Ont Health Technol Assess Ser. 2017 Jul 6;17(10):1-186. eCollection 2017.
Cerebral palsy, a spectrum of neuromuscular conditions caused by abnormal brain development or early damage to the brain, is the most common cause of childhood physical disability. Lumbosacral dorsal rhizotomy is a neurosurgical procedure that permanently decreases spasticity and is always followed by physical therapy. The objectives of this health technology assessment were to evaluate the clinical effectiveness, safety, cost effectiveness, and family perspectives of dorsal rhizotomy.
We performed a systematic literature search until December 2015 with auto-alerts until December 2016. Search strategies were developed by medical librarians, and a single reviewer reviewed the abstracts. The health technology assessment included a clinical review based on functional outcomes, safety, and treatment satisfaction; an economic study reviewing cost-effective literature; a budget impact analysis; and interviews with families evaluating the intervention.
Eighty-four studies (1 meta-analysis, 5 randomized controlled studies [RCTs], 75 observational pre-post studies, and 3 case reports) were reviewed. A meta-analysis of RCTs involving dorsal rhizotomy and physical therapy versus physical therapy confirmed reduced lower-limb spasticity and increased gross motor function (4.5%, = .002). Observational studies reported statistically significant improvements in gross motor function over 2 years or less (12 studies, GRADE moderate) and over more than 2 years (10 studies, GRADE moderate) as well as improvements in functional independence in the short term (10 studies, GRADE moderate) and long term (4 studies, GRADE low). Major operative complications, were infrequently reported (4 studies). Bony abnormalities and instabilities monitored radiologically in the spine (15 studies) and hip (8 studies) involved minimal or clinically insignificant changes after surgery. No studies evaluated the cost effectiveness of dorsal rhizotomy. The budget impact of funding dorsal rhizotomy for treatment of Ontario children with cerebral palsy was $1.3 million per year. Families reported perceived improvements in their children and expressed satisfaction with treatment. Ontario families reported inadequate medical information on benefits or risk to make an informed decision, enormous financial burdens, and lack rehabilitation support after surgery.
Lumbrosacral dorsal rhizotomy and physical therapy effectively reduces lower-limb spasticity in children with spastic cerebral palsy and significantly improves their gross motor function and functional independence. Major peri-operative complications were infrequently reported. Families reported perceived improvements with dorsal rhizotomy, and surgery and post-operative rehabilitation were intensive and demanding.
脑性瘫痪是一种由大脑发育异常或早期脑损伤引起的神经肌肉疾病谱，是儿童身体残疾的最常见原因。腰骶部背根切断术是一种神经外科手术，可永久性降低痉挛程度，术后通常需进行物理治疗。本卫生技术评估的目的是评估背根切断术的临床疗效、安全性、成本效益以及家庭观点。
我们进行了系统的文献检索，截至2015年12月，并设置自动提醒至2016年12月。检索策略由医学图书馆员制定，由一名评审员对摘要进行评审。卫生技术评估包括基于功能结局、安全性和治疗满意度的临床综述；对成本效益文献进行综述的经济学研究；预算影响分析；以及对评估该干预措施的家庭进行访谈。
共审查了84项研究（1项荟萃分析、5项随机对照试验、75项观察性前后对照研究和3项病例报告）。一项关于背根切断术加物理治疗与单纯物理治疗的随机对照试验的荟萃分析证实，下肢痉挛程度降低，粗大运动功能改善（4.5%，P = 0.002）。观察性研究报告称，在2年或更短时间内（12项研究，证据等级为中等）和超过2年时间内（10项研究，证据等级为中等）粗大运动功能有统计学意义的改善，以及在短期（10项研究，证据等级为中等）和长期（4项研究，证据等级为低）功能独立性有改善。很少有关于主要手术并发症的报告（4项研究）。通过影像学监测脊柱（15项研究）和髋关节（8项研究）的骨异常和不稳定情况，术后变化极小或在临床上无显著意义。没有研究评估背根切断术的成本效益。为安大略省脑瘫儿童提供背根切断术治疗的预算影响为每年130万美元。家庭报告称感觉孩子有改善，并对治疗表示满意。安大略省的家庭报告说，缺乏足够的关于益处或风险的医学信息以做出明智的决定，经济负担巨大，且术后缺乏康复支持。
腰骶部背根切断术和物理治疗可有效降低痉挛型脑瘫儿童的下肢痉挛程度，并显著改善其粗大运动功能和功能独立性。很少有关于主要围手术期并发症的报告。家庭报告称背根切断术有明显改善，但手术和术后康复强度大且要求高。
