Cervical dorsal rhizotomy for upper limbs spasticity. Case report.

Spasticity is a prevalent symptom of upper motor neuron syndrome, becoming debilitating when hindering voluntary movement and motor function and causing contractures and pain. Functional neurosurgery plays a crucial role in treating severe spasticity. Despite extensive literature on SDR for lower limb spasticity, there is a scarcity of papers regarding the procedure in the cervical region to alleviate upper limb spasticity. This case report details a cervical dorsal rhizotomy (CDR) performed for upper limb spasticity, resulting in significant improvement in spasticity with sustained outcomes and low complication rates. Neuroablative procedures like CDR become an option to treat spasticity.

Dorsal Rhizotomy in the Pediatric Patient.

SUMMARY: The majority of cases of dorsal rhizotomy surgeries in children are done to improve the spasticity associated with cerebral palsy, and more recent techniques are selective in nature and referred to as selective dorsal rhizotomy (SDR). The techniques applied to selective dorsal rhizotomy surgery has changed since it was first described and continues to undergo modifications. Approaches to surgery and monitoring vary slightly among centers. This article provides a review of the rationale, variety of surgical approaches, and intraoperative neurophysiologic monitoring methods used along with discussion of the risks, complications and outcomes in these surgeries.

Comparison of microvascular decompression, percutaneous radiofrequency rhizotomy, and stereotactic radiosurgery in the treatment of trigeminal neuralgia: A long term quasi-experimental study.

BACKGROUND: Microvascular decompression (MVD), radiofrequency rhizotomy (RFR), and stereotactic radiosurgery (SRS) are surgical techniques frequently used in the treatment of idiopathic trigeminal neuralgia (TN), although the results reported for each of these are diverse. OBJECTIVE: This study aimed to compare long-term pain control obtained by MVD, SRS, and RFR in patients with idiopathic TN. METHODS: To compare the results obtained by MVD, SRS, and RFR we chose a quasi-experimental, ambispective design with control groups but no pretest. A total of 52 participants (MVD n = 33, RFR n = 10, SRS n = 9) were included. Using standardized outcome measures, pain intensity, pain relief, quality of life, and satisfaction with treatment were assessed by an independent investigator. The TREND statement for reporting non-randomized evaluations was applied. Clinical outcomes were evaluated at the initial postoperative period and at 6 months, 1, 2, 3, 4, and 5 years postoperatively. RESULTS: MVD has shown better results in pain scales compared to ablative procedures. Significant differences between groups were found regarding pain intensity and pain relief at the initial postoperative period (p < 0.001) and 6 months (p = 0.022), 1 year (p < 0.001), 2 years (p = 0.002), and 3 years (p = 0.004) after the intervention. Those differences exceeded the thresholds of the minimal clinically important difference. A higher percentage of patients free of pain was observed in the group of patients treated by MVD, with significant differences at the initial postoperative period (p < 0.001) and 6 months (p = 0.02), 1 year (p = 0.001), and 2 years (p = 0.04) after the procedure. Also, a higher risk of pain recurrence was observed in the RFR and SRS groups (HR 3.15, 95% CI 1.33-7.46; p = 0.009; and HR 4.26, 95% CI 1.77-10.2; p = 0.001, respectively) compared to the MVD group. No significant differences were found in terms of quality of life and satisfaction with treatment. A higher incidence of complications was observed in the MVD group. CONCLUSION: Concerning pain control and risk of pain recurrence, MVD is superior to RFR and SRS, but not in terms of quality of life, satisfaction with treatment, and safety profile.

[Surgical procedures for treatment of spasticity]. / Chirurgische Verfahren zur Therapie von Spastik.

BACKGROUND: The causes of spasticity are various and include cerebral palsy, spinal cord injury, stroke, multiple sclerosis or other congenital or acquired lesions of the central nervous system (CNS). While there is often a partial functional component, spasticity also results in varying degrees of impairment of the quality of life. OBJECTIVE: A review of surgical treatment options for spasticity. MATERIAL AND METHODS: A systematic PubMed review of the literature on epidemiology and treatment options with a focus on neurosurgical interventions for spasticity and developments in the last 20 years as well as inclusion of still valid older landmark papers was carried out. Illustration of indications, technique, follow-up, and possible pitfalls of the different methods for the surgical treatment of spasticity. RESULTS: Depending on the affected region, the number of muscle groups, and the extent of spasticity, focal (selective peripheral neurotomy, nerve transfer), regional (selective dorsal rhizotomy), or generalized (baclofen pump) procedures can be performed. The indications are usually established by an interdisciplinary team. Conservative (physiotherapy, oral medications) and focally invasive (botulinum toxin injections) methods should be performed in advance. In cases of insufficient response to treatment or only short-term relief, surgical methods can be evaluated. These are usually preceded by test phases with, for example, trial injections. CONCLUSION: Surgical methods are a useful adjunct in cases of insufficient response to conservative treatment in children and adults with spasticity.

