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Functional Outcomes Following Selective Posterior Rhizotomy in Children with Cerebral Palsy

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Functional Outcomes Following Selective Posterior Rhizotomy in Children with Cerebral Palsy J Neurosurg 74:380-385, 1991 Functional outcomes following selective posterior rhizotomy in children with cerebral palsy WARWICK J. PEACOCK, M.D., AND LORI:"FFA A. STAUDT, M.S., P.T. Division ~)/ Neurosurgery. University ~[ Cali/ornia, Los Angeles, California L,- The recent increase in popularity of selective posterior rhizotomy demands objective documentation of surgical outcome. For this reason, the authors have analyzed the status of 25 children with spastic cerebral palsy before and after rhizotomy to determine the effects of this therapy on muscle tone, range of movement, and motor function. Postoperative tests showed a reduction in muscle tone compared with preoperative assessments. Range of motion in the lower extremities was significantly increased and improvements in functional gross motor skills were noted. An increase in range of motion in the knees and thighs during gait was detected in 18 ambulatory patients studied with computerized two-dimensional motion analysis. Prelim- inary findings indicate that selective posterior rhizotomy reduced spasticity, thereby increasing range of motion and contributing to improvements in active functional mobility. KEY WORDS 9 spasticity rhizotomy ' cerebral palsy children HE selective posterior rhizotomy procedure for proved? We addressed these questions through a con- spastic cerebral palsy has been increasingly used sistent assessment protocol using clinically applicable T by pediatric neurosurgeons at major medical yet objective measures which were performed before centers throughout the United States. Although the and after surgery. Repeated preoperative assessment of value of this treatment has been demonstrated in care- a subset of surgical candidates was added at a later date, fully selected cases, ~'t~objective documentation of sur- allowing preliminary evaluation of maturational effects gical outcome is difficult to achieve and has only re- and the stability of the measures used. By assessing a cently been addressed. 6 ~ As cerebral palsy is a complex subset of patients approximately 6 months prior to motor disorder which varies in type and severity, and surgery and then again immediately preoperatively, we the population under study is maturing with time, could evaluate changes which may be attributed to several research design issues can be raised. Comparing factors such as growth and development or physical preoperative and postoperative status without evalua- therapy treatment. Repeating the assessment 6 months tion of the stability of the measurements over time in after surgery allowed evaluation of the effects of surgical this population could be misleading. Matching patients intervention. to similarly affected controls is nearly impossible as well as controversial. There are also ethical obstacles to Clinical Material and Methods randomly assigning patients to treatment groups rather than recommending the best treatment approach based Patient Selection on clinical findings and realistic goals. Although tech- All potential candidates for surgery were examined nology for measuring muscle tone, strength, and motor by the pediatric neurosurgeon and physical therapist at behavior is improving, few clinically applicable tools the same time, and many were evaluated in a special have been developed for objective measurement of clinic which was also attended by a pediatric orthopedic changes in children with cerebral palsy. surgeon. The clinical history was taken from each pa- We have therefore approached the evaluation of tient's family to help confirm the diagnosis of cerebral patients undergoing rhizotomy with the following ques- palsy. A history of premature birth was found in 18 of tions in mind. Does selective posterior rhizotomy de- the 25 patients who participated in this study. A neu- crease spasticity? If so, do patients subsequently have rological examination emphasizing evaluation of mus- increased range of motion? Is function thereby im- cle tone and movement was performed and the patient's 380 J. Neurosurg. / Volume 74/March, 1991 Selective posterior rhizotomy for cerebral palsy strength, range of motion, motor control, postural re- TABLE 1 actions, reflexes, gait, and functional motor skills were &'aleJbr grading spasticity* assessed. The presence of contractures and orthopedic deformities was noted. The condition of the hips and Score Definition spine on x-ray studies was evaluated directly or obtained 0 hypotonic:less than normal muscle tone, floppy by report from the child's orthopedist. 