Intrathecal Baclofen
- Indication
- Oral baclofen doses are high enough to cause side effects
- Global spasticity
- Spasticity due to spinal cord lesion
- Painful spasms are present
- Due to advanced multiple sclerosis or after spinal cord injury
- Physical therapy and rehabilitation do not succeed in preventing harmful spasticity from appearing.
- Spasticity due to brain stem lesions
- Spasticity due to cerebral lesion
- Cerebral palsy patients
- Adult > children
- If able to walk, adequate doses (i.e., ones effective on the excess of tone that do not produce motor weakness) are difficult to find.
- Dystonia
Selective dorsal rhizotomy (SDR)
- SDR is a technique for permanently reducing/ removing abnormal tone in the legs.
Indicated
- Cerebral palsy, where the brain injury is stable and not progressive. (mainly children)
- Careful MDT assessment is required when considering SDR.
- GMFCS 2/3 where CP spasticity affecting legs that is interfering with mobility
- GMFCS 4/5 where CP spasticity is affecting daily care of the patient
- Post trauma
- When harmful spasticity affects the whole limb in paraplegic patients
Contraindication
- CP patients
- Progressive neurodegenerative condition as the benefits will be short- lived.
- If Dystonia will worsen after SDR.
- Significant upper limb involvement.
- More disabled GMFCS 4– 5 group is under debate.
Technique
- It involves dissecting and transecting a portion of the lumbar sensory nerve roots to disrupt the abnormal reflex feedback loop.
- Complete transection of lumbar sensory roots, causing numbness and proprioceptive deficits, and hence increased mobility difficulty.
- Using neurophysiology to select the most abnormal roots prior to sectioning them.
- The surgery is performed via an L1 laminectomy over the conus.
- Attempts to selectively
- Interrupt the small nociceptive fibers (situated laterally and centrally respectively),
- Sparing the large leminiscal fibers, which are regrouped medially.
- The L1– S1 dorsal (sensory) roots are separated from the motor roots.
- Each root is divided into three rootlets, tested with intraoperative neurophysiology to find the most abnormally active rootlets and then two out of every three rootlets are divided
- Therefore, approximately two- thirds of each sensory root is divided from L1 to S1.
- Anal sphincter monitoring is commonly used to help reduce risk of incontinence.
- The conus is exposed and L2-S2 dorsal roots separated from motor roots using a silastic sheet, Each dorsal root is divided into 3-5 fascicles using a Scheer needle, and each of these is examined with EMG.
- Only rootlets which display a significant EMG response after stimulation are sectioned, while others are spared.
- L1 rhizotomy is required to reduce spasticity in hip flexors.
Post op
- Once the spasticity is removed/reduced by SDR, the underlying muscle weakness is revealed.
- This requires intensive physiotherapy to build strength.
- 3 weeks’ intensive daily physiotherapy, prior to discharge.
- Then follow up with ongoing regular community physiotherapy
- Epidural catheter
Risks and unwanted effects of SDR
- The standard risks of any neurosurgical intradural spinal procedure
- Paralysis, numbness, and incontinence.
- Intraoperative neurophysiology helps reduce this risk to a minimum.
Outcomes
- Long- term benefits from this procedure both for spasticity control and also reducing rates of orthopaedic surgery requirement too
- The percentage of rootlets cut in SDR is linked to the degree of spasticity control, with less than 50% rootlet section associated with increased return of spasticity.
Peripheral neurotomies
- Partial sectioning of motor branches or fascicles of the nerve that innervates the targeted muscle
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