Skip to main content

Advertisement

SpringerLink
Log in

The role of intra-operative neuroelectrophysiological monitoring in single-level approach selective dorsal rhizotomy

  • Focus Session
  • Published:
Child's Nervous System Aims and scope Submit manuscript

Abstract

Objective

Selective dorsal rhizotomy via a single-level approach (SL-SDR) to treat spasticity 100% relies on the interpretation of results from the intra-operative neuroelectrophysiological monitoring. The current study is to investigate the role EMG interpretation plays during SL-SDR procedure with regard to the selection of nerve rootlets for partially sectioning in pediatric cases with spastic cerebral palsy (CP).

Methods

A retrospective study was conducted in pediatric patients with spastic CP undergone our modified rhizotomy protocol-guided SL-SDR from May 2016 to Mar. 2019 in our hospital. Our study focused on intra-operative EMG interpretation and its correlation with pre-op evaluation results, and dorsal rootlet selection difference when data of our intra-operative EMG recordings interpreted using different rhizotomy protocols.

Results

Clinical and intra-operative neuroelectrophysiological monitoring data of a total of 318 consecutive cases were reviewed, which include 231 boys and 87 girls with 32 hemiplegias, 161 diplegias, and 125 quadriplegias. Age at the time of SL-SDR in those cases was between 3.0–14.0 (5.9 ± 1.9) years. The number of targeted muscle ranged from 2 to 8 over these cases (the muscle in lower limbs with its pre-op muscle tone ≥ 2 grade, Modified Ashworth scale). Among 21,728 nerve rootlets tested (68.3 ± 8.2/case), 6272 (28.9%) were identified sphincter related by our intra-operative neuromonitoring. In the rest of 15,456 (48.6 ± 7.6/case) nerve rootlets which neuromonitoring suggested associated with lower limbs, 11,009 were taken as the dorsal ones (34.6 ± 7.4/case). A total of 3370 (10.6 ± 4.7/case) rootlets matched our rhizotomy criteria with 3061 (9.6 ± 4.1/case) sectioned 50% and 309 (1.0 ± 1.0/case) cut 75%. The rhizotomy ratio (partially transected nerve rootlets/all dorsal rootlets associated with lower limbs in a particular case) was 15.8%, 22.3%, 33.4%, 41.8%, and 45.7% across cases with their pro-op GMFCS level from I to V, respectively. Rootlets required 75% cut had a tendency to increase as well in our cases with their pro-op GMFCS level from I to V, which comprising 1.5%, 4.8%, 8.5%, 14.1%, and 15.2% of all rootlets transected, respectively. The muscle tone of 2068 targeted muscles in these cases at the time of 3 weeks after the SL-SDR was revealed a significant decrease when compared to pre-op (1.7 ± 0.5 vs. 2.7 ± 0.6). Further investigation to compare our rootlet selection with the one guided by the traditional rhizotomy criteria using our intro-operative EMG recordings in 318 cases, revealed that the overlap ratio had a tendency to increase in cases when their pre-op GMFCS level increased (39.5%, 41.3%, 52.2%, 54.1%, and 62.8% in cases with levels I–V, respectively). While our modified rhizotomy protocol successfully identified 2–23 rootlets for sectioning in all of our 318 cases, the traditional rhizotomy protocol failed to distinguish any for cutting in about 20% of cases with their pre-op GMFCS levels I and II.

Conclusions

The rhizotomy criteria fully rely on the EMG interpretation making intra-operative neuroelectrophysiological monitoring crucial when SDR is performed via a single-level approach. Our modified rhizotomy protocol is feasible, safe, and effective to guide SL-SDR to treat all types of spastic CP cases by decreasing muscle tone in particular spastic muscle groups in their lower limbs. Data of EMG responses during SL-SDR procedure and as well as the clinical outcomes based on their interpretation could help clinicians to further understand how neuronal circuits work in the spinal cord of these patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

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

    PubMed  Google Scholar 

  2. Bales J, Apkon S, Osorio M, Kinney G, Robison RA, Hooper E, Browd S (2016) Infra-conus single-level laminectomy for selective dorsal rhizotomy: technical advance. PediatrNeurosurg 51(6):284–291. https://doi.org/10.1159/000448046

    Article  Google Scholar 

  3. Zhan Q, Tang L, Wang Y, Xiao B, Shen M, Jiang S, Mei R, Lyu Z (2019) Feasibility and effectiveness of a newly modified protocol-guided selective dorsal rhizotomy via single-level approach to treat spastic hemiplegia in pediatric cases with cerebral palsy. Childs Nerv Syst:1–8. https://doi.org/10.1007/s00381-019-04194-0

  4. Fasano VA, Broggi G (1989) Functional posterior Rhizotomy. In: Park TS, Phillips LH, Peacock WJ (eds) Management of spasticity in cerebral palsy and spinal cord injury. Neurosurgery state of the art reviews, vol 4. Hanley and Belfus, Philadelphia, pp 409–412

    Google Scholar 

  5. Graham D, Aquilina K, Cawker S, Paget S, Wimalasundera N (2016) Single-level selective dorsal rhizotomy for spastic cerebral palsy. J Spine Surg 2(3):195–201. https://doi.org/10.21037/jss.2016.08.08

