Nonselective lumbosacral ventral-dorsal rhizotomy for the management of lower-limb hypertonia in nonambulatory children with cerebral palsy.

OBJECTIVE: Children with cerebral palsy (CP) often experience medically refractory hypertonia, for which there are surgical therapies including neuromodulation and rhizotomy. Traditional surgical treatment for medically refractory mixed hypertonia or dystonia includes intrathecal baclofen pumps and selective dorsal rhizotomy. A nonselective lumbosacral ventral-dorsal rhizotomy (VDR; ventral and dorsal roots lesioned by 80%-90%) has the potential to address the limitations of traditional surgical options. The authors highlighted the institutional safety and efficacy of nonselective lumbosacral VDR for palliative tone management in nonambulatory patients with more severe CP. METHODS: The authors performed a retrospective analysis of patients who had undergone lumbosacral VDR between 2022 and 2023. Demographic factors, clinical variables, and operative characteristics were collected. The primary outcomes of interest included tone control and quality of life improvement. Secondary outcome measures included, as a measure of safety, perioperative events such as paresthesias. Postoperative complications were also noted. RESULTS: Fourteen patients (7 female) were included in the study. All patients had undergone a T12-L2 osteoplastic laminoplasty and bilateral L1-S1 VDR. Nine patients had quadriplegic mixed hypertonia, 4 had quadriplegic spasticity, and 1 had generalized secondary dystonia. Following VDR, there was a significant decrease in both lower-extremity modified Ashworth Scale (mAS) scores (mean difference [MD] -2.77 ± 1.0, p < 0.001) and upper-extremity mAS scores (MD -0.71 ± 0.76, p = 0.02), with an average follow-up of 3 months. In the patient with generalized dystonia, the lower-extremity Barry-Albright Dystonia Scale score decreased from 8 to 0, and the overall score decreased from 32 to 13. All parents noted increased ease in caregiving, particularly in terms of positioning, transfers, and changing. The mean daily enteral baclofen dose decreased from 47 mg preoperatively to 24.5 mg postoperatively (p < 0.001). Three patients developed wound dehiscence, 2 of whom had concurrent infections. CONCLUSIONS: Lumbosacral VDR is safe, is effective for tone control, and can provide quality of life improvements in patients with medically refractory lower-limb mixed hypertonia. Lumbosacral VDR can be considered for palliative tone control in nonambulatory patients with more severe CP. Larger studies with longer follow-ups are necessary to further determine safety and long-term benefits in these patients.

Surgical Sphincter Saving Approach and Topical Nifedipine for Chronic Anal Fissure with Hypertonic Internal Anal Sphincter.

PURPOSE: The role of augmented internal anal sphincter (IAS) tone in the genesis of posterior chronic anal fissure (CAPF) is still unknown. Lateral internal sphincterotomy is the most employed surgical procedure, nevertheless it is burdened by high risk post-operative anal incontinence. The aim of our study is to evaluate results of sphincter saving procedure with post-operative pharmacological sphincterotomy for patients affected by CAPF with IAS hypertonia. Methods: We enrolled 30 patients, undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement; all patients received topical administration of nifedipine 0.3% and lidocaine 1.5% ointment-based therapy before and for 15 days after surgery. The primary goal was patient's complete healing and the evaluation of incontinence and recurrence rate; the secondary goal included the evaluation of manometry parameters, symptom relief and complications related to nifedipine and lidocaine administration. Results: All wounds healed within 40 days after surgery. We didn't observe any de novo postoperative anal incontinence case. We reported 2 cases of recurrences, healed after conservative therapy. We didn't report any local complications related to the administration of the ointment therapy; with whom all patients reported a good compliance. Conclusions: Fissurectomy and anoplasty with V-Y cutaneous advancement flap and topical administration of nifedipine and lidocaine, is an effective treatment for CAPF with IAS hypertonia.

Treatment of upper limb extensor hypertonia: case report.

We describe a case of wrist and finger extensor hypertonia treated successfully by division of the hypertonic musculotendinous units and functional replacement using conventional tendon transfer techniques for radial nerve palsy. This report emphasizes the important role of regional nerve blocks in assessment and in operative decision making in a case of extensor hypertonia of the upper limb.

Navigated Radiofrequency Ablation Peripheral Rhizotomy for Lumbosacral Hypertonia in a Nonambulatory Patient With Spinal Fusion: Indications, Surgical Techniques, and Lessons Learned.

