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Outcomes and Perioperative Considerations for Unilateral Selective Dorsal Rhizotomy in Children with Spastic Hemiplegia with Pre- and Postoperative Quantitative Gait Analysis Christine Hunt, D.O.1, Nicholas Wetjen, M.D.2, Kenton Kaufman, Ph.D.3, Krista Coleman Wood, P.T., Ph.D.3, Joline Brandenburg, M.D.1, Bradford Landry, D.O.1 1Department of Physical Medicine & Rehabilitation, 2Department of Neurologic Surgery, 3Department of Orthopedic Surgery Mayo Clinic, Rochester, MN Abstract Background & Objectives Methods Results: Postoperative Gait Analysis Discussion Background: Selective dorsal rhizotomy (SDR) is a Background Preoperative Baseline Characteristics Patient 1: Right SDR December 2013 • Pre-SDR, patients undergo an in-depth review of their medical procedure used to improve function, decrease pain and • Several human trials examining outcomes in SDR in children • Patient 1: 6 year old male, spastic right hemiplegia • 62.5% of sensory dorsal rootlets sectioned ( L2 to S1) history and imaging studies, consultation with a physiatrist, reduce spasticity in children and adults with cerebral palsy or neurosurgeon, and orthopedic surgeon, and evaluation with PT with spastic diplegia have been conducted, but there is a • GMFCS Level II • Normalized velocity and stride length stroke. Positive outcomes have been reported by numerous and OT. Testing includes QGA, MRI lumbar spine and brain, paucity of data describing outcomes following SDR for • 12 series of botulinum toxin • Improved hip and knee kinematics and kinetics authors but pediatric data are typically limited to patients with pelvic x-ray, and lumbar spine x-ray (if concern for scoliosis). spastic hemiplegia. Oki et al. published a retrospective • Patient 2: 6 year old female, spastic left hemiplegia spastic diplegia, quadriplegia or triplegia.1-3 Pre- and • Improved functional gait in community on follow-up reports Children are weaned off antispasticity medications prior to review of outcomes of pediatric patients with spastic • GMFCS Level I postoperative assessment has been reported using measures surgery and titrated on low dose gabapentin. hemiplegia who underwent unilateral SDR, but did not • 2 series of botulinum toxin with serial casting on left Patient 2: Left SDR May 2013 such as the Modified Ashworth Scale or visual gait perform QGA. All of their thirteen patients experienced • Patient 3: 4 year old male, spastic triplegia right > left • 36% of rootlets sectioned ( L2 to S1) Post-SDR our rehabilitation protocol includes oral assessment, but quantitative assessment with motion analysis decrease in motor tone following SDR, most showed • 4 • GMFCS Level II • Normalized velocity and cadence pharmacotherapy for pain management, knee immobilization to is lacking in this population. improvement in gait parameters, and none experienced Data collected in retrospective chart review included: • Improved kinematics of trunk, pelvis, hip, knee, ankle maintain hamstring length and decrease spasticity, and serious adverse events.4 Objective: This case series analysis reviews outcomes of • Description of past medical history including birth history, • “Excellent” improvement in gait reported on 18 month follow-up mobilization with PT 24 hours following surgical stabilization • Unilateral SDR has also been performed in adult patients children with spastic hemiplegia following unilateral SDR imaging studies, and pre-surgical interventions Patient 3: Right SDR September 2011 with a 2 week admission to inpatient rehabilitation followed by including comparison of pre- and postoperative quantitative with pain and spasticity after stroke.5 intensive outpatient therapies tapering over 1 year. • Pre- and postoperative quantitative gait analysis • 52% of rootlets sectioned (L2 to S1) gait analysis (QGA) and discusses perioperative Objectives considerations including medication, therapy and bracing. • Operative report including intraoperative EMG-directed • Normalized velocity and cadence • Our rehabilitation protocol is discussed with the family by the • To review QGA outcomes of unilateral SDR in treatment of sectioning of dorsal nerve rootlets • Improved kinematics of trunks, hip, knee, ankle physiatrist, who coordinates the team in the pre- and Methods: Pre- and post-operative quantitative gait analysis spastic hemiplegia. • Improved gait pattern and function reported on follow-up postoperative rehabilitation management. • Postoperative rehabilitation protocol (QGA) was used to quantify outcomes of three pediatric • To review perioperative considerations including physiatric No serious adverse events were reported for any patient. patients in the setting of a tertiary medical center. A management. • Postoperative clinical and functional outcomes retrospective chart review including past medical history, operative report including intraoperative EMG-directed sectioning of dorsal nerve rootlets, and rehabilitation protocol Patient 2: Left Kinematics was also analyzed to assess the postoperative outcomes.. Patient 1: Right Kinematics Patient 3: Right Kinematics Conclusions Results: All subjects demonstrated improvements in gait. All • This case series demonstrates utility of QGA as an outcomes subjects also experienced functional improvements in measurement for patients following SDR. This is the first time community ambulation and gross motor function. Two of the to the authors’ knowledge that QGA has been used to assess three subjects received Botulinum toxin injections pre- outcomes following unilateral SDR. operatively and one required no further injections to the lower limbs following surgery. • SDR in combination with perioperative rehabilitation was a successful intervention for spasticity management in these Conclusions: The results highlight objective functional pediatric subjects with spastic hemiplegia. These patients did improvement of pediatric patients with spastic hemiplegia not experience any significant adverse events following surgery. following SDR. Gait analysis data provides objective quantitative outcomes in patients undergoing unilateral SDR • QGA should be considered as an objective outcomes for spastic hemiplegia. The implications of this study are measurement for surgical and rehabilitation interventions. limited in that it is a case series analysis and thus lacks internal validity and generalizability, but the level of detail reportable in such an analysis can be used when considering the development of rehabilitation protocols for patients undergoing unilateral SDR for spastic hemiplegia, and perhaps for the development of research protocols for further References study of the surgical management of spastic hemiplegia. 1. Trost JP, Schwartz MH, Krach LE, Dunn ME, Novacheck TF. Comprehensive short- term outcome assessment of selective dorsal rhizotomy. Dev Med Child Neurol. 2008 ;50(10): 765-71. 2. McLaughlin J, Bjornson K, Temkin N, Steinbok P, Wright V 3. Engsberg JR, Ross SA, Collins DR, Park TS. Effect of selective dorsal rhizotomy in the treatment of children with cerebral palsy. J Neurosurg. 2006; 105 (1 Suppl): 8-15. 4. Oki A, Oberg W, Siebert B, Plante D, Walker M, Gooch J. Selective dorsal rhizotomy in children with spastic hemiparesis. J Neurosurg-Pediatr. 2010; 6: 353-358. 5. Fukuhara T, Kamata I. Selective posterior rhizotomy for painful spasticity in the lower Pre-SDR Post-SDR Pre-SDR Pre-SDR Post-SDR Pre-SDR Post-SDR limbs of hemiplegic patients after stroke: report of two cases. Neurosurgery. 2004; 11 months pre-op 16 months post-op 18 months pre-op 2 months pre-op 13 months post-op 6 months pre-op 13 months post-op 54: 1268-1273. © 2016 Mayo Foundation for Medical Education and Research .
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