Search

Aim: This study aimed to assess the eff ectiveness of micro-vascular decompression (MVD) with or without partial sensory rhizotomy (PSR) in the treatment of trigeminal neuralgia which is refractory to medical and functional treatments. Materials and methods: Fifty-eight patients who were dia gnosed with classical trigeminal neuralgia and underwent posterior fossa decompression surgery from 2010 to 2016 by the same surgeon were included in the study. There were two groups of patients, according to operation type, with 30 (51.7%) patients treated with MVD and 28 (48.2%) treated with MVD + PSR. Records were analysed retrospectively for intraoperative fi ndings, pain intensity scores, recurrence of pain, postoperative results and complications. Results: In the early postoperative period, immediate pain relief was similar between the groups. The recurrence rate 36 months after surgery in the MVD and MVD + PSR groups was 23.3 and 7.1%, respectively. The pain-free survival time in the MVD group was 31.83 ± 1.9 (95% CI: 28.3–35.63) months, which was shorter than the 35.14 ± 1.1 (95% CI: 32.81–37.48) months in the MVD + PSR group at 36 months after surgery (P = 0.086). Concerning postoperative complications, one patient had an acute subdural haemorrhage (1.7%) and another had facial paralysis (1.7%), while hypoesthesia was experienced in 18 (31%) patients. There were no deaths in either group. Conclusion: MVD and MVD + PSR are safe and effective procedures for classical trigeminal neuralgia. [ABSTRACT FROM AUTHOR]

Background and Introduction: Patients with brachial plexus avulsion (BPA) injuries often suffer from chronic disabling drug refractory neuropathic pain. Dorsal root entry zone (DREZ) lesioning is currently the most effective surgical procedure for this intractable brachial neuralgia following BPA.Objective: To demonstrate a novel technique of "Micro-scissor DREZotomy" developed at our institution.Procedure: A 55-year-old gentleman underwent right cervical microscissor DREZotomy for post BPA neuralgia. Exclusive use of microscissors along the posterolateral sulcus, causing mechanical disruption of the nociceptive pathways through sharp dissection, results in precise lesioning with excellent pain free outcomes.Results: The patient had complete relief of the pain and uneventful recovery following the surgery and remains to be pain free at 1 year follow up.Conclusion: Microscissor DREZotomy is a simple cost-effective technique. It can easily be performed in the peripheral centers with limited resources and is a safe and effective technique in experienced hands. [ABSTRACT FROM AUTHOR]

Background: Severe spasticity adversely affects patient functional status and caregiving. No previous study has compared efficacy between dorsal root entry zone lesioning (DREZL) and selective dorsal rhizotomy (SDR) for reduction of spasticity. This study aimed to investigate the efficacy of DREZL and SDR for attenuating spasticity, and to compare efficacy between these two methods. Methods: All patients who underwent DREZL, SDR, or both for treatment of intractable spasticity caused by cerebral pathology at Siriraj Hospital during 2009 to 2016 were recruited. Severity of spasticity was assessed using Modified Ashworth Scale (MAS) and Adductor Tone Rating Scale (ATRS). Ambulatory status was also evaluated. Results: Fifteen patients (13 males) with a mean age of 30.3 ± 17.5 years were included. Eight, six, and one patient underwent DREZL, SDR, and combined cervical DREZL and lumbosacral SDR, respectively. Eight of ten patients with preoperative bed-bound status had postoperative improvement in ambulatory status. Spasticity was significantly reduced in the DREZL group ( p < 0.001), the SDR group ( p < 0.001), and in overall analysis ( p < 0.001). SDR was effective in both pediatric and adult spasticity patients. A significantly greater reduction in spasticity as assessed by MAS score ( p < 0.001) and ATRS score ( p = 0.015) was found in the DREZL group. Transient lower limb weakness was found in a patient who underwent SDR. Conclusions: DREZL is more effective for reducing spasticity, but is more destructive than SDR. DREZL should be preferred for bed-ridden patients, and SDR for ambulatory patients. Both operations are helpful for improving ambulatory status. Gait improvement was observed only in patients who underwent SDR. Adult patients with spasticity of cerebral origin benefit from SDR. [ABSTRACT FROM AUTHOR]

Aim: To examine long-term outcomes of selective dorsal rhizotomy (SDR) 10 to 17 years after surgery.Method: Participants who underwent SDR had spastic diplegic cerebral palsy (CP), completed baseline gait analysis, and were 16 to 25 years old at follow-up. Non-SDR participants (i.e. controls) were matched on important clinical parameters at baseline but did not undergo SDR. All study participants completed six surveys assessing pain, quality of life, participation, function, and mobility. Treatment history for lower extremity surgery and antispasticity injections was tabulated. A subset of each study group returned for three-dimensional gait analysis, including kinematics, metabolic energy cost, and physical examination. Gait Deviation Index (GDI) was calculated to measure gait quality.Results: The study cohort had 24 participants with SDR and 11 without SDR. Of these, 13 patients with SDR (five males, eight females; median [IQR] age 17y 2mo [16y 8mo-17y 9mo]) and eight without SDR (three males, five females; median [IQR] age 19y 2mo [17y 3mo-21y 11mo]) completed baseline and follow-up gait analysis. Spasticity significantly decreased in those with SDR (p<0.05). Gait Deviation Index improved more in participants without SDR than those with SDR (Δnon-SDR =12.8 vs ΔSDR =9.1; p=0.01). Compared with the SDR group, participants without SDR underwent significantly more subsequent interventions (p<0.05).Interpretation: Patients in both the SDR and non-SDR groups showed improved gait quality more than 10 years after surgery. Participants without SDR had a larger improvement in gait pathology but underwent significantly more intervention. There were no differences between groups in survey measures. These results suggest differing treatment courses provide similar outcomes into early adulthood.What This Paper Adds: Selective dorsal rhizotomy (SDR) and non-SDR groups had significant improvement in gait pathology over time. The non-SDR group had significantly better gait compared with the SDR group at follow-up. The groups had similar levels of energy cost, pain, and quality of life. Non-SDR participants underwent significantly more orthopaedic surgery and antispasticity injections than SDR participants. Use of a clinically similar control group highlights that different treatment courses may result in similar outcomes into young adulthood. [ABSTRACT FROM AUTHOR]

