPN subgroups also demonstrated statistically significant improvement of both parameters. Furthermore, we found significant gait improvement among 10 ambulatory subjects. Nine bed-bound cases attained significant enhancement of sitting competency and ambulatory condition. CONCLUSION: SPN is an efficacious neurosurgical intervention in the treatment of spasticity. It is apparently beneficial in the reduction of spasticity, amelioration of functional status, facilitation of patient care and prevention of long-term musculoskeletal sequelae.

Utilization of intraoperative electromyography for selecting targeted fascicles and determining the degree of fascicular resection in selective tibial neurotomy for ankle spasticity.

BACKGROUND: Selective tibial neurotomy (STN) is an effective neurosurgical intervention for treating ankle spasticity. The authors use intraoperative electromyography (EMG) for selecting targeted fascicles and determining the degree of fascicular resection in STN. This study reports surgical techniques and outcomes of the operation. METHODS: Participants who underwent STN with utilization of intraoperative EMG were recruited. Modified Ashworth Scale (MAS), passive range of motion (PROM) of the ankle in plantar flexion and dorsiflexion, Massachusetts General Hospital Functional Ambulatory Classification (MGHFAC) and ability to attain full plantigrade stance were assessed pre- and postoperatively. RESULTS: Twenty-one STNs were performed in 15 patients. The mean pre- and postoperative MAS and PROM were 2.8 and 0.4 (p < 0.001), 39.5(o) and 66.0(o) (p < 0.001), respectively. The mean level of MGHFAC was improved from 3.3 preoperatively to 4.9 postoperatively (p < 0.01). Six non-ambulators had significant amelioration in MGHFAC level. Postoperatively, 19 of 21 lower limbs achieved full plantigrade, and 6 patients could perform selective voluntary motor control of the ankle. CONCLUSION: STN is an effective procedure for spastic ankle in well-selected cases. Intraoperative EMG helps in selection of targeted fascicles, increases objectivity in neurotomy and prevents excessive denervation.

Improvement of sitting ability and ambulation status after selective peripheral neurotomy of the sciatic hamstring nerve together with obturator branches for severe spasticity of the lower extremities.

BACKGROUND: The authors used selective peripheral neurotomy (SPN) on the sciatic and obturator nerves to restore the sitting posture and ambulation in bedridden patients suffering from severe proximal lower limb spasticity. OBJECTIVE: To study the surgical outcome of sciatic and obturator neurotomies. METHODS: All patients with refractory hamstring spasticity who encountered SPN on the hamstring nerve were recruited. Obturator neurotomy was undertaken in some individuals. The clinical assessment included modified Ashworth scale (MAS), passive range of motion (PROM), sitting competency and ambulatory condition. These parameters were compared between before and after the surgery by using the Wilcoxon signed-rank test. RESULTS: Among the sciatic neurotomy group (n = 15), the mean pre- and postoperative MAS and PROM were 3.3 and 0.8 (p < 0.01) and 78.3 and 121.7° (p < 0.01), respectively. Those measurements of the obturator nerve surgery group (n = 11) were 3.7 and 1.1 (p < 0.01) as well as 21.0 and 45.0° (p < 0.01), respectively. Seven and 8 of a total of 9 patients had statistically significant improvement in sitting ability (p = 0.016) and ambulation status (p < 0.01), respectively. CONCLUSION: Bedridden patients who suffer from severe proximal lower limb spasticity have an optimum to return to sitting and ambulate with a wheelchair after SPN of the sciatic and obturator nerves.