Rhizotomy
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| Intervention: Rhizotomy |
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| ICD-10 code: | ||
| ICD-9 code: | 03.1 | |
| MeSH | D019051 | |
| Other codes: | ||
A rhizotomy (rī-zŏt'ə-mē) is a neurosurgical procedure that selectively severs problematic nerve roots in the spinal cord, most often to relieve the symptoms of neuromuscular conditions such as multiple sclerosis, spastic diplegia and other forms of spastic cerebral palsy. In extreme cases, a rhizotomy may also be considered for a person suffering from severe back pain or a pinched nerve. The sensory nerve roots are first separated from the motor ones. Identification of the nerve fibers to be cut is then made by means of electrical stimulation. The one(s) producing the pain or other problems are identified in this way, then selectively cut.
In spasticity, rhizotomy precisely identifies, targets, and destroys the damaged nerves that don’t receive gamma amino butyric acid, which is the core problem for people with spastic cerebral palsy. In this case, those nerves which, due to not receiving GABA, generate unusual electrical activity during the testing phase are considered to be those producing too much muscle tone, and are cut, while the remaining nerves and nerve routes carrying the correct messages remain fully intact.
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[edit] Background
Chiefly, rhizotomy (also called dorsal rhizotomy, selective dorsal rhizotomy, and selective posterior rhizotomy) is a treatment for spasticity in cerebral palsy when the spasticity has proven unresponsive to less invasive procedures such as drug injections (baclofen, botox, phenol), orthopedic muscle-release surgeries, or similar methods.
It is a permanent procedure that addresses the spasticity at its neuromuscular root: i.e., in the central nervous system that contains the misfiring nerves that cause the spasticity of those certain muscles in the first place. After a rhizotomy, the patient that had suffered from severe muscle spasticity will be significantly less tight, have more range of motion and more fluidity in motion, and will never have to worry about the same muscles tightening up again, as they may have before the procedure.
This result is fundamentally unlike orthopedic surgical procedures, where any release in spasticity is essentially temporary most of the time.
[edit] Criteria
(from St. Louis Hospital files)
[edit] Those who walk independently before SPR/SDR
After the surgery all patients who were walking independently before surgery regained the independent walking within a few weeks after surgery. Patients maintain independent walking for the long term; when some have more difficulty walking independently they may eventually need an assistive device-- however, in nearly all cases spasticity can be eliminated and the quality of independent walking improves; in many patients, physical therapy and braces become unnecessary after SPR. Orthopedic surgery is rarely required after SPR.
[edit] Those who walk with walkers or crutches before SPR
In children who are 2-7 years old and walk with a walker or crutches before SPR, independent walking after the procedure is possible. Once they have achieved independent walking, they can maintain it. In children who are older than 7 years and walks with crutches, independent walking (inside or outside house) is possible. If they walk with walker at the age, they will most likely walk with a walker or crutches after the procedure, though it improves the quality of assisted walking and transition movements, and alleviates deformities of the legs. Many of these patients will need orthopedic surgeries after SPR.
[edit] Candidates for Rhizotomy
Not all patients with spastic cerebral palsy benefit from rhizotomy. For those under 18 years of age, rhizotomy requires that they be:
- At least 2 years of age
- Diagnosis of spastic diplegia, spastic quadriplegia or spastic hemiplegia
- Some form of independent mobility; for example, crawling or walking with or without an assistive device
- History of premature birth; if born at full term, child must have typical signs of spastic diplegia
- No severe damage to the basal ganglia on MRI examination
- Potential for improvement in functional skills
For adults between 19 and 40 years of age, rhizotomy requires:
- Diagnosis of spastic diplegia
- History of premature birth
- Currently ambulates independently without assistive device
- Relatively mild fixed orthopedic deformities
- Potential for functional gains after dorsal rhizotomy
- Motivation to attend intensive physical therapy and perform home exercise program
On the limited number of adult spastic diplegic people treated with rhizotomy, satisfactory functional gains in adult patients are similar to those in children. Because of this, most patients with spastic diplegia or quadriplegia should have spasticity reduced first through SDR before undergoing muscle release or tendon release procedures.
[edit] Required Circumstances
All candidates for rhizotomy must have good muscle strength in the legs and trunk. This is demonstrated by the ability to support full weight on the feet and hold a posture against gravity. There must also be evidence of adequate motor control, or the ability to make reciprocal movements for crawling or walking, and to move quickly from one posture to another. There must also be a a history of delayed motor development wherein the person has shown progression in motor development, but spasticity hampers the development of skills and/or causes gait patterns like the scissors gait. In adults, the primary requirements are that the person is able to ambulate independently, but spasticity limits energy, flexibility, walking speed and balance and sometimes causes pain/muscle spasms.
[edit] Post-Surgical Restrengthening
Typically this means physical therapy 4-5 times per week for 3-6 months postoperatively, and with decreasing frequency for an additional year or more, typically 16 months after surgery.
[edit] Conditions That Preclude SPR
Individuals with CP who possess the following would most likely not be candidates for the surgery. They include those who have suffered meningitis, congenital brain infection, congenital hydrocephalus unrelated to premature birth, head trauma, or familial disease; people who have a mixed CP with predominant rigidity or dystonia, significant athetosis, or ataxia; and those who have severe scoliosis. However, as with any procedure, an individual evaluation is needed in all instances to determine eligibility.
[edit] See also
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