SURGICAL MANAGEMENT OF INTRACTABLE SPASTICITY

Abstract

Background: Spasticity is motor disorder characterized by a velocity dependent incease in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome. Objectives: Comparison between spinally based surgical procedure and peripherally based surgical procedures in management of hypertonia in the lower limbs of pediatrics. Patients and methods: Over 3-year period selected, fifty children with intactable, lower limb spasticity were prospectively treated by selective neurotomy (group A, 35 patients) and dorsal rhizotomy (group B, 15 patients) with 6-month follow up. This study aimed at evaluation of the results of the surgical procedures utilized. Results: The operative duration was longer with dorsal rhizotomy mean of 292.2 minutes versus 76.8 minutes with neurotomy (p = 0.001). The hospital stay was longer with dorsal rhizotomy with mean of 6.2 days versus 1.7 days with neurotomy (p = 0.001). Of the total rhizotomies, 24/45 muscles exhibited significant improvement with G5 + G4 power versus 6/45 muscles preoperative (p = 0.001). Marked improvement of the muscle tone following neurotomies as 52/75 muscles had normal tone and 23/72 muscles had mild spasticity following neurotomies (p = 0.001). Marked improvement of the muscle tone following dorsal rhizotomies (p = 0.001). Selective peripheral neurotomy produced excellent improvement of the preoperative restricted joint movement (p = 0.001). The mean ankle dorsiflexion after neurotomies of ankle plantar flexors was 18.77° representing 94% of normal range movement versus 7.2° preoperatively representing 36% of normal movement with improvement rate of 161.1%. Dorsal rhizotomies had excellent improvement of the preoperatively restricted joint movement (p = 0.001). 18/35 patients were ambulatory following neurotomies of the spastic lower limb muscles versus 7/35 patients preoperatively. Only a patient still could not walk after neurotomy versus 10/35 patients preoperatively (p = 0.001). 11/15 patients were ambulatory following dorsa rhizotomies versus 2/15 patients preoperatively (p = 0.001) of whom 3/11 patients had normal walk G5 (p = 0.001). 29/35 patients had no or occasionally mild lower limb pain following neurotomies versus 4/35 patients preoperatively (p = 0.001). A patient still had frequent severe pain following neurotomies versus 26/35 patients had G3, G4 pain which was of high significance. 13/15 patients had no or occasionally mild pain in lower limbs following dorsal rhizotomy versus 2/15 patients preoperatively (p = 0.001). The H/M ratio following neurotomies showed marked reduction of the ratio, the mean was 0.14 versus 0.63 preoperatively. The H/M ratio following dorsal rhizotomies showed marked reduction of the ratio, the mean was 0.11 versus 0.58 preoperatively. Conclusion: Both neurotomies and dorsal rhizotomies were safe surgical procedures and were provided with good improvement in respect of: muscle power, severity of spasticity, patient’s ambulation, gait, range of joint movement, associated pain, functional disability and nerve excitability with no significnat diffference between both procedures. Keywords: intractable, spasticity