Background/Aims: Selective dorsal rhizotomy for spastic cerebral palsy is an effective and well-validated surgical approach. Multiple techniques have been described in the past including multiple laminectomies and a single-level laminectomy at the level of the conus. There is considerable technical challenge involved with a single-level laminectomy approach. Methods: We report here a modification of the single- level laminectomy that selectively analyzes each individual nerve root with electromyography to separate dorsal and ventral nerve roots through comparison of stimulus responses. Results: In 18 children with cerebral palsy who underwent this operation there was a mean improvement in the Modified Ashworth Scale of 2.0 with no reported incidence of muscle weakness, sensory loss, or neurogenic bladder. Conclusion: This approach allows for a modification of selective dorsal rhizotomy through a single-level laminectomy and tailors the selection of nerve root sectioning to the individual patient of interest while still maintaining its effectiveness. [ABSTRACT FROM AUTHOR]

Purpose: This research examines an approach for enhancing the efficiency of spinal surgery utilising the technological capabilities and design functionalities of wearable headsets, in this case Google Glass. The aim was to improve the efficiency of the selective dorsal rhizotomy neurosurgical procedure initially through the use of Glass via an innovative approach to information design for an intraoperative monitoring display.Methods: Utilising primary and secondary research methods the development of a new electromyography response display for a wearable headset was undertaken.Results: Testing proved that Glass was fit for purpose and that the new intraoperative monitor design provided an example platform for the innovative intraoperative monitoring display; however, alternative wearable headsets such as the Microsoft HoloLens could also be equally viable.Conclusion: The new display design combined with the appropriate wearable technology could greatly benefit the selective dorsal rhizotomy procedure. [ABSTRACT FROM AUTHOR]

Background/Study Aims Percutaneous radiofrequency trigeminal rhizotomy (RTR) is a standardized treatment for trigeminal neuralgia, yet it has been associated with serious complications related to the cannulation of the foramen ovale. Some of these complications, such as carotid injury, are potentially lethal. Neuronavigation was recently proposed as a method to increase the procedure's safety. All of the techniques described so far rely on pre- or intraoperative computed tomography scanning. Here we present a simple method based on magnetic resonance imaging (MRI) (radiation free) used to target the foramen ovale under navigation guidance. Patients/Material and Methods We retrospectively analyzed nine patients who had undergone navigated percutaneous RTR based solely on preoperative MRI and compared them with 35 patients who underwent conventional RTR guided by fluoroscopy. We analyzed immediate and late outcome and categorized the results into pain free, > 70% pain reduction, and persistent pain. We also compared groups in terms of the duration of the procedure and the complication rates. Here we describe the navigation method in detail and review the anatomical landmarks for target definition. Results The duration of the surgical procedure was similar in both groups (32.1 in the standard technique versus 34.5 minutes with navigation; p = 0.5157). There was no significant difference between groups regarding pain reduction at the immediate (p = 1.0) or late follow-up (p = 0.6284) time points. Furthermore, no serious complications were observed in the navigated group. Conclusions We present a simple radiation-free method for neuronavigation-assisted percutaneous RTR. This method proved to be safe and effective, and it is especially recommended for young, inexperienced neurosurgeons. [ABSTRACT FROM AUTHOR]

