Selective dorsal rhizotomy in children with spastic hemiparesis

Clinical article

Restricted access

Object

Neurological conditions including cerebral palsy, brain injury, and stroke often result in severe spasticity, which can lead to significant deformity and interfere with function. Treatments for spasticity include oral medications, intramuscular botulinum toxin type A injections, orthopedic surgeries, intrathecal baclofen pump implantation, and selective dorsal rhizotomy (SDR). Selective dorsal rhizotomy, which has been well studied in children with spastic diplegia, results in significant reduction in spasticity and improved function in children. To the authors' knowledge, there are no published outcome data for SDR in patients with spastic hemiparesis. The object of this study was to examine the effects of SDR on spastic hemiparesis.

Methods

A 2-year study was undertaken including all children with spastic hemiparesis who underwent SDR at the authors' institution. The degree of spasticity, as measured by the Modified Ashworth Scale or quality of gait rated using the visual gait assessment scale, the gait parameters, and velocity were compared in patients before and after undergoing SDR.

Results

Thirteen children (mean age 6 years 7 months) with spastic hemiparesis underwent SDR performed by the same surgeon during a 2-year period. All of the patients had a decrease in tone in the affected lower extremity after the procedure. The mean reduction in tone in 4 muscle groups (hip adductors, knee flexors, knee extensors, and ankle plantar flexors) according to the modified Ashworth scale score was 2.6 ± 1.26 (p < 0.0001). The quality of gait was assessed in 7 patients by using the visual gait assessment scale. This score improved in 6 patients and remained the same in 1. Stride length and gait velocity were measured in 4 children. Velocity increased in 3 patients and decreased in a 3-year-old child. Parents and clinicians reported an improvement in quality of gait after the procedure. Stride length increased bilaterally in 3 patients and increased on one side and decreased on the other in the other patient.

Conclusions

Selective dorsal rhizotomy showed efficacy in the treatment of spastic hemiparesis in children. All of the patients had decreased tone after SDR as measured by the modified Ashworth scale. The majority of patients had qualitative and quantitative improvements in gait.

Abbreviations used in this paper: MAS = modified Ashworth scale; PCMC = Primary Children's Medical Center; SDR = selective dorsal rhizotomy; VGAS = visual gait assessment scale.

Article Information

Address correspondence to: Judith L. Gooch, M.D., Department of Physical Medicine and Rehabilitation, University of Utah, 100 Mario Capecchi Drive, Salt Lake City, Utah 84132. email: judith.gooch@imail.org.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Photograph showing patient positioning for the SDR procedure. The incision is limited to the area over the L-1 spinous process.

  • View in gallery

    Sagittal (left) and axial (right) plane ultrasonographic images demonstrating the conus medullaris at the L-1 level.

  • View in gallery

    Graph showing change in tone as measured by the MAS in patients with spastic hemiparesis before (gray bars) and after (black bars) SDR. The MAS includes measurement of hip adductors, knee flexors, knee extensors, and ankle plantar flexors. The line indicates change in the MAS score.

  • View in gallery

    Graph showing change in VGAS (adapted from Physician Rating Scale3) in patients with spastic hemiparesis before (gray bars) and after (black bars) SDR. The line indicates change in VGAS.

  • View in gallery

    Graph showing change in time to walk 30 ft in patients with spastic hemiparesis before (gray bars) and after (black bars) SDR. The line indicates the change in time to walk 30 ft.

References

1

Abbott RJohann-Murphy MShiminski-Maher TQuartermain DForem SLGold JT: Selective dorsal rhizotomy: outcome and complications in treating spastic cerebral palsy. Neurosurgery 33:8518571993

2

Albright AL: Neurosurgical treatment of spasticity: selective posterior rhizotomy and intrathecal baclofen. Stereotact Funct Neurosurg 58:3131992

3

Bohannon RWSmith MB: Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 67:2062071987

4

Dickens WESmith MF: Validation of a visual gait assessment scale for children with hemiplegic cerebral palsy. Gait Posture 23:78822006

5

Engsberg JRRoss SACollins DRPark TS: Effect of selective dorsal rhizotomy in the treatment of children with cerebral palsy. J Neurosurg 105:1 Suppl8152006

6

Flett PJStern LMWaddy HConnell TMSeeger JDGibson SK: Botulinum toxin A versus fixed cast stretching for dynamic calf tightness in cerebral palsy. J Paediatr Child Health 35:71771999

7

Graham HKAoki KRAutti-Rämö IBoyd RNDelgado MRGaebler-Spira DJ: Recommendations for the use of botulinum toxin type A in the management of cerebral palsy. Gait Posture 11:67792000

8

Hays RMMcLaughlin JFGeiduschek JMBjornson KFGraubert CS: Evaluation of the effects of selective dorsal rhizotomy. Ment Retard Dev Disabil Res Rev 3:1681741997

9

Koman LAMooney JF IIISmith BPGoodman AMulvaney T: Management of spasticity in cerebral palsy with botulinum-A toxin: report of a preliminary, randomized, double-blind trial. J Pediatr Orthop 14:2993031994

10

Koman LAMooney JF IIISmith BPWalker FLeon JM: Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: a randomized, double-blind, placebo-controlled trial. J Pediatr Orthop 20:1081152000

11

McLaughlin JBjornson KTemkin NSteinbok PWright VReiner A: Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol 44:17252002

12

McLaughlin JFBjornson KFAstley SJGraubert CHays RMRoberts TS: Selective dorsal rhizotomy: efficacy and safety in an investigator-masked randomized clinical trial. Dev Med Child Neurol 40:2202321998

13

Palisano RRosenbaum PWalter SRussell DWood EGaluppi B: Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol 39:2142231997

14

Park TSOwen JH: Surgical management of spastic diplegia in cerebral palsy. N Engl J Med 326:7457491992

15

Peacock WJStaudt LA: Functional outcomes following selective posterior rhizotomy in children with cerebral palsy. J Neurosurg 74:3803851991

16

Steinbok PReiner AMBeauchamp RArmstrong RWCochrane DDKestle J: A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy. Dev Med Child Neurol 39:1781841997

17

Subramanian NVaughan CLPeter JCArens LJ: Gait before and ten years after rhizotomy in children with cerebral palsy spasticity. Neurosurg Focus 4:1E31998

18

Trost JPSchwartz MHKrach LEDunn MENovacheck TF: Comprehensive short-term outcome assessment of selective dorsal rhizotomy. Dev Med Child Neurol 50:7657712008

19

Ubhi TBhakta BBIves HLAllgar VRoussounis SH: Randomised double blind placebo controlled trial of the effect of botulinum toxin on walking in cerebral palsy. Arch Dis Child 83:4814872000

20

van Schie PEVermeulen RJvan Ouwerkerk WJKwakkel GBecher JG: Selective dorsal rhizotomy in cerebral palsy to improve functional abilities: evaluation of criteria for selection. Childs Nerv Syst 21:4514572005

21

Wright FVSheil EMDrake JMWedge JHNaumann S: Evaluation of selective dorsal rhizotomy for the reduction of spasticity in cerebral palsy: a randomized controlled tria. Dev Med Child Neurol 40:2392471998

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 50 50 18
Full Text Views 60 60 14
PDF Downloads 101 101 11
EPUB Downloads 0 0 0

PubMed

Google Scholar