Surgical Treatment for Spasticity: Selective Dorsal Rhizotomy ­ Technique and Literature Review

Spasticity is amotor disorder that leads to a resistance to passive jointmovement. Cerebral palsy is the most important cause of spasticity and can be caused by several factors, including multiple gestations, alcoholism, infections, hemorrhages, drowning, and traumatic brain injuries, among others. There aremany scales that help tomeasure andmonitor the degree of impairment of these patients. The initial treatment should focus on the causal factor, such as tumors, inflammation, degenerative diseases, hydrocephalus, etc. Subsequently, the treatment of spastic musculature includes oral or intrathecal myorelaxants, spinal cord electrostimulation, neurotomies, Lissauer tract lesion, dentatotomy and selective dorsal rhizotomy. The latter is a safetechnique, possibleto beperformed inmost centers with neurosurgical support, and it is effective in the treatment of severe spasticity. In this article, the authors describe the surgical technique and conduct a review the literature.

Rizotomia dorsal seletiva (RDS) para espasticidade: técnica minimamente invasiva no cone medular / Selective dorsal rhizotomy (SDR) for spasticity: minimally invasive technique at conus medullaris

A rizotomia dorsal seletiva é um procedimento cirúrgico bem aceito no manejo da espasticidade e tem como objetivo o alívio desse sintoma em pacientes cuidadosamente selecionados. Neste estudo, apresentamos o método que utilizamos em nosso serviço para indicação de pacientes, bem como a técnica cirúrgica e o método de monitorização neurofisiológica intraoperatória utilizado para otimizar os resultados. Realizamos também uma revisão bibliográfica utilizando os sites de busca da PubMed/MedLine e Lilacs, com artigos publicados entre os anos de 1965 e 2013. Os descritores utilizados foram: "rizotomia", "espasticidade", "paralisia cerebral" e "monitorização intraoperatória". Foram selecionados 17 artigos para este estudo.

Selective dorsal rhizotomy is a well-accepted cirurgic procedure utilized for relieving spasticity in carefully selected patients. In this work, we present the method we use to indicate the patients, the operative technique, and the intraoperative monitoring technique used in order to obtain the best results. We also reviewed the literature through the online databases PubMed/MedLine and Lilacs, with published papers from 1965 to 2013, descriptors included "rhizotomy", "spasticity", "cerebral palsy" and "intraoperative monitoring". We selected 17 articles for this study.

[Application of exercise therapy on rehabilitation after selective posterior rhizotomy (SPR) in children with cerebral palsy].

OBJECTIVE: To observe the clinical effect of exercise therapy on rehabilitation after selective posterior rhizotomy (SPR) in children with cerebral palsy, so as to provide reliable rehabilitation method for children with cerebral palsy. METHODS: Two hundred and twenty-six children with cerebral palsy were treated in the study during September 2003 to April 2007. All the patients were randomly divided into the training and control groups. There were 113 patients in the treatment group, including 66 males and 47 females, ranging in age from 3 to 8 years, with an average of (6.5 +/- 1.2) years, and the patients were treated with SPR as well as exercise therapy. Among 113 patients in the control group, 59 patients were male and 54 patients were female, ranging in age from 3 to 10 years, with an average of (6.9 +/- 1.5) years, and the patients were treated with SPR simply. Gross Motor Function Measure (GMFM), passive range of motion and muscle tension were used to evaluate therapeutic effects before and after treatment for both groups. RESULTS: All the patients were followed up for 6 to 18 months (averaged 8 months). There were significant improvements in training group compared with the control group on GMFM (134.29 +/- 46.43, P < 0.05), passive range of motion (dorsiflexion of the ankle 14.2 +/- 3.1 degree, P < 0.05) and muscle tension (1.27 +/- 0.42, P < 0.05). CONCLUSION: Physical therapy has more effective on rehabilitation after SPR for children with cerebral palsy, which can decrease spasticity and muscle tension and improve motor function.

Longitudinal construct validity of the GMFM-88 total score and goal total score and the GMFM-66 score in a 5-year follow-up study.

BACKGROUND: The Gross Motor Function Measure (GMFM) is the instrument most commonly used to measure gross motor function in children with cerebral palsy (CP). Different scoring options have been developed, and their measurement properties have been assessed. Limited information is available regarding longitudinal construct validity. OBJECTIVE: The objective of this research was to study the longitudinal construct validity of 3 scoring options: the 88-item GMFM (GMFM-88) total, the GMFM-88 goal total, and the 66-item GMFM (GMFM-66). DESIGN: A clinical measurement design was used in this study. METHODS: Forty-one children with CP diplegia who were undergoing selective dorsal rhizotomy (SDR) were monitored with the GMFM for 5 years. The mean age at SDR was 4.4 years (range=2.5-6.6). Two subgroups for gross motor function before surgery were created according to the Gross Motor Function Classification System (GMFCS): GMFCS levels I to III and GMFCS levels IV and V. This study included results obtained before SDR and at 6, 12, and 18 months and 3 and 5 years after SDR. The effect size (ES) and the standardized response mean (SRM) were calculated. RESULTS: At 6 months postoperatively, ES and SRM values were small (

