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Frequency distribution in intraoperative stimulation-evoked EMG responses during selective dorsal rhizotomy in children with cerebral palsy-part 2: gender differences and left-biased asymmetry.

ABSTRACT: INTRODUCTION:Spinal reflexes reorganize in cerebral palsy (CP), producing hyperreflexia and spasticity. CP is more common among male infants, and gender might also influence brain and spinal-cord reorganization. This retrospective study investigated the frequency of higher-graded EMG responses elicited by electrical nerve-root stimulation during selective dorsal rhizotomy (SDR), prior to partial nerve- root deafferentation, considering not only segmental level and body side, but also gender. METHODS:Intraoperative neuromonitoring (IOM) was used in SDR to pinpoint the rootlets most responsible for exacerbated stimulation-evoked EMG patterns recorded from lower-limb muscle groups. Responses were graded according to an objective response-classification system, ranging from no abnormalities (grade 0) to highly abnormal (grade 4+), based on ipsilateral spread and contralateral involvement. Non-parametric analysis of data with repeated measures was primarily used in investigating the frequency distribution of these various EMG response grades. Over 7000 rootlets were stimulated, and the results for 65 girls and 81 boys were evaluated, taking changes in the composition of patient groups into account when considering GMFCS levels. RESULTS:The distribution of graded EMG responses varied according to gender, laterality, and level. Higher-graded EMG responses were markedly more frequent in the boys and at lower segmental levels (L5, S1). Left-biased asymmetry in higher-graded rootlets was also more noticeable in the boys and in patients with GMFCS level I. A close link was observed between higher-grade assessments and left-biased asymmetry. CONCLUSIONS:Detailed insight into the patient's initial spinal-neurofunctional state prior to deafferentation suggests that differences in asymmetrical spinal reorganization might be attributable to a hemispheric imbalance.

SUBMITTER: Wolter S

PROVIDER: S-EPMC7434795 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Frequency distribution in intraoperative stimulation-evoked EMG responses during selective dorsal rhizotomy in children with cerebral palsy-part 2: gender differences and left-biased asymmetry.

Wolter Simone S Haberl Hannes H Spies Claudia C Sargut T Alp TA Martin John H JH Tafelski Sascha S van Riesen Anne A Küchler Ingeborg I Wegner Brigitte B Scholtz Kathrin K Thomale Ulrich-W UW Michael Theodor T Murphy James F JF Schulz Matthias M

Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 20200625 9

<h4>Introduction</h4>Spinal reflexes reorganize in cerebral palsy (CP), producing hyperreflexia and spasticity. CP is more common among male infants, and gender might also influence brain and spinal-cord reorganization. This retrospective study investigated the frequency of higher-graded EMG responses elicited by electrical nerve-root stimulation during selective dorsal rhizotomy (SDR), prior to partial nerve- root deafferentation, considering not only segmental level and body side, but also gen ...[more]

PMID: 32588175

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Project description:BackgroundSelective dorsal rhizotomy (SDR) is an irreversible surgical procedure involving the division of selected sensory nerve roots, followed by intensive physiotherapy. The aim is to improve function and quality of life in children with cerebral palsy and a Gross Motor Function Classification System (GMFCS) level of II or III (walks with or without assistive devices, respectively). We assessed gross motor function before and after SDR and postoperative quality of life in a study commissioned by NHS England.MethodsWe did a prospective observational study in five hospitals in England who were commissioned to perform SDR on children aged 3-9 years with spastic diplegic cerebral palsy. The primary outcome was score changes in the 66-item Gross Motor Function Measure (GMFM-66) and seven domains of the Cerebral Palsy Quality of Life Questionnaire ([CP-QoL] social wellbeing and acceptance, feelings about functioning, participation and physical health, emotional wellbeing and self-esteem, access to services, family health, and pain and impact of disability) from before to 24 months after SDR.FindingsFrom Sept 4, 2014, to March 21, 2016, 137 children underwent SDR. The mean age was 6·0 years (SD 1·8). The mean GMFM-66 score increased after SDR with an annual change of 3·2 units (95% CI 2·9 to 3·5, n=137). Of the seven CP-QoL domains, five showed significant improvements over time: feelings about functioning mean annual change 3·0 units (95% CI 2·0 to 4·0, n=133), participation and physical health 3·9 units (2·5 to 5·3, n=133), emotional wellbeing and self-esteem 1·3 units (0·2 to 2·3, n=133), family health 2·0 units (0·7 to 3·3, n=132), and pain and impact of disability -2·5 units (-3·9 to -1·2, n=133). 17 adverse events were reported in 15 children, of which none were severe and 15 (88%) resolved.InterpretationSDR improved function and quality of life in the 24 months after surgery in children with cerebral palsy classified as GMFCS levels II and III. On the basis of these findings, an interim national policy decision was made that SDR would be funded for eligible children in England from 2018.FundingNational Institute for Health and Care Excellence, National Institute for Health Research Biomedical Research Centre, NHS England.