1 normal:no increase in muscle tone 2 mild: slight increase in tone, "catch" in limb movement Patient selection criteria included the presence of or minimal resistance to movement through less than primary spasticity which seriously interfered with func- half of the range tion or care but was associated with little or no rigid- 3 moderate:more marked increase in tone through most of ity, dystonia, hypotonia, athetosis, or ataxia and no sig- the range of motion but affected part is easily moved nificant weakness in antigravity muscle groups of the 4 severe:considerable increase in tone, passive movement difficult trunk and lower extremities. Individuals with contrac- 5 extreme:affected pall rigid in flexion or extension lures and deformities were recommended for orthope- *Scale modified from those of Ashworth3 and Bohannon and dic surgery alone or in combination with rhizotomy. Smith? Surgical reduction of spasticity was not performed if the patient appeared to be dependent on spasticity for standing and walking. Goals of either improving exist- The 27 individuals who returned for follow-up study ing function or easing daily care were established. Pre- included 15 boys and 12 girls with cerebral palsy. Of operative physical therapy was recommended at a fre- these 27 children, eight were spastic diplegic patients quency of three to five times per week and children who walked independently without assistive devices but were scheduled for surgery approximately 6 months with abnormal posture; 14 were spastic diplegic or from the initial evaluation. This allowed time for re- quadriplegic patients who could walk with assistive peated evaluation and preoperative strengthening. devices or support; two had spastic quadriplegia and were nonambulatory but could creep on the floor; and Operative Technique three were severely affected, with total body involve- Selective division of posterior nerve rootlets from ment. Only one of these three severely affected patients L-2 to S-2 was performed bilaterally at the level of was included in the study as it was impossible to obtain the cauda equina, as previously described, m The intra- accurate measurements on the other two children. This operative electromyographic (EMG) recording tech- child's disability was the result of a severe head injury nique was expanded to monitor responses from 10 mus- and he lacked functional independent movement. The cle groups simultaneously. Needle electrodes were used mean age at surgery for the 25 patients studied was 5.9 to record activity in the hip adductor, quadriceps, tibi- years (range 3.25 to 10.25 years). Additionally, a group alis anterior, hamstrings, and gastrocnemius muscles of of 12 patients (six of whom were also in the group of both lower extremities. Those rootlets associated with 25 who returned for follow-up review) underwent both gradually decreasing or steady squared-off responses a baseline evaluation (several months before surgery) during electrical stimulation at a threshold voltage were and a preoperative evaluation (1 day before surgery), spared. Electromyographic responses were classified as which allowed comparison of status over time prior to abnormal if they were incremental, clonic, multiphasic, any surgical intervention. or sustained. Rootlets associated with these responses were divided. Responses that spread to inappropriate Evaluation Procedures" or contralateral muscle groups were also considered One of the authors (a physical therapist with experi- abnormal and used as the basis for rootlet section. The ence in evaluation of children with cerebral palsy) per- patient's clinical condition, the number and distribu- formed the assessments. Preoperative evaluations were tion of rootlets being divided, and observable muscle made within 1 week prior to surgery, usually 1 day reactions were also taken into account when EMG prior to the procedure. Postoperative examinations oc- responses were equivocal. Approximately 60 to 70 root- curred between 5 and 14 months postoperatively (mean lets were tested in each patient and about 25% to 50% 8.9 months). Baseline evaluations on 12 patients were were sacrificed. made between 2 and 7 months prior to surgery (mean Patients were discharged home after 8 days. Outpa- 4.6 months). Assessments of muscle tone, range of tient physical therapy was prescribed at a frequency of motion, gross motor skills, and (in ambulatory patients) 3 to 5 days per week for the first 6 to 12 months. gait were performed. Some children did not undergo all tests due to either the unavailability of equipment or Patient Sample lack of patient cooperation. All 42 patients who underwent selective posterior rhizotomy between May, 1987, and December, 1988, Muscle Tone were entered into the study. Fifteen individuals were Clinical assessment of muscle tone at rest was per- unable to return for follow-up evaluation due to the formed using a variation of the modified Ashworth need to travel long distances, but the postoperative scale ~'5 (Table 1). Resistance to passive
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