Selective Dorsal Rhizotomy for Spasticity
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Selective dorsal rhizotomy (SDR) is used primarily to treat children with lower-extremity spasticity, also known as spastic diplegia or diparesis. The primary goal of SDR is to reduce spasticity and to improve lower-extremity function. Patients who ultimately benefit most from the procedure typically have pure spasticity involving the lower limbs, good cognitive function and strength, no fixed contractures, and postural stability.
Although the procedure has been successful in adolescents and even young adults, it is generally performed in a younger population (aged 3-8 years). [1] Patients with spastic quadriparesis (all 4 extremities involved) also benefit from SDR, but improvements in the upper extremities are typically less predictable and dramatic than those seen in the lower extremities. If a child with spastic quadriparesis has a significant component of dystonia, however, SDR may not be the best treatment option, and other modalities, including intrathecal baclofen, should be considered. [2]
Cerebral palsy is one of the most common congenital neurological conditions in children, affecting more than 10,000 newborns each year in the United States. Its incidence in 8-year-old children is approximately 3.6 per 1000. [3] Intractable spasticity can cause pain, sleep disorders, increased energy requirements, interference with positioning and difficulty transferring the child, and complications with dressing and body hygiene. Individuals with spasticity often develop contractures and pressure sores that compound treatment. [4] More than 90% of children survive into adulthood if motor and feeding skills are ensured, which rests on the abilities of the individual, as well as caregivers.
In some cases, a child may use his or her spasticity for postural support in upright positions. If the child has poor underlying muscle strength, spastic tone often becomes the means by which the child is able to provide postural stability. Assessment of postural tone is important in the preoperative evaluation, as removal of this spastic tone may result in decreased ambulatory potential. [5]
Among patients with exceptionally poor strength and tone dependence, SDR may not lead to an optimal outcome.
Dorsal rhizotomy, which literally means to cut or sever a dorsal nerve root, was initially presented as a surgical treatment by Dr. Otfrid Foerster in 1911 at a meeting for the Royal Society of Medicine. [6]
A subsequent review by Foerster, including 159 cases of spasticity, also recognized the importance of root conservation in order to preserve the balance between spasticity and flaccidity. By careful electrical stimulation of specific roots, he proposed selective root cutting in order to preserve a certain degree of function. [7]
Their work advanced the concept of a more selective dorsal rhizotomy, with rootlets chosen initially based on clinically identified spastic muscle groups segregated by their disabling or beneficial effects. Further modification of Foerster’s technique by Fasano et al, described as “functional posterior rhizotomy,” promoted the use of intraoperative electrostimulation for root selection instead of the Gros method of clinical identification. This allowed proprioceptive afferents to be saved and better functional outcomes to be achieved, further solidifying the procedure now known as SDR. [8]
The exact anatomical localization of the Ia sensory input to the spinal cord at the dorsal root entry zone by Sindou in 1974 made SDR a more functional possibility. [9] Severance of these specific inputs would allow for loss of tone without concomitant loss of other sensory input or motor control.
Since popularization and further revision by Peacock and Eastman in 1981, the procedure has remained an important treatment for spasticity control, specifically in those with cerebral palsy. [10]
Normal muscle tone depends on balanced excitatory and inhibitory influences on alpha motor neurons, which are nerves that begin in the spinal cord and travel via peripheral nerves to innervate skeletal muscles. Alpha motor neurons are the principle effectors of motor tone and control. Inhibitory interneurons influence alpha motor neurons within the spinal cord and are activated by cortical upper motor neurons. Excitatory influences come from both muscle spindles and Golgi tendon organs, which are located in the skeletal muscle/tendon, and send information to the spinal cord via afferent sensory fibers of peripheral nerves.