O Impacto da rizotomia dorsal seletiva na qualidade de vida de crianças espásticas portadoras de paralisia cerebral / The impact of seletctive dorsal rhizotomy on the quality of life of spastic children with cerebral palsy

Objetivo: A rizotomia dorsal seletiva (RDS) é uma técnica clássica para tratamento da espasticidade em crianças com paralisia cerebral. Em nosso Serviço, é utilizada, além do objetivo funcional (deambulação), para melhoria da qualidade de vida da criança e do cuidador. O propósito do estudo foi avaliar a eficácia e o impacto do procedimento nesses indivíduos. Materiais e métodos: Um questionário sobre a qualidade de vida das crianças e cuidadores foi elaborado e enviado a 16 cuidadores de crianças submetidas à RDS, sendo posteriormente recuperados e analisados. Resultados: A maioria dos cuidadores julgou que houve melhora nos diversos quesitos relacionados à rotina diária, à facilitação para realização de cuidados e no posicionamento e transporte de criança. A maioria percebeu melhora no bem-estar e no estado de saúde. Dos cuidaores, 94 por cento se declararam satisfeitos com o procedimento. Conclusão: A RDS parece melhorar a qualidade de vida de crianças gravemente comprometidas pela espasticidade na PC, bem como a de seus cuidadores...

Loss and recovery of voluntary hand movements in the macaque following a cervical dorsal rhizotomy.

The recovery of manual dexterity was analyzed in the macaque following a cervical dorsal root section that abolished cutaneous feedback from selected digits of one hand. Monkeys were trained to retrieve a target object from a clamp using thumb and index finger opposition. Dorsal rootlets containing electrophysiologically identified axons projecting from the thumb and index finger were then cut in two monkeys (Group 1). In four others (Group 2), additional rootlets shown to innervate the middle finger and thenar eminence were also transected. Three performance parameters were analyzed before and following the rhizotomy: 1) percentage of successful retrievals; 2) digital stratagem (the pattern of digit opposition); and 3) contact time (duration of digit contact with the object before its retrieval). During the first postoperative week, hand function was severely impaired in all monkeys. Over the following weeks, Group 1 monkeys recovered the ability to retrieve the object by opposing the index finger and thumb in >80% of trials. Group 2 monkeys also regained some function in the impaired hand: each monkey adopted a stratagem for grasping the target, using digits that were incompletely deafferented. In the terminal experiment, hand representation in the contralateral somatosensory cortex was electrophysiologically mapped to define hand deafferentation and cortical reactivation further. There was a close correspondence between the cortical map and digit use. Our data imply that the recovery of precision grip using the thumb and index finger depends on the survival of afferents innervating these digits, as well as the proliferation of their central terminals.

Rizotomia seletiva posterior ou tratamento neuroevolutivo bobath para a criança com disfunção neuromotora espástica? / Selective posterior rhizotomy or bobath neuro-developmental treatment for the child with spastic neuromotor dysfunction?

A espasticidade encontra-se geralmente presente em crianças com Disfunção Neuromotora. Neste estudo, abordamos duas formas de tratamento que atuam na normalização do tônus, sendo uma cirúrgica e outra conservadora. A Rizotomia Seletiva Posterior caracteriza-se pela secção parcial das raízes aferentes lombo-sacrais. Já o Tratamento Neuroevolutivo Bobath utiliza técnicas manuais para adequar o tônus e, concomitantemente, proporcionar funcionalidade a criança. O objetivo do trabalho consiste na análise criteriosa das duas terapias, visando avaliar a necessidade de submeter o paciente a um procedimento invasivo. Pretendemos, desta forma, ampliar os conhecimentos dos profissionais que constituem uma equipe multidisciplinar, no sentido de facilitar a escolha do tratamento adequado para estas crianças com Disfunção Neuromotora. Independentemente do método eleito, é importante ressaltar que a qualidade de vida deve ser sempre priorizada. Portanto, o paciente precisa ser tratado como um todo, adequando o tônus e permitindo-lhe função. E de extrema importância a avaliação criteriosa individualizada, uma vez que a Rizotomia Seletiva Posterior pode atuar come complemento a reabilitação, na promoção de melhores resultados.

Spasticity is generally found in children with Neuromotor Dysfunction. In this study, we approach two forms of treatment that act in the normalization of the tone: one surgical and other conservative. The Selective Posterior Rhizotomy is characterized by the partial section of the afferent lombosacral roots. As for the Bobath Neuro-developmental treatment, some manual techniques are used to adequate the tone, and accordingly, to allow the children to make use of their functions. The objective of this paper is to analyze carefully both therapies, aiming at evaluating the need to submit the patient to surgery. We intend to enlarge the knowledge of professionals taking part of a Multidiscipline team, to facilitate the choice of the best treatment for children with Neuromotor Dysfunction. Regardless of the method chosen it is important to remark that the quality of life must be a priority. Therefore, the patients have to be treated as a whole, enabling them to adequate tone and allowing them to use the function. It is extremely important to have a very careful individual evaluation, once the Selective Posterior Rhizotomy can be a complement to rehabilitation for a better outcome.

