Xiao Bo
Shanghai Children's Medical Center, National Children' Medical Center, Shanghai, China.
Adv Tech Stand Neurosurg. 2025;51:123-138. doi: 10.1007/978-3-031-86441-4_10.
Selective dorsal rhizotomy (SDR) is a surgical intervention aimed at reducing spasticity in children with cerebral palsy. This chapter introduces an innovative approach to SDR, utilizing crescendo single-pulse evoked compound muscle action potential (CMAP) interpretation for rootlet selection. The method combines preoperative spastic muscle identification, intraoperative neurophysiological monitoring, and a precise stimulation protocol to guide the selective sectioning of sensory nerve roots. The chapter outlines the setup for crescendo single-pulse stimulation-guided SDR, including preoperative muscle group identification, intraoperative monitoring channels, and surgical approach. It details the stimulation protocol and defines criteria for motor nerves, sphincter-associated sensory nerves, and lower limb-associated sensory nerves based on evoked CMAP patterns. The concept of a "rhizotomy ratio" is introduced as a potential metric correlating with the severity of the patient's condition. Midterm outcomes of this approach are presented, based on a cohort of 481 cases with a minimum 2-year follow-up across all 5 levels of the Gross Motor Function Classification System (GMFCS). Results show muscle tone decreased by an average of 1.0 level in spastic muscle groups immediately after surgery, with a tendency to continue reducing by an additional 0.8 level in the following 2 years post-SDR. Motor function improved significantly, with 39.1% of patients advancing by one or two GMFCS levels (in 432 cases with preop GMFCS levels II-V), concurrent with intensive rehabilitation programs. The greatest improvements were observed in children who underwent surgery before age six and those with less severe preoperative motor impairments. The chapter also discusses postoperative rehabilitation strategies tailored to the gradual reduction in muscle tone experienced by children following SDR. Gait analysis in mild cases indicates improved walking patterns post-SDR. Overall, this crescendo single-pulse stimulation-guided SDR approach demonstrates promising outcomes in reducing spasticity and improving motor function in children with cerebral palsy, with minimal complications reported.
选择性背根切断术（SDR）是一种旨在降低脑瘫患儿痉挛状态的外科手术干预方法。本章介绍了一种SDR的创新方法，即利用渐强单脉冲诱发复合肌肉动作电位（CMAP）解释来选择神经根。该方法结合了术前痉挛肌肉识别、术中神经生理监测和精确的刺激方案，以指导感觉神经根的选择性切断。本章概述了渐强单脉冲刺激引导下的SDR设置，包括术前肌肉群识别、术中监测通道和手术方法。它详细介绍了刺激方案，并根据诱发的CMAP模式定义了运动神经、括约肌相关感觉神经和下肢相关感觉神经的标准。引入了“切断术比率”的概念，作为与患者病情严重程度相关的潜在指标。基于481例病例的队列研究呈现了该方法的中期结果，所有病例均在粗大运动功能分类系统（GMFCS）的5个级别上进行了至少2年的随访。结果显示，术后痉挛肌肉群的肌张力立即平均下降1.0级，在SDR后的接下来2年中有继续下降0.8级的趋势。运动功能显著改善，39.1%的患者（在432例术前GMFCS级别为II - V的病例中）GMFCS级别提高了一或两级，同时进行了强化康复计划。在6岁前接受手术的儿童和术前运动障碍较轻的儿童中观察到了最大的改善。本章还讨论了针对SDR后儿童肌张力逐渐降低而制定的术后康复策略。轻度病例的步态分析表明SDR后步行模式有所改善。总体而言，这种渐强单脉冲刺激引导下的SDR方法在降低脑瘫患儿的痉挛状态和改善运动功能方面显示出了有前景的结果，且报告的并发症极少。