Brain injury in cerebral palsy prevents descending spinal cord tracts from providing the necessary inhibitory influence, creating an imbalance of overabundant excitatory input. The stretch reflex arc between the spinal cord and skeletal muscle continues to receive excitatory input from Ia afferents traveling from the muscle through the peripheral sensory nerve’s dorsal root, without adequate opposing inhibition from the brain’s descending tracts, ultimately causing what is termed spasticity. Spasticity is defined as a velocity-dependent increase in stretch reflexes, which translates to a clinical increase in resistance to passive movement. By decreasing the excitatory afferent input from the dorsal roots, the amount of excitation experienced by the alpha motor neurons can be reduced, therefore reducing spasticity. [11]
SDR has been demonstrated to be beneficial in children with bilateral lower-extremity spasticity due to upper motor neuron injury in cerebral palsy. Patients who achieve the best outcomes are those who are personally motivated, younger, and ambulatory and who exhibit good proximal strength and motor control in the lower extremities. [12]
SDR is also likely to benefit patients with significant lower-extremity spasticity whose reduction in tone will be helpful in improving function and/or easing the burden of care.
The ability to participate in a rigorous postoperative physical therapy program is essential and must be discussed with families and caregivers in advance. [11]
In some cases, a child may use his or her spasticity for postural support in upright positions. If the child has poor underlying muscle strength, spastic tone often becomes the means by which the child is able to provide postural stability. Assessment of postural tone is important in the preoperative evaluation, as removal of this spastic tone may result in decreased ambulatory potential. [5]
Among patients with exceptionally poor strength and tone dependence, SDR may not lead to an optimal outcome.
Technical Considerations
Successful motor tone reduction in SDR and proper surgical technique are based on principles of nerve anatomy with regard to the sensorimotor reflex loop and the anatomic position of sensory and motor roots.
Sensory nerve roots contain efferent signals that contribute to the maintenance of motor tone, which is abnormally high in cerebral palsy because of a lack of supraspinal inhibition. Therefore, in order to reduce motor tone without causing motor weakness, only the sensory nerve rootlets (and not motor) must be cut in SDR. The sensory nerve rootlets can be identified by their anatomic position as they exit the canal dorsally and must also be confirmed as sensory nerve using intraoperative electrophysiologic monitoring.
Complications of SDR [13] include sensory changes such as dysesthesias or hyperesthesias, which may be avoided by limiting the number of dorsal rootlets cut.
Postoperative urinary retention or sphincter dysfunction may be avoided with intraoperative identification and avoidance of sectioning sacral nerve roots.
Postoperative cerebrospinal fluid leak is avoided with water-tight dural closure and overlying fascial closure, as well as dermal closure with a running nylon suture.
Immediately after surgery, patients typically have a significant reduction in spasticity, often unmasking underlying muscle weakness. [14] Pudendal monitoring, in an attempt to avoid such complications, is practiced by many institutions. [15]
Pediatric studies have demonstrated the importance of early intervention [16, 17] ; outcomes are often better in patients younger than 8 years. [1]
Since modernization of SDR, 3 randomized controlled trials have examined the clinical safety and improved outcomes of SDR compared with physical therapy alone; all 3 studies confirm that SDR reduces spasticity, although only 2 of the 3 studies demonstrated a statistically significant advantage in functional outcome. [10, 1, 18]
A subsequent meta-analysis demonstrated significant spasticity reduction and functional improvements after comprehensive treatment with SDR and follow-up physiotherapy. [19] Another more recent study comparing SDR to intrathecal baclofen pump determined that both result in significant improvements in tone, function, and passive range of motion, but SDR provided a larger magnitude of improvement. [20]
In a meta-analysis of the 3 randomized clinical trials of SDR, [21, 19] 82 patients younger than 8 years underwent either SDR with physiotherapy or physiotherapy alone. Outcome measures at 9-12 months included lower-extremity spasticity (Ashworth scale) and overall function (Gross Motor Function Measure). Both a statistically significant reduction in spasticity and a greater functional improvement were shown in children undergoing SDR with physiotherapy compared to those who underwent physiotherapy alone. Multivariate analysis also showed a direct correlation between the amount of dorsal root tissue transected and the amount of functional improvement, despite the variability of technique between institutions.
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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.
Barbara CS Hamilton Columbia University College of Physicians and Surgeons
Disclosure: Nothing to disclose.
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.
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.
Selective Dorsal Rhizotomy for Spasticity
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