Selective dorsal rhizotomy: Analysis of two rootlet sectioning techniques.

OBJECTIVE: To analyze and compare the efficacy of two selective dorsal rhizotomy (SDR) techniques with intraoperative neurophysiological monitoring, using instrumented three-dimensional gait analysis. INTRODUCTION: SDR is a common, irreversible surgical treatment increasingly used to address gait disturbances in children with chronic non-progressive encephalopathy by reducing spasticity. Various techniques have been used, which mainly differ in the percentage of rootlets selected for sectioning. A greater proportion of rootlets sectioned leads to a more effective reduction of spasticity; however, there is a potential risk of unwanted neurological effects resulting from excessive deafferentation. While there is evidence of the short- and long-term benefits and complications of SDR, no studies have compared the effectiveness of each technique regarding gait function and preservation of the force-generating capacity of the muscles. MATERIALS AND METHODS: Instrumented three-dimensional gait analysis was used to evaluate two groups of patients with spastic cerebral palsy treated by the same neurosurgeon in different time periods, initially using a classic technique (cutting 50% of the nerve rootlets) and subsequently a conservative technique (cutting no more than 33% the nerve rootlets). RESULTS: In addition to an increase in knee joint range of motion (ROM), in children who underwent SDR with the conservative technique, a statistically significant increase (p = 0.04) in the net joint power developed by the ankle was observed. Patients who underwent SDR with the conservative technique developed a maximum net ankle joint power of 1.37 ± 0.61 (unit: W/BW), whereas those who were operated with the classic technique developed a maximum net ankle joint power of 0.98 ± 0.18 (unit: W/BW). The conservative group not only showed greater improvement in net ankle joint power but also demonstrated more significant enhancements in minimum knee flexion during the stance phase and knee extension at initial contact. CONCLUSION: Our results show that both techniques led to a reduction in spasticity with a positive impact on the gait pattern. In addition, patients treated with the conservative technique were able to develop greater net ankle joint power, leading to a better scenario for rehabilitation and subsequent gait.

Clinical response to surgical decompression in atypical pediatric Bow Hunter's syndrome suggesting alternative pathophysiology: Case report.

Bow Hunter's syndrome is a rare cause of posterior circulation ischemia, produced by the mechanical and reversible occlusion of the vertebral artery during cephalic rotation. Diagnosis requires clinical suspicion and careful inspection of images with three-dimensional reconstruction. The study of choice is dynamic digital subtraction angiography (DSA). Treatment alternatives are: medical, surgical or endovascular. We report the case of an 8-year-old boy with recurrent infarctions of the posterior circulation secondary to the dissection of the vertebral artery, in association with an occipital bone spur. Dynamic DSA was negative. Conservative initial management was elected with cervical immobilization and anticoagulation, but due to persistence of symptoms, surgical decompression was decided. The patient did not repeat symptoms postoperatively and returned to his usual life. This is the first case reported to our knowledge of a surgical pediatric patient with asymptomatic atypical compression of VA secondary to BHS, whose dynamic angiography was negative, suggesting an alternative mechanism of the syndrome.