| OBJECTIVESIt still remains challenging to treat spastic cerebral palsy(SCP)by using selective dorsal rhizotomy(SDR)via a single-level approach when guided by the traditional electromyography(EMG)response grading system.Our aim is to assess the feasibility and effectiveness of a newly modified protocol guided single-level laminectomy SDR followed by intensive rehabilitation for at least 12 months to treat such pediatric patients,and to compare different rhizotomy protocols guided single-level laminectomy SDR with regard to range of nerve rootlets transaction and features.METHODSA retrospective cohort review was conducted in the pediatric cases with SCP undergone our newly modified protocol guided single-level approach SDR followed by intensive rehabilitation program for at least 12 months in Shanghai Children’s Hospital since September 2015 to December 2017.Inclusion and exclusion criteria were set for the selection of patients in the current study.There were 12 hemiplegic cases and 72 diplegic or quadriplegic cases with SCP enrolled in our study.Our study focused on the muscular tone,joint range of movement(ROM),muscular strength,the gross motor function classification system(GMFCS)grading,the gross motor function measure-66 items(GMFM-66)scores pre and at least 12 months post-operation and the factors influencing outcomes for this newly modified rhizotomy scheme.Besides,intro-operative neuromonitoring data of 26 cases met the criteria of traditional protocol.Intro-operative management based on two different rhizotomy protocols was compared with regard to number of nerve rootlets requiring transected and number of nerve rootlets which needed 75% transection.RESULTS1)With a mean of 20.7 months rehabilitation program,5 of 6 cases who were with GMFCS level Ⅱ pre-operatively improved their GMFCS level at the last assessment.The ratio of improvement of all the 12 pediatric cases with hemiplegic SCP was 41.7%.GMFM-66 score at last assessment was significantly better than at baseline in all cases(85.8±9.2 vs.76.1±10.5,p=0.034).The muscular tone,strength,active/passive ROM of joints involved in lower extremities were reported improved significantly as well.Kinematics of joints of hip,knee and ankle on the affected side in our cases demonstrated a major correction,along with improvement of their foot pressure patterns to the ground during their gait cycles.2)With a mean of 23.3 months follow-up,there were 35 cases downgraded one level and 6 cases downgraded two levels with regard to GMFCS level.The degrading rate of all the 72 cases with diplegic/quadriplegic SCP was 56.9%.The ratio of improvement of 52 cases who were with GMFCS level Ⅰ-Ⅲ pre-operatively was 63.5%(33/52)which was significantly higher than the one(10.5%,2/19)of 19 cases who were treated by traditional protocol(p=0.000,odds ratio,O.R.: 14.763,95% confidence interval,C.I.: 3.071~70.970).Downgrading of GMFCS level was observed significantly better in cases with baseline of GMFCS level Ⅱ and Ⅲ(33/48 vs.8/20,p = 0.027)than those of Ⅳ and Ⅴ.Improvement of GMFM-66 score was significantly better in cases with baseline of GMFCS level Ⅰ-Ⅲ(9.1±3.2 vs.7.2±4.0,p=0.044)than those of Ⅳ and Ⅴ.Status of pre-operation GMFCS level(p=0.027,O.R.: 3.300,95% C.I.: 1.117~9.746)and type of CP(p=0.011,O.R.: 3.250,95% C.I.: 1.159~9.116)were the factors associated with the improvement of gross motor function at 12 months post-operation.3)Intro-operative neuromonitoring data of 5 hemiplegic and 21 diplegic or quadriplegic cases met with the criteria of traditional protocol.The number of rootlets stimulated in surgery was 53.4±10.4 per case in our study.Each procedure resulted in the test of 36.6±7.7 dorsal rootlets.In 5 cases with hemiplegia,rootlets requiring transected were identified in all of these patients when based on the newly modified protocol and only one when guided by the traditional one.In 21 cases with diplegia and quadriplegia,the transection number of dorsal rootlets and rootlets requiring 75% cutting was 12.6±2.5 and 6.1±1.4 per cases based on the newly modified protocol,and 13.3±2.0 and 7.9±1.7 per cases on the traditional protocol,respectively,with p=0.002 in 75% transection branch.In 22 cases with pre-op GMFCS level Ⅱ-Ⅴ,the number of dorsal rootlets transected was 12.3±2.8 and 12.9±2.9 per case when based on protocol of the newly modified one and the traditional one,respectively.Number of rootlets needed 75% cutting was 5.9±1.9(newly modified protocol)vs.7.5±2.4(traditional protocol)per case with p=0.020.The newly modified protocol succeeded in identifying rootlets requiring transection in all 4 cases with pre-op GMFCS level Ⅰ,whilst the traditional protocol identified none.CONCLUSIONS1)All types of spastic CP cases can benefit from single-level laminectomy SDR when guided by the newly modified protocol.2)Single-level laminectomy SDR when guided by the newly modified protocol is feasible and effective to treat pediatric CP cases with spastic hemiplegia.Pediatric CP cases with spastic hemiplegia could benefit from SDR guided by this simplified rhizotomy scheme with regard to the muscle tone,strength of those spastic muscles,ROM(both passive and active)of joints that involved in their lower limbs,and their motor function including GMFCS level and GMFM-66 score as well.3)The gross motor function of children with diplegic/quadriplegic SCP undergone the newly modified protocol guided single-level laminectomy SDR followed by intensive rehabilitation improved dramatically 12 months after the commencement of the treatment.The efficacy is similar to the one of SDR guided by traditional protocol.It is even better than the traditional protocol in the degrading rate of children with GMFCS level Ⅰ-Ⅲ pre-operation.Children could benefit from this procedure more for those with baseline of GMFCS level Ⅰ-Ⅲ and who were diplegic.4)The number of dorsal rootlets needed transection and 75% cutting was less when single-level laminectomy SDR was guided by the newly modified protocol than by the traditional protocol.Furthermore,SDR via single-level approach guided by the newly modified protocol was indicated in all types of SCP patients.Based on its minimally invasive nature,this newly modified protocol has shown the trend of less invasive approach and more precise nerve rhizotomy in SDR surgery. |
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