Search

BACKGROUND: Lower-extremity spasticity and impaired gait control after central nervous system injury are challenging to improve, because spasticity limits residual motor control while providing mechanical support. Highly selective partial neurectomies (HSPNs) can substantially reduce spasticity but may have greater risks in patients with complex lower-extremity spastic gait. OBJECTIVE: To examine the potential of ultrasound- and stimulation-guided highly selective motor nerve blocks (HSMNBs) to assess the potential impact of reduced spasticity on gait. METHODS: In this retrospective series, six patients underwent HSMNBs with movement assessment before and after the block. Range of motion, strength, position angles, surface electromyography, lower limb kinematics, and patient satisfaction were assessed. RESULTS: Pre- and post-HSMNB movement analysis yielded dichotomous gait kinematics, which facilitated surgical decisions. Of the 59 metrics evaluated, 82% demonstrated a positive improvement post-block (62% improved more than one standard deviation (SD) of typically developing means, 49% improved > 2 SD) and 16% demonstrated a negative change (2% worsened > 1 SD). CONCLUSION: HSMNB provided clear efficacy in changing clinical, surface electromyography, and gait parameters. Movement analysis provided clear and robust objective and patient-centered evidence for surgical guidance. This protocol may provide utility in evaluation of patients being considered for HSPNs for complex spastic gait patterns. [ABSTRACT FROM AUTHOR]

Aim: To compare function and gait in a group of children older than most children who received selective dorsal rhizotomy (SDR) with age- and function-matched peers who received either orthopedic surgery or no surgical intervention. Method: A retrospective study examined ambulatory children with diplegic cerebral palsy, aged between 10 years and 20 years and categorized in Gross Motor Function Classification System (GMFCS) levels I or II. Three groups were considered: (1) children who had selective dorsal rhizotomy (n = 8; two females, six males; mean age 15y 4mo at SDR, 16y 8mo at follow-up); (2) children who had orthopedic surgery (n = 9; three females, six males; mean age 14y 6mo at SDR, 15y 1mo at follow-up), and (3) children who had no surgical intervention (n = 9; two females, seven males; mean age 15y 6mo at follow-up). Longitudinal measures of gait analysis (velocity, gait deviation index, and gait variable scores) and gross motor function (GMFCS level, Gross Motor Function Measure scores, and centiles) were examined. Results: No significant differences were found between changes in gait comparing rhizotomy with orthopedic surgery; however, the group who received orthopedic surgery demonstrated improved gait compared with the group without surgical intervention. Longitudinal comparisons of gross motor function demonstrated a decrease in the group who received SDR. Between-group analysis of outcomes also demonstrated worse outcomes of the SDR group compared with the orthopedic surgery group and with the no surgical intervention group. Interpretation: Rhizotomy in older children was associated with functional declines compared with similar children who had no surgery and with those who underwent orthopedic surgery. This suggests that age greater than 10 years might be a contraindication for SDR if the goal is to improve motor skills.

Aim: To understand the long‐term effects of comprehensive spasticity treatment, including selective dorsal rhizotomy (SDR), on individuals with spastic cerebral palsy. Method: This was a pre‐registered, multicenter, retrospectively matched cohort study. Children were matched on age range and spasticity at baseline. Children at one center underwent spasticity treatment including SDR (Yes‐SDR, n=35) and antispastic injections. Children at two other centers had no SDR (No‐SDR, n=40 total) and limited antispastic injections. All underwent subsequent orthopedic treatment. Participants returned for comprehensive long‐term assessment (age ≥21y, follow‐up ≥10y). Assessment included spasticity, contracture, bony alignment, strength, gait, walking energy, function, pain, stiffness, participation, and quality of life. Results: Spasticity was effectively reduced at long‐term assessment in the Yes‐SDR group and was unchanged in the No‐SDR group. There were no meaningful differences between the groups in any measure except the Gait Deviation Index (Yes‐SDR + 11 vs No‐SDR + 5) and walking speed (Yes‐SDR unchanged, No‐SDR declined 25%). The Yes‐SDR group underwent more subsequent orthopedic surgery (11.9 vs 9.7 per individual) and antispastic injections to the lower limbs (14.4 vs <3, by design). Interpretation: Untreated spasticity does not cause meaningful impairments in young adulthood at the level of pathophysiology, function, or quality of life. This original article is commented by Chambers on page 532 of this issue. [ABSTRACT FROM AUTHOR]