BACKGROUND AND OBJECTIVES: Radiofrequency ablation (RFA) is a destructive therapy which causes target tissue destruction by application of a thermal dose. Neurosurgical applications of RFA are well-described for myriad chronic pain and movement disorder diagnoses. In fact, RFA pallidotomy and thalamotomy are the initial procedures from which the field of neurosurgical management for movement disorders emerged. RFA rhizotomy for post-traumatic spasms was popular in the 1970s and 1980s, although it was largely abandoned after the invention and Food and Drug Administration approval of intrathecal baclofen therapy. RFA has not been described as a primary treatment of hypertonia in nonambulatory children. METHODS: We report a case of computer-navigated, nonselective RFA peripheral rhizotomy for a nonambulatory child with a history of severe scoliosis and spinal fusion, where an open rhizotomy was technically impractical. RESULTS: Navigation to and ablation of the bilateral L1-L5 peripheral nerves with this approach was successful, and the patient experienced bilateral lower extremity tone improvement. CONCLUSION: We use this case to highlight considerations in indications, our applied operative technique, and lessons learned from this novel application of RFA peripheral rhizotomy in children.

Botulinum toxin-induced relaxation of the sphincter of Oddi may select patients with acalculous biliary pain who will benefit from cholecystectomy.

BACKGROUND: Acalculous biliary pain may be due to gallbladder dyskinesia or sphincter of Oddi (SO) hypertension. These two etiologies are difficult to differentiate because the gallbladder ejection fraction may be low and the SO manometry results may be abnormal in both. Cholecystectomy is advised for patients with biliary dyskinesia, but it often exacerbates biliary pain for patients with SO hypertension. The biliary pain response to relaxation of the SO using botulinum toxin may indicate appropriate treatment for patients with acalculous biliary pain. METHODS: The protocol-based management of 25 patients with acalculous biliary pain and two gallbladder ejection fraction estimations less than 40% who had 100 units of botulinum toxin injected into their SO musculature to relax the sphincter has been audited. Patients whose pain was temporarily relieved after botulinum toxin injection were offered endoscopic biliary sphincterotomy, and patients who failed to experience benefit after botulinum toxin injection were assessed for laparoscopic cholecystectomy. RESULTS: Botulinum toxin was injected into the SO of 25 patients, with 11 experiencing temporary biliary pain relief. Of these patients, 10 consented to undergo endoscopic biliary sphincterotomy, with relief of biliary pain in all cases. A total of 14 patients had a negative response to botulinum toxin treatment, with 10 of these patients progressing to laparoscopic cholecystectomy, which resulted in biliary pain relief in eight cases. CONCLUSION: Botulinum toxin-induced relaxation of the SO may help to direct appropriate therapy for patients with acalculous biliary pain. The data from this study supports the establishment of a randomized clinical trial.

Fissurectomy combined with anoplasty and injection of botulinum toxin in treatment of anterior chronic anal fissure with hypertonia of internal anal sphincter: a pilot study.

BACKGROUND: In patients affected by anterior chronic anal fissure (CAAF) with hypertonia of the internal anal sphincter (IAS), the role of IAS hypertonia remains unclear. The aim of this study was to evaluate the efficacy of fissurectomy combined with advancement flap and IAS injection of botulinum toxin in healing the CAAF with hypertonia of IAS resistant to medical therapy. METHODS: Ten consecutive patients were enrolled. Anorectal manometry was performed preoperatively and at 6 months. CAAF with hypertonia was defined as those associated with maximum resting pressure (MRP) values higher than 85 mmHg. All patients underwent fissurectomy and anoplasty with advancement skin flap combined with the intrasphincter injection of 30 UI of botulinum toxin. Complete healing, MRP changes, relief of symptoms and immediate and long-term complications were recorded. RESULTS: Complete healing was observed in all patients within 30 days of the operation. The intensity and duration of pain post-defecation was reduced significantly starting from the first defecation. In all subjects, the preoperative MRP values were significantly reduced at 6 months. One month after surgery, three patients reported anal incontinence, two of them had complained preoperatively. The only postoperative complications were minor. CONCLUSIONS: Fissurectomy combined with advancement flap and intrasphincter injection of botulinum toxin results in complete healing, significant MRP reduction and full relief of symptom in all patients, thus it represents a valid procedure in preventing the occurrence of anal incontinence.

