Dorsal Rhizotomy for Spasticity (Stereotactic and Functional Neurosurgery) Part 2

Postoperative Care

The patient is kept in a flat or lateral recumbent position for the first 5 postoperative days to prevent leakage of cerebrospinal fluid. Patients are logrolled without rotation of the spine to prevent strain on the incision, the lumbar muscles and the dura, and to protect the skin and mobilize respiratory secretions. Typically, intravenous narcotics are used for analgesia for the first 2 postoperative days, during which the patient remains in the pediatric intensive care unit. The Foley catheter is kept in place until at least the third postoperative day. Intra- and postoperative antibiotics are by choice of the surgeon. On postoperative day number 3, bedside physical therapy is instituted for bed mobility, range of motion, and family teaching. To avoid elevated cerebrospinal fluid pressure at the dural incision, elevation of the head is not allowed until the third postoperative day, whereas sitting and assisted transfers are initiated on day five. Regular, intensive physical therapy is provided on an outpatient basis after discharge to help patients regain previous strength and to improve their functional skills beyond the preop-erative levels.

Stimulation of a right L3 rootlet demonstrating contralateral spread to the merged quadriceps/adductor and tibialis anterior/gastroc-nemius channels.

Figure 6 Stimulation of a right L3 rootlet demonstrating contralateral spread to the merged quadriceps/adductor and tibialis anterior/gastroc-nemius channels.


Reduction of spasticity can be appreciated on clinical examination immediately after surgery [12]. Multiple studies have documented decreased spas-ticity and improvements in functional ability, sitting and standing balance, and ambulation [1,2,13-22]. Assessment of function and documentation of outcome after treatment are difficult to standardize in patients with cerebral palsy because of the wide range of variability in the population as well as ongoing development and maturation. Standardized assessments, such as the Gross Motor Function Measure (GMFM), have only recently been developed [23,24] and used in evaluating treatment outcome [14]. Other measures, such as the Pediatric Evaluation of Disability Inventory [17] and the Chattecx Balance System [15] have been systematically applied to evaluation of treatment outcome, with demonstrated improvements in functional ability and sitting balance, respectively. Gait analysis has demonstrated improvements in hip and knee range of motion, stride length, and speed of ambulation [25,26], and in joint motion and foot placement [5,20,27-30]. Foot-floor contact pattern evaluation frequently demonstrates a change from primarily forefoot only at initial contact during ambulation to a heel or flatfoot position [28]. Occasionally excessive knee flexion, likely related to decreased calf muscle strength, requires orthotic intervention; however, selective posterior rhizotomy has been shown to decrease the overall rates of orthopedic procedures required in children with spastic cerebral palsy [31]. Other unexpected benefits, so-called ”distant effects,” such as decreased seizure frequency [32], greater bladder control [32,33], improved speech, and greater upper extremity range of movement have been observed [2,3,32]. Improvements in cognitive function [34], behavior, and emotional control [32] have also been reported.


Potential long-term neurosurgical problems include sensory loss, increased weakness, persistent spasticity, bowel or bladder dysfunction, sexual dysfunction, and spinal instability or deformity. Surgical complications such as hemorrhage, infection, or cerebrospinal fluid leakage, or anesthetic complications such as pulmonary problems are possible. The most frequent postoperative complications are fever, postcatheterization cystitis, and marginal oxygen saturation. Transient hyperesthesias are commonly noted after rhi-zotomy, although it has been the observation of the author that these are seen less frequently and resolve more quickly when the percentage of rootlets sectioned is kept to a minimum. After reduction in tone by rhizotomy, muscle weakness may become more apparent, either unmasked or exacerbated by the procedure. This weakness tended to improve with physiotherapy [32]. Clinically significant residual spasticity limiting improvements in functional outcome may persist. This is probably the result of an insufficient percentage of rootlets being sectioned [35,36].

Excellent outcomes and a low complication rate can be achieved through a multidisciplinary team approach combining careful patient selection, intraoperative EMG monitoring with judicious sectioning of dorsal rootlets, and intensive postoperative physical and occupational therapy. These patients should have coordinated follow-up and management with both the pediatric orthopedist, neurosurgeon, and urologist if indicated. Preexisting structural deformities are not addressed by the rhizotomy procedure, and children with neuromuscular disorders should have regular, ongoing orthopedic assessments as development progresses.

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