Upper-extremity spasticity and functionality after selective dorsal rhizotomy for cerebral palsy: a systematic review.

OBJECTIVE: Lumbosacral selective dorsal rhizotomy is a neurosurgical treatment option to reduce spasticity in the lower extremities in children with cerebral palsy. Surprisingly, concomitant improvement of spasticity in the upper extremities and functionality of the hands has been sporadically reported postoperatively. In this systematic review, the authors aimed to quantify the postoperative improvement in upper-extremity spasticity and functionality, identify predictors, and discuss underlying mechanisms. METHODS: The authors searched the MEDLINE and Embase databases for studies reporting upper-extremity outcomes in cerebral palsy patients after selective dorsal rhizotomy that reported one or more of the following clinical scales: the Ashworth Scale (AS), the Modified AS (MAS), the fine motor skills domain of the Peabody Developmental Motor Scales (PDMS), the Quality of Upper Extremity Skills Test (QUEST), the self-care domain of the Functional Independence Measure for Children (WeeFIM), or the self-care domain of the Pediatric Evaluation of Disability Inventory (PEDI). The authors arbitrarily divided postoperative follow-up into short-term (< 6 months), medium-term (6-24 months), and long-term (> 24 months) follow-up. A 1-point change in MAS score has been reported as clinically significant. To assess bias, the Cochrane Collaboration's tool and ROBINS-I tool were used. RESULTS: The authors included 24 articles describing 752 patients. Spasticity reduction of the upper extremities ranged from 0.30 to 0.55 (AS) and between 0 and 2.9 (MAS) at medium-term follow-up. This large variability may partially be attributed to a floor effect since patients with normal upper-extremity function would not be expected to have further improvement. QUEST improvement ranged from 2.7% to 4.5% at medium-term follow-up. The mean improvements in functional skills of the self-care domain of the PEDI were 4.3 at short-term and 7 at medium-term follow-ups and ranged from 10.8 to 34.7 at long-term follow-up. There are insufficient data to draw meaningful conclusions regarding the PDMS fine motor skills and the WeeFIM self-care domains. CONCLUSIONS: The literature suggests that a pronounced postoperative spasticity reduction in the lower extremities and a moderately severe preoperative upper-extremity spasticity may positively predict postoperative reduction in upper-extremity spasticity. There are at least 5 hypotheses that may explain the postoperative reduction in upper-extremity spasticity and functionality: 1) a somatosensory cortex reorganization favoring the hand region over the leg region, 2) a decrease in abnormal electrical transmission throughout the spinal cord, 3) an indirect result of improved posture due to improved truncal and leg stability, 4) an indirect consequence of occupational/physical therapy intensification, and 5) a maturation effect. However, all remain unproven to date.

The Effect of Selective Dorsal Rhizotomy on Hip Displacement in Children With Cerebral Palsy: A Long-term Follow-up Study.

BACKGROUND: Hip displacement is common in children with cerebral palsy (CP). Spasticity in the hip adductor muscles, hip flexors, and medial hamstrings has been identified as a possible cause of progressive hip displacement. Selective dorsal rhizotomy (SDR) aims to reduce lower extremity spasticity in children with CP. Here, we investigate the influence of SDR on hip displacement in children with CP at long-term follow-up, a minimum of 5 years post-SDR. METHODS: A retrospective review of children undergoing SDR at a Canadian pediatric hospital was completed. Migration percentage (MP) was measured on pelvis radiographs taken in the 6 months before SDR and minimum 5 years post-SDR or before hip surgery. The number of hips with displacement, defined as MP >30%, and the number of children with at least 1 hip displaced were determined. A linear mixed-effects model was used to assess potential risk factors for poor outcome post-SDR, defined as having MP >40% or surgical intervention for hip displacement. RESULTS: Ninety children [50 males, 40 females, Gross Motor Function Classification System (GMFCS) levels I to V: 1/13/24/43/9] with a mean follow-up of 8.5 years (SD 5.1) were included. The mean age at SDR was 4.9 years (SD 1.5); more than half of children (52%) had hip displacement at the time of SDR. Post-SDR, MP exceeded 30% in 0 (0%) of children at GMFCS level I, 1 (8%) at II, 11 (46%) at III, 31 (72%) at IV, and 7 (78%) at V. A poor outcome was associated with preoperative MP, age, and GMFCS level. CONCLUSIONS: The incidence of hip displacement post-SDR was consistent with population-based studies when evaluated by GMFCS. Our findings suggest that SDR has neither a positive nor negative effect on hip displacement when assessed at least 5 years postintervention. LEVEL OF EVIDENCE: Level IV.