Project description:IntroductionSelective dorsal rhizotomy (SDR) is a neurosurgical intervention intended to permanently reduce spasticity in the lower limbs and improve mobility in selected children with cerebral palsy (CP). Despite SDR having been performed worldwide for the past 30 years, there is moderate quality of evidence that SDR is effective in reducing spasticity with low to very low evidence of its effectiveness in improving gait, function and participation, using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Published studies have described outcomes for groups that differ in selection, surgical technique and postoperative rehabilitation making it difficult for clinicians to use this information to advise families on best management. There is substantial community interest in SDR. A small number of children with CP undergo SDR in Australia each year and some families seek the intervention at international sites. Capturing clinical outcomes and adverse event (AE) data for Australian children undergoing SDR will provide clinicians with information to help guide families considering SDR.Methods and analysisThe Australian SDR Research Registry is a national registry of multidimensional outcomes for Australian children undergoing SDR in an Australian or overseas centre. Data will be collected for up to 10 years following the surgery, to include surgery and admission details, surgical and long-term AEs, and outcome measures across the body structure and functions, activity and participation domains of the International Classification of Functioning, Disability and Health. Data will be collected at baseline, during inpatient admission and at 1, 2, 5 and 10 years post. The aim of collecting these data is to improve understanding of short-, medium- and long-term outcomes and adverse effects of the intervention.Ethics and disseminationThis study was approved by the individual Human Research and Ethics committees at the five Australian tertiary hospitals involved. Results will be disseminated via peer-reviewed publications and conference presentations.Trial registration numberACTRN12618000985280; Pre-results.

Project description:Background: Postherpetic occipital neuralgia (PHON) is a neuropathic pain condition that usually presents as paroxysmal pain that is stabbing in nature.[5,7] It involves the occiput and posterior scalp in the distribution of the greater and/or lesser occipital nerves. It usually develops after an episode of shingles.[5,7] Treatment usually first consists of medical therapy and then progresses to invasive treatment (e.g., peripheral nerve stimulation, spinal cord epidural stimulation, C2-C3 ganglionectomy, or dorsal root entry zone [DREZ] rhizotomy).[1-4,6] Here, we present a case of persistent PHON that was treated with C1-C3 DREZ. Case Description: A 37-year-old female had a history of several episodes of shingles involving the left neck and occiput; they resolved after treatment with valacyclovir. Subsequently, however, she developed severe lancinating pain of the neck and the occiput and was diagnosed with PHON. Initially, she was treated with oxcarbazepine but was stopped due to cognitive side effects. She then had a cervical spinal cord stimulator implanted which produced relief for several years; it was later removed due to breakage of the electrodes. She then underwent a left- sided C1-C2 hemilaminectomy with a C1-C3 DREZ procedure.[1] Postoperatively, she had immediate resolution of her pain, but developed a new left hemiparesis (4+/5), accompanied by imbalance, decreased sensation to light touch, and loss of proprioception. On 6 weeks follow up, the pain was still relieved, and she exhibited significant improvement in her left-sided hemiparesis and hemisensory deficit to which returned to baseline. Similar outcome was maintained at four months follow up. Conclusion: Although high cervical DREZ lesions may effectively treat post herpetic/occipital neuralgia that fails other measures, there may be associated major neurological morbidity that makes this procedure acceptable as a salvage option, and after clearly explaining the risks to the patient.

Dataset Information

Frequency distribution in intraoperative stimulation-evoked EMG responses during selective dorsal rhizotomy in children with cerebral palsy-part 2: gender differences and left-biased asymmetry.

Publications

Frequency distribution in intraoperative stimulation-evoked EMG responses during selective dorsal rhizotomy in children with cerebral palsy-part 2: gender differences and left-biased asymmetry.

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