Conus-level combined dorsal and ventral lumbar rhizotomy for treatment of mixed hypertonia: technical note and complications

View More View Less
  • 1 Florida State University College of Medicine, Tallahassee, Florida;
  • 2 Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital;
  • 3 Department of Neurological Surgery and
  • 5 Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center;
  • 4 Pediatric Rehabilitation, Monroe Carell Jr. Children’s Hospital, Vanderbilt University Medical Center;
  • 6 Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center; and
  • 7 Department of Pediatrics, Division of Developmental Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Combined dorsal and ventral rhizotomy is an effective treatment for patients with concurrent spasticity and dystonia, with the preponderance of complaints relating to their lower extremities. This operative approach provides definitive relief of hypertonia and should be considered after less-invasive techniques have been exhausted. Previously, the surgery has been described through an L1–S1 laminoplasty. In this series, 7 patients underwent a conus-level laminectomy for performing a lumbar dorsal and ventral rhizotomy. Technical challenges included identifying the appropriate-level ventral roots and performing the procedure in children with significant scoliosis. Techniques are described to overcome these obstacles. The technique was found to be safe, with no infections, CSF leaks, or neurogenic bladders.

ABBREVIATIONS BAD = Barry-Albright Dystonia; GMFCS = Gross Motor Function Classification System; GMFM = Gross Motor Function Measure; MAS = Modified Ashworth Scale; SDR = selective dorsal rhizotomy; TOF = train-of-four.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Ranbir Ahluwalia: Florida State University College of Medicine, Tallahassee, FL. ra16@med.fsu.edu.

INCLUDE WHEN CITING Published online October 9, 2020; DOI: 10.3171/2020.6.PEDS20295.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Nahm NJ, Graham HK, Gormley ME Jr, Georgiadis AG. Management of hypertonia in cerebral palsy. Curr Opin Pediatr. 2018;30(1):5764.

  • 2

    Verrotti A, Greco R, Spalice A, Pharmacotherapy of spasticity in children with cerebral palsy. Pediatr Neurol. 2006;34(1):16.

  • 3

    Bonouvrié LA, Becher JG, Vles JSH, Intrathecal baclofen treatment in dystonic cerebral palsy: a randomized clinical trial: the IDYS trial. BMC Pediatr. 2013;13:175.

    • Search Google Scholar
    • Export Citation
  • 4

    Albright AL, Barry MJ, Shafton DH, Ferson SS. Intrathecal baclofen for generalized dystonia. Dev Med Child Neurol. 2001;43(10):652657.

    • Search Google Scholar
    • Export Citation
  • 5

    Warsi NM, Tailor J, Coulter IC, Selective dorsal rhizotomy: an illustrated review of operative techniques. J Neurosurg Pediatr. 2020;25(5):540547.

    • Search Google Scholar
    • Export Citation
  • 6

    Park TS, Dobbs MB, Cho J. Evidence supporting selective dorsal rhizotomy for treatment of spastic cerebral palsy. Cureus. 2018;10(10):e3466.

    • Search Google Scholar
    • Export Citation
  • 7

    Wang KK, Munger ME, Chen BP, Novacheck TF. Selective dorsal rhizotomy in ambulant children with cerebral palsy. J Child Orthop. 2018;12(5):413427.

    • Search Google Scholar
    • Export Citation
  • 8

    Albright AL, Tyler-Kabara EC. Combined ventral and dorsal rhizotomies for dystonic and spastic extremities. Report of six cases. J Neurosurg. 2007;107(4)(suppl):324327.

    • Search Google Scholar
    • Export Citation
  • 9

    Abdel Ghany WA, Nada M, Mahran MA, Combined anterior and posterior lumbar rhizotomy for treatment of mixed dystonia and spasticity in children with cerebral palsy. Neurosurgery. 2016;79(3):336344.

    • Search Google Scholar
    • Export Citation
  • 10

    Park TS, Johnston JM. Surgical techniques of selective dorsal rhizotomy for spastic cerebral palsy. Technical note. Neurosurg Focus. 2006;21(2):e7.

    • Search Google Scholar
    • Export Citation
  • 11

    Bales J, Apkon S, Osorio M, Infra-conus single-level laminectomy for selective dorsal rhizotomy: technical advance. Pediatr Neurosurg. 2016;51(6):284291.

    • Search Google Scholar
    • Export Citation
  • 12

    Graham D, Aquilina K, Cawker S, Single-level selective dorsal rhizotomy for spastic cerebral palsy. J Spine Surg. 2016;2(3):195201.

  • 13

    Ou C, Kent S, Miller S, Steinbok P. Selective dorsal rhizotomy in children: comparison of outcomes after single-level versus multi-level laminectomy technique. Can J Neurosci Nurs. 2010;32(3):1724.

    • Search Google Scholar
    • Export Citation
  • 14

    Garriz-Luis M, Sanchez-Carpintero R, Alegre M, Tejada S. Selective dorsal rhizotomy: a review of the literature on this technique for the treatment of spasticity in infantile cerebral palsy. Article in Spanish. Rev Neurol. 2018;66(11):387394.

    • Search Google Scholar
    • Export Citation
  • 15

    Wall EJ, Cohen MS, Abitbol JJ, Garfin SR. Organization of intrathecal nerve roots at the level of the conus medullaris. J Bone Joint Surg Am. 1990;72(10):14951499.

    • Search Google Scholar
    • Export Citation
  • 16

    Arslan M, Cömert A, Açar , Lumbosacral intrathecal nerve roots: an anatomical study. Acta Neurochir (Wien). 2011;153(7):14351442 Published correction in Acta Neurochir (Wien). 2013;155(3):557.

    • Search Google Scholar
    • Export Citation
  • 17

    Hauck EF, Wittkowski W, Bothe HW. Intradural microanatomy of the nerve roots S1-S5 at their origin from the conus medullaris. J Neurosurg Spine. 2008;9(2):207212.

    • Search Google Scholar
    • Export Citation

Metrics