Copyright of Universitas Médica is the property of Pontificia Universidad Javeriana and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: The objective of this study was to evaluate the effectiveness of percutaneous controlled radiofrequency trigeminal rhizotomy (RF-TR) in patients with bilateral trigeminal neuralgia (BTN). Patients were analyzed after RF-TR in terms of outcome, safety and complications. Methods: Eighty-nine BTN patients underwent 186 RF-TR procedures. Eighty-seven patients had idiopathic trigeminal neuralgia (ITN) and two patients had multiple sclerosis (2.2%). Fifty-six (62.9%) were women and 33 (37.1%) were men. Ages ranged from 29 to 85 years. Anesthesia was administered at a determined optimal level, allowing patient cooperation for controlled and selective lesioning. Results: The mean follow-up period was 101.71 ± 77.7 months. Familial occurrence was seen in two (2.2%) patients. Synchronized pain was observed in 25 (28.2%) patients. Pain occurrence on the contralateral side was observed with an average duration of 124.7 ± 87.13 months. Fifty-four of the 89 patients underwent 146 RF-TR procedures for both sides and 35 underwent 40 RF-TR procedures for one side. Complete pain relief or partial satisfactory pain relief was achieved on the medically treated side in 35 patients. During follow-up, 36 patients required the second procedure and 7 required the third procedure. Acute pain relief was reported in 86 (96.6%) patients. Early (<6 months) pain recurrence was observed in 11 (12.3%) and late (>6 months) recurrence in 25 (28.0%) patients. Complications included diminished corneal reflex in four (2.1%) patients, keratitis in two (1.1%), masseter dysfunction in four (2.1%), dysesthesia in two (1.1%), and anesthesia dolorosa in one (0.5%). Conclusions: RF-TR is an effective, selective, well-controlled, and effortlessly repeatable procedure for treating BTN, especially in the elderly, in terms of low morbidity and mortality rates and high rate of satisfactory pain relief. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to explore changes in motor function up to 10 years after selective dorsal rhizotomy (SDR). Method The participants comprised 29 children (20 males, nine females) with bilateral spastic diplegia who were consecutively operated on at a median age of 4 years and 3 months and followed until a median age of 15 years. SDR was combined with physiotherapy and regular follow-up visits. The distribution of preoperative Gross Motor Function Classification System (GMFCS) levels was as follows: I, n=1; II, n=7; III, n=8; IV, n=12; and V, n=1. Muscle tone in hip flexors, hip adductors, knee flexors, and plantar flexors was assessed with the modified Ashworth scale, passive range of motion in hip abduction, popliteal angle, maximum knee extension, dorsiflexion of the foot was measured with a goniometer, and gross motor function was assessed using the Gross Motor Function Measure (GMFM-66). The results were compared with preoperative values, taking into account age at the time of SDR. Results After 10 years, muscle tone in hip flexors, hip adductors, knee flexors and plantar flexors was normalized in 19, 24, 13 and 23 participants respectively; mean change in passive range of motion ranged from −2.0° to 8.6°, and the mean increase in GMFM-66 was 10.6. Changes in GMFM-66 were associated with preoperative GMFCS level and GMFM-66 scores. Interpretation Children who underwent SDR and physiotherapy and were regularly followed up by an experienced team showed improved gross motor function for up to 10 years postoperatively. [ABSTRACT FROM AUTHOR]

The article discusses a study that evaluated the long-term effects of selective dorsal rhizotomy (SDR) in pediatric patients with cerebral palsy (CP). The subjects were prospectively assessed at different time periods after SDR. It was found that baseline muscle tone at the knee, hop, and ankle level showed a high degree of spasticity that normalized after SDR. The spasticity-reducing effect of SDR is seen to suggest that contracture development in CP is not mediated only by spasticity.

The article discusses a study that compares function and gait in a group of certain older children who received selective dorsal rhizotomy (SDR) with age- and function-matched children who received either no surgery or orthopedic surgery. Ambulatory children with diplegic cerebral palsy and categorized in levels I or II of the Gross Motor Function Classification System (GMFCS). It was found that the group that received orthopedic surgery showed improved gait compared with the group that did not undergo surgery.

Afferent inputs are known to modulate the activity of locomotor central pattern generators, but their role in the generation of locomotor patterns remains uncertain. This study sought to investigate the importance of afferent input for producing bilateral, coordinated hindlimb stepping in adult cats. Following complete spinal transection, animals were trained to step on the moving belt of a treadmill until proficient, weight-bearing stepping of the hindlimbs was established. Selective dorsal rhizotomies of roots reaching various segments of the lumbosacral enlargement were then conducted, and hindlimb stepping capacity was reassessed. Depending on the deafferented lumbosacral segments, stepping was either abolished or unaffected. Deafferentation of mid-lumbar (L3/L4) or lower-lumbar (L5-S1) segments abolished locomotion. Locomotor capacity in these animals could not be restored with the administration of serotonergic or adrenergic agonists. Deafferentation of L3, L6, or S1 had mild effects on locomotion. This suggested that critical afferent inputs pertaining to hip position (mid-lumbar) and limb loading (lower-lumbar) play an important role in the generation of locomotor patterns after spinal cord injury. [ABSTRACT FROM AUTHOR]

The foramen of Vesalius (FV) is located in the greater wing of the sphenoid bone between the foramen ovale (FO) and the foramen rotundum in an intracranial view. The FO allows the passage of the mandibular branch of trigeminal nerve, which is the target of the trigeminal radiofrequency rhizotomy. We analyzed its location, morphology, morphometry and interrelation among other foramina. 400 macerated adult human skulls were examined. A digital microscope (Dino-Lite plus®) was used to capture images from the FV. A digital caliper was used to perform the measurements of the distance between the FV and other foramina (FO, foramen spinosum and the carotid canal) in an extracranial view of the skull base. In the 400 analyzed skulls, the FV was identified in 135 skulls (33.75%) and absent on both sides in 265 skulls (66.25%). The FV was observed present bilaterally in 15.5% of the skulls. The incidence of unilateral foramen was 18.25% of the skulls of which 7.75% on right side and 10.5% on left side. The diameter of the FV was measured and we found an average value of 0.65 mm, on right side 0.63 mm and on the left side 0.67 mm. We verified that positive correlations were statistically significant among the three analyzed distances. This study intends to offer specific anatomical data with morphological patterns (macroscopic and mesoscopic) to increase the understanding of the FV features as frequency, incidence and important distances among adjacent foramina. [ABSTRACT FROM AUTHOR]