    Article  PubMed  PubMed Central  Google Scholar 

  6. Peacock WJ, Arens LJ (1982) Selective posterior rhizotomy for the relief of spasticity in cerebral palsy. S Afr Med J 62(4):119–124

    CAS  PubMed  Google Scholar 

  7. Gul SM, Steinbok P, McLeod K (1999) Long-term outcome after selective posterior rhizotomy in children with spastic cerebral palsy. PediatrNeurosurg 31(2):84–95. https://doi.org/10.1159/000028839

    Article  CAS  Google Scholar 

  8. Langerak NG, Lamberts RP, Fieggen AG, Peter JC, Peacock WJ, Vaughan CL (2007) Selective dorsal rhizotomy: long-term experience from Cape Town. Childs Nerv Syst 23(9):1003–1006. https://doi.org/10.1007/s00381-007-0383-9

    Article  PubMed  Google Scholar 

  9. Ou C, Kent S, Miller S, Steinbok P (2010) Selective dorsal rhizotomy in children: comparison of outcomes after single-level versus multi-level laminectomy technique. Can J NeurosciNurs 32(3):17–24

    Google Scholar 

  10. Fasano VA, Broggi G, Zeme S (1988) Intraoperative electrical stimulation for functional posterior rhizotomy. Scand J Rehabil Med Suppl 17:149–154

    CAS  PubMed  Google Scholar 

  11. Staudt LA, Nuwer MR, Peacock WJ (1995) Intraoperative monitoring during selective posterior rhizotomy: technique and patient outcome. Electroencephalogr Clin Neurophysiol 97(6):296–309

    Article  CAS  Google Scholar 

  12. Steinbok P, Kestle JR (1996) Variation between centers in electrophysiologic techniques used in lumbosacral selective dorsal rhizotomy for spastic cerebral palsy. PediatrNeurosurg 25:233–239. https://doi.org/10.1159/000121131

    Article  CAS  Google Scholar 

  13. Turner RP (2009) Neurophysiologic intraoperative monitoring during selective dorsal rhizotomy. J Clin Neurophysiol 26(2):82–84. https://doi.org/10.1097/WNP.0b013e31819f9077

    Article  PubMed  Google Scholar 

  14. Georgoulis G, Brînzeu A, Sindou M (2018) Dorsal rhizotomy for children with spastic diplegia of cerebral palsy origin: usefulness of intraoperative monitoring. J NeurosurgPediatr 22(1):89–101. https://doi.org/10.3171/2018.1.PEDS17577

    Article  Google Scholar 

  15. D'Aquino D, Moussa AA, Ammar A, Ingale H, Vloeberghs M (2018) Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children. Acta Neurochir 160(4):811–821. https://doi.org/10.1007/s00701-017-3349-z

    Article  PubMed  Google Scholar 

  16. Lazareff JA, Valencia Mayoral PF (1990) Histological differences between rootlets sectioned during selective posterior rhizotomy by two surgical techniques. Acta Neurochir 105(1–2):35–38

    Article  CAS  Google Scholar 

  17. Morota N, Abbott R, Kofler M, Epstein FJ, Cohen H (1995) Residual spasticity after selective posterior rhizotomy. Childs Nerv Syst 11(3):161–165

    Article  CAS  Google Scholar 

  18. Mittal S, Farmer JP, Poulin C, Silver K (2001) Reliability of intraoperative electrophysiological monitoring in selective posterior rhizotomy. J Neurosurg 95(1):67–75

    Article  CAS  Google Scholar 

  19. McLaughlin J, Bjornson K, Temkin N, Steinbok P, Wright V, Reiner A, Roberts T, Drake J, O'Donnell M, Rosenbaum P, Barber J, Ferrel A (2002) Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol 44(1):17–25

    Article  Google Scholar 

  20. Morota N (2019) Clinically practical formula for preoperatively estimating the cutting rate of the spinal nerve root in a functional posterior rhizotomy. Childs Nerv Syst 35(4):665–672. https://doi.org/10.1007/s00381-018-04027-6

    Article  PubMed  Google Scholar 

Download references

Funding

This study was funded by Shanghai Hospital Development Center (grant number 16CR3090B) and Science and Technology Commission of Shanghai Municipality (grant number 18411962600).

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China

    Bo Xiao, Qijia Zhan, Wenbin Jiang & Rong Mei

  2. Department of Pediatric Neurosurgery, Dana Children’s Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel

    Shlomi Constatntini

  3. Department of Neurosurgery, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA

    Samuel R. Browd

Authors
  1. Bo Xiao
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shlomi Constatntini
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Samuel R. Browd
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Qijia Zhan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Wenbin Jiang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rong Mei
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bo Xiao.

Ethics declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Shlomi Constatntini contributed to the work equally and should be regarded as co-first authors

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Xiao, B., Constatntini, S., Browd, S.R. et al. The role of intra-operative neuroelectrophysiological monitoring in single-level approach selective dorsal rhizotomy. Childs Nerv Syst 36, 1925–1933 (2020). https://doi.org/10.1007/s00381-019-04408-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00381-019-04408-5

Keywords

Search

Navigation