Artikel
Selective dorsal lumbo-sacral rhizotomy for spasticity in children. Why should the mini-invasive approach be preferred?
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Veröffentlicht: | 30. Mai 2008 |
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Objective: Most of the Authors perform selective dorsal rhizotomy (SDR) at lumbo-sacral level through an intraforaminal approach. We always used the juxtamedullary approach. The aim of our study is to analyze the pros an contra of our choice.
Methods: We prospectively studied 28 spastic cerebral palsy patients. Age was 4–25 years (mean: 12.7). SDR was performed through a laminectomy of L1, eventually extended to the inferior half of T12 and/or superior half of L2. Lumbo-sacral posterior rootlets were stimulated in their juxtamedullary segments, where they are naturally separated each other and from the anterior rootlets. Results were evaluated (mean follow-up: 7.5 years) using the usual clinical criteria, poli-EMG, computerized gate analysis (in the last 16 cases), and spine X-rays.
Results: Reliable intraoperative electrophysiological responses were usually obtained with a very low threshold current (0.1–2 volts). Between 28% and 76% (mean: 52%) of the stimulated rootlets were cut. Spastic hypertonia of the lower limbs was markedly and definitely reduced in all cases (mean preoperative Ashworth score: 3.54; final post-operative Ashworth score: 1.42). Improvement of gate was noted in all pre-operatively ambulatory patients. Suprasegmentary effects were recorded in 73% of cases. Post-operative complications were limited to transient patchy hypoesthesia in 21% of cases. Opioid analgesia was never required for controlling post-operative pain, and early mobilization in the 3rd–5th day was usually possible. Mild anterolisthesis of L1 was documented in 2 cases.
Conclusions: Juxtamedullary selective posterior rhizotomy provides a less invasive approach. It should be preferred to the juxtaforaminal approach because it gives at least the same results, does not increase the risk of sphincters damage, greatly reduces post-operative pain, and probably allows to record more reliable muscular responses.