Spinal cord injury results not only in motor and sensory dysfunctions, but also in loss of normal urinary bladder functions. A number of clinical studies were focused on the strategies for improvement of functions of the bladder. Completely dorsal root rhizotomy or selective specific S2-4 dorsal root rhizotomy suppress autonomic hyper-reflexia but have the same defects: it could cause detrusor and sphincter over-relaxation and loss of reflexive erection in males. So precise operation needs to be considered. We designed an experimental trail to test the possibility on the basis of previous study. We found that different dorsal rootlets which conduct impulses from the detrusor or sphincter can be distinguished by electro-stimulation in SD rats. Highly selective rhizotomy of specific dorsal rootlets could change the intravesical pressure and urethral perfusion pressure respectively. We hypothese that for neurogenic bladder following spinal cord injury, highly selective rhizotomy of specific dorsal rootlets maybe improve the bladder capacity and the detrusor sphincter dyssynergia, and at the same time, the function of other pelvic organ could be maximize retainment. [ABSTRACT FROM AUTHOR]

The perceived need for electrophysiological guidance (EPG) during selective dorsal rhizotomy (SDR) has limited the frequency with which SDR is performed. The need for EPG during SDR has been questioned. At our institution, of >200 children with SDR for spastic cerebral palsy, 22 children underwent SDR without EPG using clinical guidance (no EPG group). Electrophysiological stimulation was used to distinguish dorsal from ventral roots. The remainder had SDR with EPG. The purpose of this study was to compare outcomes between the groups having SDR with and without EPG. The 22 patients in the no EPG group were matched with 22 controls in whom EPG was used, with respect to Gross Motor Function Classification System score (GMFCS) and age. The 12-month outcomes with respect to motor function score, hip adductor spasticity (Ashworth), hip abduction range of motion (ROM), quadriceps power [Medical Research Council (MRC)], WeeFIM, Quality of Upper Extremities Skills Test (QUEST), and incidence of complications were compared. There were no statistically significant differences preoperatively with respect to GMFCS, age, gross motor function, Ashworth or MRC scores, joint ROM, WeeFIM, or QUEST. At 1 year after SDR, there were no differences between the groups in the incidence of complications or outcome measures. Percentage of dorsal roots cut was similar, but the duration of surgery was significantly shorter in the no EPG group. There was no advantage of doing SDR with EPG compared to no EPG. SDR can reasonably be done in centers where EPG is not available, but electrophysiological stimulation to distinguish dorsal from ventral roots may be useful in avoiding complications. [ABSTRACT FROM AUTHOR]

This study retrospectively evaluated the safety and efficacy of selective dorsal rhizotomy (SDR) in participants who underwent a rigorous selection process, uniform surgical procedure, and a standardized postoperative rehabilitation process. Outcome measures assessed were the Ashworth scale for spasticity, the Gillette Gait Index (GGI) for overall gait pathology, oxygen cost for gait efficiency, and the Gillette Functional Assessment Questionnaire (functional walking ability scale; [FAQ]) for functional mobility. Outcomes were evaluated for 136 children (81 males, 55 females; mean age 7y 3mo [SD 2y 1mo], range 3y 5mo–18y 9mo) for an average of 18.3 months (SD 4.4mo) postoperatively. All participants had a diagnosis of cerebral palsy (CP): 10 quadriplegia, 19 triplegia, and 107 diplegia. Preoperative Gross Motor Function Classification System levels were: Level I n=6; Level II n=64; Level III n=59, and Level IV n=7. All outcome measures improved for the group as a whole. Spasticity improved with 66 to 92% of possible gain in Ashworth scores; GGI was 7.5 times more likely to have a good as opposed to a poor outcome; energy efficiency improved in over half of the participants, and the FAQ demonstrated a statistically significant improvement of 0.9 levels ( p<0.001). The rate of complications was low, with peri- and postoperative complications resolved by time of discharge. [ABSTRACT FROM AUTHOR]

Rationale Selective dorsal rhizotomy (SDR) is a surgical technique developed over the past decades to manage patients diagnosed with cerebral palsy suffering from spastic diplegia. It involves selectively lesioning sensory rootlets in an effort to maintain a balance between elimination of spasticity and preservation of function. Several recent longterm outcome studies have been published. In addition, shorter follow-up randomized controlled studies have compared the outcome of patients having undergone physiotherapy alone with those that received physiotherapy after selective dorsal rhizotomy. Materials and methods In this account, we will discuss the rationale and outcome after SDR. The outcome is addressed in terms of the gross motor function measurement scale (GMFM), degree of elimination of spasticity, strength enhancement, range of motion, fine motor skills, activity of daily living, spastic hip, necessity for postoperative orthopedic procedures, bladder and sphincteric function, and finally possible early or late complications associated with the procedure. Conclusion We conclude that SDR is a safe procedure, which offers durable and significant functional gains to properly selected children with spasticity related to cerebral palsy. [ABSTRACT FROM AUTHOR]