Rizotomia seletiva posterior ou tratamento neuroevolutivo bobath para a criança com disfunção neuromotora espástica? / Selective posterior rhizotomy or bobath neuro-developmental treatment for the child with spastic neuromotor dysfunction?

A espasticidade encontra-se geralmente presente em crianças com Disfunção Neuromotora. Neste estudo, abordamos duas formas de tratamento que atuam na normalização do tônus, sendo uma cirúrgica e outra conservadora. A Rizotomia Seletiva Posterior caracteriza-se pela secção parcial das raízes aferentes lombo-sacrais. Já o Tratamento Neuroevolutivo Bobath utiliza técnicas manuais para adequar o tônus e, concomitantemente, proporcionar funcionalidade a criança. O objetivo do trabalho consiste na análise criteriosa das duas terapias, visando avaliar a necessidade de submeter o paciente a um procedimento invasivo. Pretendemos, desta forma, ampliar os conhecimentos dos profissionais que constituem uma equipe multidisciplinar, no sentido de facilitar a escolha do tratamento adequado para estas crianças com Disfunção Neuromotora. Independentemente do método eleito, é importante ressaltar que a qualidade de vida deve ser sempre priorizada. Portanto, o paciente precisa ser tratado como um todo, adequando o tônus e permitindo-lhe função. E de extrema importância a avaliação criteriosa individualizada, uma vez que a Rizotomia Seletiva Posterior pode atuar come complemento a reabilitação, na promoção de melhores resultados.(AU)

Spasticity is generally found in children with Neuromotor Dysfunction. In this study, we approach two forms of treatment that act in the normalization of the tone: one surgical and other conservative. The Selective Posterior Rhizotomy is characterized by the partial section of the afferent lombosacral roots. As for the Bobath Neuro-developmental treatment, some manual techniques are used to adequate the tone, and accordingly, to allow the children to make use of their functions. The objective of this paper is to analyze carefully both therapies, aiming at evaluating the need to submit the patient to surgery. We intend to enlarge the knowledge of professionals taking part of a Multidiscipline team, to facilitate the choice of the best treatment for children with Neuromotor Dysfunction. Regardless of the method chosen it is important to remark that the quality of life must be a priority. Therefore, the patients have to be treated as a whole, enabling them to adequate tone and allowing them to use the function. It is extremely important to have a very careful individual evaluation, once the Selective Posterior Rhizotomy can be a complement to rehabilitation for a better outcome.(AU)

Changes in ankle spasticity and strength following selective dorsal rhizotomy and physical therapy for spastic cerebral palsy.

OBJECT: In this investigation the authors quantified changes in ankle plantarflexor spasticity and strength following selective dorsal rhizotomy (SDR) and intensive physical therapy in patients with cerebral palsy (CP). METHODS: Twenty-five patients with cerebral palsy (CP group) and 12 able-bodied volunteers (AB controls) were tested with a dynamometer. For the spasticity measure, the dynamometer was used to measure the resistive torque of the plantarflexors during passive ankle dorsiflexion at five different speeds. Data were processed to yield a single value that simultaneously encompassed the three key elements associated with spasticity: velocity, resistance, and stretch. For the strength test, the dynamometer rotated the ankle from full dorsiflexion to full plantarflexion while a maximum concentric contraction of the plantarflexors was performed. Torque angle data were processed to include the work done by the patient or volunteer on the machine. Plantarflexor spasticity values for the CP group were significantly greater than similar values for the AB control group prior to surgery but not significantly different after surgery. Plantarflexor strength values of the CP group were significantly less than those of the AB control group pre- and postsurgery. Postsurgery strength values did not change relative to presurgery values. CONCLUSIONS: The spasticity results of the present investigation agreed with those of previous studies indicating a reduction in spasticity for the CP group. The strength results did not agree with the findings of most previous related literature, which indicated that a decrease in strength should have occurred. The strength results agreed with a previous investigation in which knee flexor strength was objectively examined, indicating that strength did not decrease as a consequence of an SDR. The methods of this investigation could be used to improve SDR patient selection.

Pain, anxiety, and cooperativeness in children with cerebral palsy after rhizotomy: changes throughout rehabilitation.

Assessed pain, anxiety, physical functioning, and cooperativeness in 32 children with spastic cerebral palsy. This is the first study to assess children throughout rehabilitation following selective posterior rhizotomy. Results of the Observational Scale of Behavioral Distress and observer Likert ratings confirmed the hypothesis that children's pain and anxiety decrease over time. Children's physical functioning and cooperativeness improve over time. No significant correlation was found between pain and changes in physical functioning. Cognitive impairment, parental involvement, and children's pain behaviors explained 77% and 56% of the variance in two forms of cooperativeness. Research and clinical implications are discussed, and special considerations regarding pain assessment and management in this population are addressed.