Archer Jacob, Yaacoub Alan P, Angulo-Parker Francisco, Fritsch Gloria, Riner Shana, Coon Ann, Johnson Sarah K, Delima Sarah, Jea Andrew, Raskin Jeffrey S
Section of Pediatric Neurosurgery, Department of Neurological Surgery, Riley Hospital for Children, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana.
Indiana University School of Medicine, Indianapolis, Indiana.
Oper Neurosurg. 2019 Sep 1;17(3):E103-E104. doi: 10.1093/ons/opy392.
Severe lower limb spasticity can hinder motor tasks and negatively impacts the quality of life in patients with cerebral palsy. Selective dorsal rhizotomy is a well-established neurosurgical intervention aimed at reducing muscle spasticity in patients with such neuromuscular conditions. Long-term outcomes of selective dorsal rhizotomy have been promising among the authors' institutional series of patients. In this case, we demonstrate the use of L1-S1 osteoplastic laminoplasty and L1-S1 selective dorsal rhizotomy in a 5-year-old male patient with cerebral palsy and spastic lower extremity diplegia. Favorable selection criteria for this case included disabling lower extremity diplegia, young age, good core strength, no cognitive delay, and strong rehabilitation potential. The patient's preoperative functional status was noncommunity ambulator (Gross Motor Function Classification System Level III) with walker use and good dynamic balance. Prior to the procedure, he demonstrated an overall decreased muscle strength in bilateral lower extremities with bilateral hamstring spasticity (Ashworth 3) and bilateral heel cord spasticity (Ashworth 4). Rhizotomy was performed with identification and selective sectioning of dorsal nerve roots with abnormal stimulation patterns. Fibers with unsustained discharge of appropriate muscles were identified and spared. No intraoperative or postoperative complications were encountered. The patient had minimal back pain and surgical morbidity postoperatively. Following the procedure and highly structured inpatient and outpatient rehabilitation therapies, the patient exhibited significant improvement in gait velocity (84%) and gait cadence (66%) at 5 months. Additionally, the patient demonstrated greater independence of activities of daily living and improvements in mobility by Pediatric Evaluation Disability Index. Patient consent was obtained from the parent.
严重的下肢痉挛会妨碍运动任务，并对脑瘫患者的生活质量产生负面影响。选择性脊神经后根切断术是一种成熟的神经外科干预措施，旨在减轻此类神经肌肉疾病患者的肌肉痉挛。在作者所在机构的一系列患者中，选择性脊神经后根切断术的长期效果一直很可观。在此病例中，我们展示了在一名患有脑瘫和痉挛性下肢双侧瘫的5岁男性患者中使用L1 - S1骨成形性椎板成形术和L1 - S1选择性脊神经后根切断术。该病例的有利选择标准包括致残性下肢双侧瘫、年龄小、核心力量良好、无认知延迟以及强大的康复潜力。患者术前的功能状态为非社区步行者（粗大运动功能分类系统III级），需使用助行器且动态平衡良好。在手术前，他双侧下肢整体肌力下降，双侧腘绳肌痉挛（Ashworth 3级）和双侧跟腱痉挛（Ashworth 4级）。通过识别并选择性切断具有异常刺激模式的背神经根来进行脊神经后根切断术。识别出并保留了适当肌肉无持续放电的纤维。术中及术后均未出现并发症。患者术后背痛轻微，手术并发症少。经过手术以及高度结构化的住院和门诊康复治疗后，患者在5个月时步态速度提高了84%，步频提高了66%。此外，患者在日常生活活动中表现出更大的独立性，并且根据儿童残疾评估指数，其活动能力也有所改善。已获得患儿家长的患者知情同意。