Purpose The author describes the history of functional posterior rhizotomy (FPR), the surgical procedure currently used, and the results together with its future perspective in Japan. The modern form of FPR was introduced to Japan in 1995, and the first surgery was carried out in 1996. Despite initial resistance from orthopedic surgeons, the procedure has eventually gained wide recognition in the country. Materials and Methods The author has operated on 98 patients (60 boys and 38 girls, aged from 2 to 19 years old) by the end of 2006. Most patients were mild to severely disabled children with spastic hypertonia because of cerebral palsy and other diseases. The surgical procedure used is based on the Peacock's procedure with some modification for the mildly disabled children whose spasticity was predominantly the muscles of the ankle joint. Intraoperative neurophysiology was an indispensable tool for preserving urogenital function and for judging which root/rootlet to be cut. Results Seventeen to 83% of the root/rootlets were found to be abnormal and were cut, clearly correlating with the degree of disability. However, there was a wide difference in the cutting rate, even in children with the same degree of disability. The result of surgery in this group of patients was the same as in previously published data. Twenty out of 51 patients (39%) followed for more than a year at the current institute showed improved locomotion after FPR. Thirty patients (59%) demonstrated suprasegmental effects after FPR. Conclusion The role of FPR will grow in importance as a treatment for spasticity in Japan in the future. [ABSTRACT FROM AUTHOR]

Background: Children undergoing selective dorsal rhizotomy (SDR) experience severe pain postoperatively; a pain related to both the extensive surgical exposure with multilevel laminectomy and nerve root manipulation. We sought to define an optimal dose of continuous intrathecal (IT) morphine and bupivacaine to treat this severe pain. The aim of this study was to compare two different concentrations of morphine in a fixed dose of bupivacaine with regard to the analgesic effect and survey if they differed in side effects. Methods: Twenty-six children, aged 2.7–7.4 years undergoing SDR were included in this study. Postoperatively 11 children received a continuous infusion of morphine 0.4 μg.kg−1.h−1 and bupivacaine 40 μg.kg−1.h−1 (low-dose group) and 15, a continuous infusion of morphine 0.6 μg.kg−1.h−1 and bupivacaine 40 μg.kg−1.h−1 (high-dose group). The Behavioral Observational Pain Scale (BOPS) was used to evaluate pain. Results: Better pain relief was obtained in the high-dose group seen in lower BOPS score compared with the low-dose group [ P = 0.03, Fisher's permutation test and P = 0.06 Wilcoxon–Mann–Whitney (WMW) test]. The low-dose group received seven times as much ketobemidone 0.43 ± 0.54 mg.kg−1 48 h−1 compared with 0.06 ± 0.09 mg.kg−1 48 h−1 in the high-dose group ( P = 0.0005 Fisher's permutation test, P = 0.0017 WMW test). There was no statistical difference in pruritus and postoperative nausea and vomiting between the groups. Respiratory and hemodynamic depression was not found. Conclusion: This study shows that, compared with low-dose, the higher dose of continuous IT morphine combined with bupivacaine, significantly reduce pain score and postoperative intravenous analgesic requirements without increasing adverse effects. [ABSTRACT FROM AUTHOR]

Background: Medically refractory trigeminal neuralgia (TN) has been treated with a variety of minimally invasive techniques, all of which have been compared with microvascular decompression. For patients not considered good surgical candidates, percutaneous retrogasserian glycerol rhizotomy (GR) and gamma knife (GK) radiosurgery are two minimally invasive techniques in common practice worldwide and used routinely at Jefferson Hospital for Neuroscience. Using a common pain scale outcomes questionnaire, we sought to analyze efficacies and morbidities of both treatments.Methods and Materials: Between June 1994 and December 2002, 79 patients were treated with GR and 109 patients underwent GK for the treatment of TN. GR was performed with fluoroscopic guidance as an overnight inpatient procedure. GK was performed using a single 4-mm shot positioned at the root exit zone of the trigeminal nerve. Radiation doses of 70-90 Gy prescribed to the 100% isodose line were used. Treatment outcomes including pain response, pain recurrence, treatment failure, treatment-related side effects, and overall patient satisfaction with GK and GR were compared using a common outcomes scale. Using the Barrow Neurologic Institute pain scale, patients were asked to define their level of pain both before and after treatment: I, no pain and no pain medication required; I, occasional pain not requiring medication; IIIa, no pain and pain medication used; IIIb, some pain adequately controlled with medication; IV, some pain not adequately controlled with medication; and V, severe pain with no relief with medication. We used posttreatment scores of I, II, IIIa, and IIIb to identify treatment success, whereas scores of IV and V were considered treatment failure. Results were compiled from respondents and analyzed using SAS software. Statistical comparisons used log-rank test, univariate and multivariate logistic regression, Fisher's exact test, and Wilcoxon test with significance established at p < 0.05.Results: There were 63 evaluable GK patients and 36 evaluable GR patients. The median follow-up time was 34 and 29 months for the GR and GK groups, respectively. The median age was 69 and 70 years and the median number of years with TN pain was 6 and 7 years in the GR and GK groups, respectively. Thirty-one GR (86%) and 58 GK (92%) patients achieved a successful treatment outcome (p = 0.49). The median time to pain relief was < or = 24 h in the GR group and 3 weeks in the GK group (p < 0.001, ordinal logistic regression). Nineteen GR and 26 GK patients experienced pain recurrence or pain never relieved (p = 0.30). The median time to pain recurrence was 5 and 8 months in the GR and GK groups, respectively (p = 0.22). At last follow-up, however, a statistically significant greater number of GR vs. GK patients had failed treatment. Twelve or 33% of GR patients, whereas 8 or 13% of GK patients, had BNI scores of 4 or 5 (p = 0.019, Fisher's exact test). When both initial and late treatment failures were combined, the overall rate of treatment failures was 39% in the GR group and 24% in the GK group (p = 0.023, log-rank). More GR patients developed facial numbness and facial numbness morbidity than GK patients: 19 GR (54%) and 17 GK patients (30%) developed new facial numbness and 12 GR and 7 GK patients reported either somewhat or very bothersome facial numbness (p = 0.018). On multivariate analysis, only treatment with GK and severity of pain before treatment significantly predicted treatment response. GK patients were more likely to have a lower pain score at last follow-up than were GR patients (p = 0.005, OR = 4.3), and patients with pretreatment pain scores of 5 were more likely to have lower posttreatment pain scores than patients with pretreatment pain scores of 4 and lower (p = 0.003, OR = 4.0).Conclusion: Despite greater facial numbness morbidity and a higher failure rate, GR provided more immediate pain relief than GK. GR therefore should be considered in patients with disabling trigeminal pain requiring urgent pain relief. For all other patients, GK provides better long-term pain relief with less treatment-related morbidity, and should therefore be considered the preferred treatment for patients with medically refractory trigeminal neuralgia who are not suitable candidates for microvascular nerve decompression. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study is to evaluate the effect of selective dorsal rhizotomy (SDR) on functional abilities in a well-defined group of ambulatory children with spastic diplegia. Methods: Nine children were selected for SDR (mean age 65 months, range 43–82 months). Gross motor function was measured with the Gross Motor Function Measure (GMFM-88). Self-care was assessed with the Pediatric Evaluation of Disability Inventory (PEDI) and gait pattern was measured with the Edinburgh Visual Gait Score (EGS). There were nine single-case research designs with a 12-month follow-up after surgery. Results: After 12 months the mean improvement in the total GMFM-88 scores was 8.8%. On an individual level, all patients improved significantly in comparison with baseline. Functional skills and care-giver assistance measured with the PEDI showed significant improvement. Improvement in gait was also found; in particular, better initial contact and heel-lift resulted in an increased EGS. Conclusion: In this well-defined group of ambulatory children SDR had a small but significant positive effect on gross motor function, self-care and gait pattern. [ABSTRACT FROM AUTHOR]

