Role of intraoperative electrophysiological monitoring during ...

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Introduction: In the developing world, the prevalence of cerebral palsy (CP) is not well established but estimates are 1.5-5.6 cases per 1000 live births. 20 Selective dorsal rhizotomy (SDR) is a widely practiced form of surgical treatment for children with spasticity of cerebral origin, predominately due to cerebral palsy. 3 In SDR, partial sectioning of the dorsal roots from L2 to S1 or S2 is usually performed. [15, 22, 28] Clinically significant improvements in functional [4-8, 10, 12, 14, 15, 21, 25, 26, 28] outcome have been reported by several groups. Percentage of sectioned rootlets is guided by clinical findings and interoperative electrophysiological monitoring (EPM). [10, 13, 29] Intraoperative monitoring uses continuous recording of electromyography (EMG) in lower limb muscles and anal sphincter, and its response to simulation of selected rootlets. [13, 24, 26] Intraoperative electrophysiological (EP) stimulation can be valuable in achieving a balance between elimination of spasticity and [13, 26, 27, 29] preservation of underlying strength. EMG monitoring helps also to avoid complications, especially sphincter paralysis and sensory loss in extremities. 2 There are significant variations among centers in many aspects of the EP guidance and applied criteria for dorsal rhizotomies. [13, 24, 26, 27] The aim of this study is to evaluate the applied techniques of EPM used during SDR for treating spasticity in Egyptian children with cerebral palsy and its rule for preservation of sphincters’ innervation. 2
Methods: Twenty-two children (fourteen boys and eight girls) with a diagnosis of spastic cerebral palsy underwent selective dorsal rhizotomies (SDR), using intraoperative EMG recording, between May 2006 and September 2009. All patients were presented to neurology or neurosurgery outpatient clinic at Ain Shams University Hospitals with intractable spasticity (showing progressively decreasing or even no response to medical and/or physical therapy). The patients' ages at surgery ranged from 4 to 15 years, with a median age of 8.3 years. Twelve of them were diplegic (54%), 8 of the diplegic children (36%) were able to control bowel at time of surgery. None of the quadriplegic children (46%) was able to control bowel at time of surgery. Informed consents were taken from patients' parents for surgery and research. The inclusion criteria were significant lower extremity spasticity which interfered with passive movement, positioning and care and was intractable to other treatment modalities. Children with severe fixed contractures at multiple lower limb joints, dyskinesia, truncal hypotonia and radiological (MRI) abnormality of the basal ganglia were excluded and they did not undergo the procedure. Children underwent full preoperative clinical assessment including history taking (especially perinatal and developmental history and bowel control); general and neurological examination; and assessment of power of quadriceps (using Medical Research Council Scale (MRCS) 30 ); range of movement (ROM) of hip abduction (using manual goniometer 11 ); and tone grading of adductor muscles (using the modified Ashworth scale (MAS) 1 ). Conventional electromyography for preoperative evaluation of pelvic muscles, anal and urethral sphincters. Routine laboratory investigations and MRI brain were conducted for all children. 3
Page 1: Role of intraoperative electrophysi
Page 5 and 6: Table 1: Grading of Motor Responses
Page 7 and 8: Results: From the twenty-two childr
Page 9: Discussion: The concept of SDR is i
Page 12 and 13: References: 1. Bohannon RW, Smith M

Role of intraoperative electrophysiological monitoring during ...

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