Conus-level combined dorsal and ventral lumbar rhizotomy for treatment of mixed hypertonia: technical note and complications.

Combined dorsal and ventral rhizotomy is an effective treatment for patients with concurrent spasticity and dystonia, with the preponderance of complaints relating to their lower extremities. This operative approach provides definitive relief of hypertonia and should be considered after less-invasive techniques have been exhausted. Previously, the surgery has been described through an L1-S1 laminoplasty. In this series, 7 patients underwent a conus-level laminectomy for performing a lumbar dorsal and ventral rhizotomy. Technical challenges included identifying the appropriate-level ventral roots and performing the procedure in children with significant scoliosis. Techniques are described to overcome these obstacles. The technique was found to be safe, with no infections, CSF leaks, or neurogenic bladders.

[Treatment of neurogenic detrusor hyperactivity: detrusor myomectomy]. / Traitement de l'hyperactivité détrusorienne neurologique: détrusoromyomectomie.

This article reviews the technical principles and results of bladder auto-augmentation by detrusor myomectomy. This technique has been regularly presented since the 1970s as an alternative to enterocystoplasty, especially in children. This review of the literature demonstrates that the current results of bladder auto-augmentation are highly controversial. Most series of patients with neurogenic bladder with a relatively long mean follow-up (about 6 years) conclude on the inefficacy of this technique on both symptoms and objective parameters (urodynamic results). It therefore seems difficult to recommend bladder auto-augmentation by detrusor myomectomy as a reliable alternative to enterocystoplasty, which remains the reference technique.

[Clinical efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter in the treatment of puborectalis syndrome with high anal pressure].

OBJECTIVE: To explore the efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter(IAS) in the treatment of puborectalis syndrome with high anal pressure. METHODS: Twenty-five cases of puborectalis syndrome with high anal resting pressure in the preoperative examination received the operation of partial resection of puborectalis combined with mutilation of IAS in Zhongnan Hospital of Wuhan University between January 2013 and May 2015. The position of puborectalis was confirmed by touching with the exposure under the transfixion device, and a transverse incision was made by electrotome between 3 and 5 o'clock direction of puborectalis, then partial puborectalis was lifted by vessel clamp at 5 o'clock direction, and about 0.5 cm of muscular tissue was resected. Between 8 to 10 o'clock direction of anal tube, about 1 cm length of transverse incision was made by electrotome, then partial IAS was lifted by vessel clamp and cut off. Preoperative and postoperative 3-month anorectal manometry and defecography were carried out. Wexner constipation score and Cleveland Clinic incontinence score were implemented before surgery and 3, 6, 12 months after operation. This study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-ORB-16007695). RESULTS: Of the 25 cases, 18 were male and 7 were female, the average age was 55 years old and the average course of disease was 9 years. Compared with pre-operation, the postoperative 3-month anal resting pressure and maximal squeeze pressure were significantly decreased [(53.56±9.05) mmHg vs. (92.44±7.06) mmHg, (142.80±20.35) mmHg vs. (210.88±20.56) mmHg, respectively, both P=0.000]; anorectal angulation at resting state and forced defecation state increased significantly [(102.32±4.96)degree vs. (95.88±4.01)degree, (117.88±5.95)degree vs. (89.52±3.25)degree, respectively, both P=0.000]. Wexner constipation score of postoperative 3-month, 6-month, 12-month (8.28±3.91, 7.40±3.64 and 8.04±4.74) was significantly lower than the preoperative score (16.00±3.69, all P<0.05), while the score was not significantly different among 3 time points after operation (P>0.05). Cleveland Clinic incontinence score was 0 at postoperative 6 and 12 months, and revealed 20 cases were effective among all the surgical patients(80%). CONCLUSION: Partial resection of puborectalis combined with mutilation of internal anal sphincter can effectively reduce anal pressure and improve symptoms of outlet obstruction, which is an effective method in the treatment of puborectalis syndrome with high anal pressure.

Selective posterior rhizotomy and soft-tissue procedures for the treatment of cerebral diplegia.