Functional recovery after large excision of dorsal roots is absent because of both the limited regeneration capacity of the transected root, and the inability of regenerating sensory fibers to traverse the dorsal root entry zone. In this study, bioresorbable guidance conduits were used to repair 6-mm dorsal root lesion gaps in rats, while neurotrophin-encoding adenoviruses were used to elicit regeneration into the spinal cord. Polyester conduits with or without microfilament bundles were implanted between the transected ends of lumbar dorsal roots. Four weeks later, adenoviruses encoding NGF or GFP were injected into the spinal cord along the entry zone of the damaged dorsal roots. Eight weeks after injury, nerve regeneration was observed through both types of implants, but those containing microfilaments supported more robust regeneration of calcitonin gene-related peptide (CGRP)-positive nociceptive axons. NGF overexpression induced extensive regeneration of CGRP(+) fibers into the spinal cord from implants showing nerve repair. Animals that received conduits containing microfilaments combined with spinal NGF virus injections showed the greatest recovery in nociceptive function, approaching a normal level by 7-8 weeks. This recovery was reversed by recuffing the dorsal root through the centre of the conduit, demonstrating that regeneration through the implant, and not sprouting of intact spinal fibers, restored sensory function. This study demonstrates that a combination of PNS guidance conduits and CNS neurotrophin therapy can promote regeneration and restoration of sensory function after severe dorsal root injury. [ABSTRACT FROM AUTHOR]

Suprasegmental effects following selective posterior rhizotomy have been frequently reported. However, few studies have used validated functional outcome measures to report the surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine the long-term impact of lumbosacral dorsal rhizotomy on fine motor skills. The study population comprised children with debilitating spasticity who underwent SPR and were evaluated by a multidisciplinary team preoperatively, at 6 months and 1 year postoperatively. Quantitative standardized assessments of upper extremity function were obtained using the fine motor skills section of the Peabody Developmental Motor Scales (PDMS) test. Of 70 patients who met the entry criteria for the study, 45 and 25 completed the 3- and 5-year assessments, respectively. Statistical analysis demonstrated significant improvements in grasping, hand use, eye-hand coordination, and manual dexterity at 1 year after SPR. More importantly, all improvements were maintained at 3 and 5 years following SPR. This study supports that significant improvements in upper extremity fine motor function using the PDMS evaluative measure are present after SPR and that these suprasegmental benefits are durable.Copyright © 2002 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