The results of selective posterior rhizotomy in fifty patients (group I) and of soft-tissue procedures in fifty patients (group II), all 100 of whom had cerebral diplegia and were seen in a private office, were reviewed retrospectively. No effort was made to randomize the treatment, as the selection criteria for the two procedures are different. We evaluated the range of motion and the ability and quality of walking preoperatively and postoperatively as well as the need for additional operative intervention in the two groups. The average age of the patients in both groups was five years (range, three to twelve years in group I and one to thirteen years in group II). The average duration of follow-up in both groups was four years (range, one to six years in group I and one to seven years in group II). Thirty-two patients (64 percent) in group I and forty-one patients (82 percent) in group II were able to walk independently at the latest follow-up examination. Both groups had an over-all improvement in the ranges of abduction of the hips and dorsiflexion of the ankles, a decrease in the flexion contractures of the hips, and more normal popliteal angles; however, with the numbers available, there were no significant differences in these measurements between the two groups at the 0.05 percent confidence level. Despite the overall improvement in range of motion, thirty-one patients in the rhizotomy group subsequently had soft-tissue releases, and twenty-two patients in the soft-tissue-release group had additional operative intervention.

Neurosurgical management of abnormal muscle tone in childhood.

No longer are only a limited number of treatments available to help children and their families deal with childhood hypertonia. It is now possible to provide a child with a treatment specific to his or her muscle tone problems and consequently meet the family's functional goals. The prospects can only improve over the next few years, given the level of interest exhibited by pediatric neuro- and orthopedic surgeons supported by pediatricians, pediatric physical and occupational therapists, pediatric neurologists, and pediatric physiatrists.

Controlled nerve ablation with direct current: parameters and mechanisms.

Spastic hypertonus (muscle over-activity) often develops after spinal cord injury or stroke. Chemodenervating agents such as Botulinum toxin A (BtA) and phenol are often used to treat this condition. We have previously shown that the use of direct current (DC) to create controlled lesions of peripheral nerves may provide a means of reducing spastic hypertonus. Here, we explored a range of stimulation parameters that could be used clinically. Nerves were lesioned with DC in chronically implanted animals and the outcome was tracked over many months. In addition, we used DC to ablate nerves in animals with decerebrate rigidity (an animal model of spastic hypertonus) and we explored the possible mechanisms of DC nerve ablation. We found that nerve ablation with DC was effective in reducing hypertonus. Some stimulation paradigms were more likely to be clinically acceptable than others. Furthermore we showed that nerve regeneration occurs in the months following DC nerve ablation and we demonstrated that the ablation procedure is repeatable, much like BtA treatment. Regarding mechanism, our results did not support the hypothesis that DC caused nerve damage by overactivating sodium channels. Rather, the mechanism of damage seems to be related to changes in pH.

Detrusorectomy reduces the need for augmentation and use of antimuscarinics in children with neuropathic bladders.

OBJECTIVE: To assess bladder behaviour and long-term outcome after detrusorectomy in children. MATERIAL AND METHODS: Between 1990 and 2001, 49 detrusorectomies were performed (mean follow-up: 9.6 years) in children with neuropathic bladders (mean age at surgery: 9.8 years). Urodynamic study (UDS) was done before surgery (pre-UDS) and after surgery (UDS-1 and UDS-2). Bladder behaviour was assessed as good, fair or poor depending on the volume and intravesical pressure. In all patients, oxybutynin and clean intermittent catheterization were used preoperatively. In 24 patients, good bladder compliance and capacity were seen before detrusorectomy. RESULTS: Good and fair outcomes were observed in 35 (71%) patients at 1 year and in 39 (79%) patients 6 years after detrusorectomy. In 30 (60%) patients, there was hardly any difference between the first and second follow-up. In 9 (18%) patients, formal bowel bladder augmentation was necessary: in 6 (12%) because of poor compliance and in 3 because of small bladder volume and incontinence. Seven patients improved during follow-up, 5 of them after resuming oxybutynin. In 11 patients, oxybutynin could be stopped, and in 2 the dosage could be reduced to once daily. CONCLUSIONS: The good short-term results of detrusorectomy generally remain unchanged at long-term follow-up. Detrusorectomy can reduce the need for antimuscarinics, and the need for formal bladder augmentation in selected cases.

Platysmectomy: an effective intervention for facial synkinesis and hypertonicity.

OBJECTIVES: To describe a procedure to permanently address platysmal synkinesis and hypertonicity and to report changes in quality of life associated with platysmectomy using the Facial Clinimetric Evaluation instrument. METHODS: Chemodenervation significantly relieves platysmal synkinesis in almost all patients with significant face and neck synkinesis associated with dynamic facial expressions. We recently began to offer platysmectomy as part of a permanent solution to chronic superficial torticollis-like neck symptoms. For a 10-month period, 24 patients underwent the procedure, and preoperative and postoperative Facial Clinimetric Evaluation data were obtained from 21 patients (88%). RESULTS: In 19 patients, platysmectomy was performed using local anesthesia without sedation. In the remaining 5 patients, platysmectomy was performed using general anesthesia concurrent with free gracilis transfer for smile reanimation. No intraoperative or postoperative complications occurred. Overall, the patients' quality of life significantly improved after platysmectomy (P = .02). CONCLUSION: Platysmectomy is straightforward and seems effective in treating neck synkinesis associated with chronic hypertonic platysmal activity.

Novel repair of tension-free midurethral sling erosion into the urethra.

Severe urinary tract injury is a relatively uncommon occurrence after the placement of a tension-free vaginal tape sling. Bladder perforation is the most common urinary tract injury, but bladder drainage for a few days is usually the only intervention that is required. Urethral erosions of synthetic sling tapes are much rarer, but can result in more significant sequelae such as voiding dysfunction or fistula formation. A 50-year-old woman had an erosion of a synthetic, tension-free midurethral sling through the urethra. She underwent resection of the sling with closure of the urethral defect. The internal urethral sphincter was used during the primary repair to cover the defect because of periurethral scarring and fibrosis. This technique may reduce the risk of subsequent fistula formation, and may be a less invasive alternative to the use of a Martius interposition flap.

Stereological study of collagen and elastic system in the detrusor muscle of bladders from controls and patients with infravesical obstruction.

OBJECTIVE: Compare detrusor muscle of normal and patients with infravesical obstruction, quantifying the collagen and elastic system fibers. MATERIALS AND METHODS: We studied samples taken from bladders of 10 patients whose ages ranged from 45 to 75 years (mean = 60 years), who underwent transvesical prostatectomy for treatment of BPH. Control material was composed of 10 vesical specimens, removed during autopsies performed in cadavers of accident victims, with ages between 18 and 35 years (mean = 26 years). RESULTS: The results of collagen and elastic fibers quantification (volumetric density) demonstrated the following results in percentage (mean +/- standard deviation): collagen in BPH patients = 4.89 +/- 2.64 and 2.32 +/- 1.25 in controls (p < 0.0001), elastin in BPH patients = 10.63% +/- 2.00 and 8.94% +/- 1.19 in controls (p < 0.0001). CONCLUSION: We found that the components of connective tissue, collagen and elastic system fibers are increased in the detrusor muscle of patients with infravesical obstruction, when compared to controls.

Predictive value of initial urodynamic pattern on urinary continence in patients with myelomeningocele.

AIMS: To investigate whether the initial urodynamic pattern may predict urinary continence and the need for adjunctive incontinence surgery in patients with myelomeningocele. PATIENTS AND METHODS: One hundred and twenty-three patients with myelomeningocele were included in our retrospective study. The patients were divided based on the urodynamic pattern at initial evaluation into four categories: overactive detrusor with overactive (spastic) sphincter (group 1, n = 43), overactive detrusor with underactive/acontractile sphincter (group 2, n = 37), underactive/acontractile detrusor with overactive (spastic) sphincter (group 3, n = 8), and underactive/acontractile detrusor with underactive/acontractile sphincter (group 4, n = 35). Urinary continence status at the last follow-up and the need for adjunctive incontinence surgery were compared between the four groups. RESULTS: Mean follow-up was 10 years and mean age at the last follow-up 17 years. A socially acceptable continence status (continent or socially dry) was achieved in 74% and was significantly different among the four groups (P = 0.023): 86% and 87% of the patients in group 1 and 3 became continent or socially dry, but only 57% and 74% of those in group 2 and 4, respectively. Although none of the patients in group 3 underwent adjunctive incontinence surgery compared to about 25% in the other groups, statistically the difference was not significant (P = 0.48). CONCLUSIONS: The initial urodynamic pattern is very useful in counseling families by predicting urinary continence in patients with myelomeningocele. The chances of becoming continent or at least socially dry are best for patients with overactive (spastic) sphincter.