A previous randomized clinical trial compared selective dorsal rhizotomy (SDR) plus postoperative intensified physiotherapy (group 1) with intensified physiotherapy alone (group 2) for children with spastic diplegic cerebral palsy. At the end of this trial, all patients in group 2 had an SDR, followed by further intensified physiotherapy. This study was performed to determine if the additional intensified physiotherapy before SDR, as occurred in group 2, improved long-term motor outcome. Outcomes were compared in the two groups, i.e. group 1 without intensified physiotherapy before SDR and group 2 with intensified physiotherapy before SDR. The primary outcome measure was the Gross Motor Function Measure (GMFM). Lower-limb spasticity, range and strength were secondary outcome measures. Baseline assessments had been done for the prior clinical trial. For this study, patients were reassessed by physiotherapists blinded to the treatment group. Thirteen children in each group were studied at a mean follow-up of 53 months. The mean improvement in GMFM was 10.0 in group 1 and 10.4 in group 2 (p = 0.9). Improvements in spasticity and range were similar in the two groups. There was no significant change in muscle strength in either group. It was concluded that in this relatively small series of patients, additional intensified physiotherapy before SDR did not improve motor outcomes.Copyright © 2002 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Spasticity occurs in children and adults due to a wide range of conditions, including cerebral palsy, head and spinal cord trauma, cerebrovascular accidents and multiple sclerosis. Multiple treatment options have been described, including medical and surgical treatments. Medical treatments include intramuscular botulinum A toxin, oral baclofen and supportive bracing. Surgical approaches include selective posterior rhizotomy, intrathecal baclofen and orthopedic procedures to address deformities. Many reports have been published on these different treatment options, but rarely has a comparison been made between them. Therefore, this review is aimed at comparing selective posterior rhizotomy and intrathecal baclofen injection for spasticity due to cerebral palsy, especially in children.Copyright © 2001 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Summary Between the years 1974 and 1999, 1,672 patients with medically intractable trigeminal neuralgia (TN) were treated by percutaneous controlled radiofrequency (RF) rhizotomy by the senior author and co-workers at the Department of Neurosurgery, Ankara University School of Medicine. Sixteen hundred cases (95.7%) were found to have idiopathic TN, while 72 cases (4.3%) were classified as symptomatic. In the latter group, TN was found to be caused by multiple sclerosis (MS) in 17 cases (23.6%), one of whom had bilateral TN. All patients having TN with MS (17 cases) underwent percutaneous controlled radiofrequency rhizotomy (25 procedures) as the procedure of choice. The MS patients were followed for an average of 60 months (range: 6–141 months). Complete pain relief was achieved with a single procedure in 12 of the 17 MS cases (70.6%). Early (less than 2 weeks) pain recurrence was seen in two patients (11.8%), while the overall recurrence rate was 29.4%. A second procedure was required to control TN in three cases (17.6%), a third in one (5.9%), and twice for each side for the case with bilateral TN (5.9%). Pain was completely relieved in 14 cases (82.4%) with single or multiple RF rhizotomies. In three cases (17.6%), partial pain control was achieved with RF rhizotomy, and the patients continued to receive adjunctive medical therapy. No complications were observed. All 17 patients (100%) were classified to have done well with RF rhizotomy. Satisfactory results and good long-term pain control were obtained in patients having TN due to MS with percutaneous controlled RF rhizotomy. The authors propose that RF rhizotomy may be a safe and effective procedure in the neurosurgical armamentarium for the treatment of patients having TN due to MS. [ABSTRACT FROM AUTHOR]

The ability to perform a ‘selective’ dorsal rhizotomy has been challenged. EMG responses are inconsistent and often do not represent reflex responses. We perform nonselective partial dorsal rhizotomy (NSPDR) when reflex response is not evident. Ten children undergoing primarily NSPDR were evaluated preoperatively and postoperatively with the Modified Ashworth Scale, gait lab analyses gross motor function measure and the NSPDR was performed by nonselectively sectioning 50–75% of the dorsal roots not demonstrating a reflex response. Standard selective rhizotomy was performed in the remainder. Only 17 of 106 (16%) dorsal roots demonstrated reflex responses. The results reported in this study demonstrate a benefit to patients undergoing primarily NSPDR which is similar to that reported for patients in whom a selective procedure was intended.Copyright © 2000 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

A retrospective analysis of data collected prospectively was performed to determine the long-term outcome of lumbosacral selective posterior rhizotomy (SPR) in children with spastic cerebral palsy (CP). The study population comprised children with spastic CP, who had SPR more than 4 years prior to the time of the study and had quantitative standardized assessments of lower limb spasticity (Ashworth scale), range of motion measured goniometrically, muscle strength (MRC scale) and ambulatory function, both preoperatively and at 1 year after SPR. Children meeting these criteria were reassessed at 5 years after SPR using the same measures. Hip adductor spasticity, hip abduction range of motion and quadriceps strength were chosen as the primary outcome measures for statistical analysis. Of 80 patients who met the entry criteria for the study, 33 completed the 5-year assessments. Significant improvements in spasticity, range of motion and muscle strength were noted both at 1 year and at 5 years after SPR. The preoperative, 1-year and 5-year values were as follows: hip adductor spasticity (Ashworth scale) = 4.1, 2.1, 2.2; hip abduction range of motion (degrees) = 20.4, 39.9, 31.7, and quadriceps strength (MRC scale) = 3.6, 4.0, 4.1. Ambulatory function seemed to be better at 1 and 5 years compared to baseline, but no statistical analysis was done for this secondary outcome measure. It was concluded that improvements in lower limb motor outcome are present at 1 year after SPR, and that these improvements are generally maintained at 5 years.Copyright © 1999 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Changes in upper extremity and self-care performance following selective posterior rhizotomy (SPR) are reported frequently, but rarely quantified. In this study, 36 children with spastic cerebral palsy were assessed preoperatively and 1 year following SPR using the Quality of Upper Extremity Skills Test (QUEST). Twenty-six children were assessed at similar intervals using the Functional Independence Measure for Children (WeeFIM) as a measure of self-care performance. Wilcoxon matched-pair signed-rank tests were used to compare the QUEST total scores and the WeeFIM motor, cognitive, and total scores before and after SPR. One year after SPR, the total QUEST scores were significantly better (median improvement = 3.2%, p < 0.0001), as were the WeeFIM motor (median improvement = 9.5, p < 0.0001), cognitive (median improvement = 1.0, p < 0.008), and total (median improvement = 11.0, p < 0.0001) scores. The results indicate quantifiable improvements in upper extremity function, and motor and cognitive self-care skills in children 1 year after SPR. [ABSTRACT FROM AUTHOR]

Selective dorsal rhizotomy (SDR) has been shown to be an effective treatment for the spasticity of cerebral palsy, but few studies have addressed specifically the side effects of the procedure. A retrospective study was performed to determine the frequency and nature of complications in 158 children who had undergone SDR at British Columbia’s Children’s Hospital from 1987 to 1996. Intraoperative, preoperative (immediate postoperative until discharge at approximately 7 days) and postdischarge complications occurred in 3.8, 43.6 and 30% of patients, respectively. The most common intraoperative complication was aspiration pneumonia, which was experienced by 2 patients (1.3%). Perioperatively, sensory changes were found in 8.9% of the children, and transient urinary retention in 4.4%. Complications after discharge included back pain starting more than 6 months after surgery in 10.8%, sensory changes in 13.9%, and neurogenic bladder or bowel problems in 12.7%. Persistent sensory changes occurred in 3.8%, were not important functionally, and tended to occur in patients with the largest amount of dorsal root tissue cut. In 8 patients (5.1%), bladder and/or bowel dysfunction attributed to the SDR was present at the latest follow-up, although in only 2 patients (1.3%) this dysfunction was a definite complication of the rhizotomy. The use of pudendal monitoring and/or cutting less than 50% of the S2 roots may have been associated with a lower incidence of long-term sphincter dysfunction. Data about the nature and frequency of complications may result in further modifications to the SDR procedure, and is critical for counseling about SDR and alternative options available for treatment of the child with spastic cerebral palsy. [ABSTRACT FROM AUTHOR]

The aim of this study was to clarify the morphological characteristics of the communicating branch between the spinal accessory nerve and the anterior root of the first cervical nerve (McKenzie branch), a structure severed during intradural selective rhizotomy for treatment of spasmodic torticollis. The right and left sides of 50 upper cervical segments of spinal cords were dissected and examined under a surgical microscope. Seven of the total 100 samples were found to have the McKenzie branch. Two types of McKenzie branch, which run close to the vertebral artery, were also identified, which might be helpful for improving the surgical results of intradural selective rhizotomy. [ABSTRACT FROM AUTHOR]

The article discusses the study about the surgical approaches to trigeminal neuralgia based on other factors such as age and medical comorbid factors. These include Microvascular decompression for the root-entry zone of trigeminal, Percutaneous microballoon compression involves passing microballoon catheter and Percutaneous retrogasserian glycerol rhizotomy.

Objective The aim of this study was to describe the anatomic trajectory of the extracranial needle for percutaneous rhizotomy and correlate this with structures at risk during such a procedure. Methods Six sides from 3 frozen fresh Caucasian heads were used in this study. Hartel anatomic landmarks for percutaneous trigeminal rhizotomy procedures were used. A free hand technique was then used, and intraprocedural visualization of the needle was performed with fluoroscopy. When the procedure was completed, the face was dissected along with the needle pathway up to the foramen ovale in order to evaluate for any damaged structures. Results On all sides, the needle passed lateral to the buccinator muscle and near the parotid duct to then pierce the superior head of the lateral pterygoid muscle to enter the infratemporal fossa. This placed the needle near the buccal nerve on all sides, although no direct injury was noted. Although very near, no branches of the facial nerve or artery were damaged. On 1 side, the maxillary artery was pierced. Conclusions To our knowledge, this is the first study to describe the detailed extracranial anatomic needle pathway using the Hartel approach. Such data might help surgeons better recognize potential complications from such procedures. [ABSTRACT FROM AUTHOR]

Study design: Case report. Objectives:To show the feasibility of sacral deafferentation as a salvage procedure to resolve life-threatening autonomic dysreflexia. Setting: Paraplegic center in Switzerland. Method and results: In a patient presenting with acute autonomic dysreflexia leading to cardiac arrest, sacral deafferentation could prevent further episodes of autonomic dysreflexia. Conclusion:In patients with spinal cord injury, autonomic dysreflexia can be triggered by the bladder even without detrusor overactivity. In these cases, sacral deafferentation may be the only salvage procedure to prevent further serious health problems. Thus, this procedure augments the armamentarium of urologists dealing with patients suffering from spinal cord lesions. [ABSTRACT FROM AUTHOR]

The author discusses the article "Functional decline in children undergoing selective dorsal rhizotomy after age 10," by B. A. MacWilliams and colleagues and published within the issue. It focuses on how two similar groups of adolescents with cerebral palsy underwent selective dorsal rhizotomy (SDR) and single event multi-level surgery (SEMLS). The study also discusses how SDR is more likely to be appropriate in early childhood and that it may be generally inappropriate in adolescence when other factors apart from spasticity are more important.

The author discusses the article "Does loss of spasticity matter? A 10-year follow-up after selective dorsal rhizotomy in cerebral palsy," by K. Tedroff and colleagues and published in the issue. The study followed up on 15 patients ten years after they underwent selective dorsal rhizotomy (SDR) and assessed outcome measures such as the Modified Ashworth Scale (MAS), Gross Motor Function Measure 88 (GMFM-88) and the Wilson gait scale. The authors also found that the spasticity-reducing effect of SDR did not seem to improve long-term functioning.

A personal narrative is presented which explores the author's experience performing a routine lumbar radiofrequency rhizotomy.