Spasticity Interventions: Decision-Making and Management.

Spasticity results from an abnormality of the central nervous system and is characterized by a velocity-dependent increase in muscle tone or stiffness. In children, it can cause functional impairments, delays in achieving developmental or motor milestones, participation restrictions, discomfort, and musculoskeletal differences. Unique to children is the ongoing process of a maturing central nervous system and body, which can create the appearance of worsening or changing spasticity. Treatment options include physical interventions such as stretching, serial casting, and bracing; oral and injectable medications; and neurosurgical procedures such as selective dorsal rhizotomy and intrathecal baclofen pump.

A systematic review of complications following selective dorsal rhizotomy in cerebral palsy.

PURPOSE: The literature lacks a concise overview of complications secondary to selective dorsal rhizotomy (SDR). The aim of this study was to systematically review the literature regarding post-SDR complications, and to present them concisely. METHODS: The protocol of the review was registered on Open Science Framework. Studies on SDR in cerebral palsy were included. The studies to be included used SDR for management of spasticity in patients with cerebral palsy. The long-term complications of SDR mentioned in the articles were inventoried. RESULTS: Thirty studies were included for qualitative review. Twenty-one types of complication were identified. Structural complications were the commonest: scoliosis (214/1,043, 20.5%), hyperlordosis (101/552, 18.2%), spondylolysis (55/574, 9.5%) and kyphosis (67/797, 8.4%). Neurological complications comprised constipation (70/485, 14.4%), hip subluxation (3/29, 10.3%), spastic syndrome (4/47, 8.5%), sensory changes (106/1290, 8.2%) and urinary incontinence (61/1013, 6%). CONCLUSION: This review should help surgeons and parents alike to know about the potential complications of SDR. Complications may affect quality of life and should be weighed. Although the majority of these complications were managed conservatively, there would still be a physical, psychological and financial burden which should be taken into account. Screening should be continued vigorously throughout skeletal growth and at reduced frequency thereafter, for timely intervention in case of structural complications.

Neurosurgical management of elevated tone in childhood: interventions, indications and uncertainties.

Elevated tone (hypertonia) is a common problem in children with physical disabilities. Medications intended to reduce tone often have limited efficacy, with use further limited by a significant side effect profile. Consequently, there has been growing interest in the application of Neurosurgical Interventions for the Management of Posture and Tone (NIMPTs). Three main procedures are now commonly used: selective dorsal rhizotomy (SDR), intrathecal baclofen (ITB) and deep brain stimulation (DBS). This review compares these interventions, along with discussion on the potential role of lesioning surgery. These interventions variably target spasticity and dystonia, acting at different points in the distributed motor network. SDR, an intervention for reducing spasticity, is most widely used in carefully selected ambulant children with cerebral palsy. ITB is more commonly used for children with more severe disability, typically non-ambulant, and can improve both dystonia and spasticity. DBS is an intervention which may improve dystonia. In children with certain forms of genetic dystonia DBS may dramatically improve dystonia. For other causes of dystonia, and in particular dystonia due to acquired brain injury, improvements following surgery are more modest and variable. These three interventions vary in terms of their side-effect profile and reversibility. There are currently populations of children for who it is unclear which intervention should be considered (SDR vs ITB, or ITB vs DBS). Concerns have been raised as to the equity of access to NIMPTs for children across the UK, and whether the number of surgeries performed each year meets the clinical need.

Efficacy of Selective Dorsal Rhizotomy and Intrathecal Baclofen Pump in the Management of Spasticity.

BACKGROUND: Neurosurgical indications and interventions provided in the management of spasticity have evolved significantly over time. Selective dorsal rhizotomy (SDR) and intrathecal baclofen (ITB) pumps have been used to improve mobility, reduce lower extremity spasticity, and increase quality of life in patients with various diagnoses. METHODS: Studies describing ITB and SDR outcomes in adult and pediatric patients were identified from Medline and Embase databases. Only publications between January 1990 to January 2021 were included. Combinations of search terms 'Selective Dorsal Rhizotomy', 'Selective Posterior Rhizotomy', 'functional posterior rhizotomy', 'intrathecal baclofen pump', and 'spasticity' were used. Only studies in English language and those that included parameters for lower extremity outcome (i.e., spasticity, ambulation) were included. Only studies describing follow-up 12 months or greater were included. Case reports, reviews without primary data, or inaccessible publications were excluded. RESULTS: Two hundred and ninety publications between January 1990 to January 2021 were identified. Of these, 62 fit inclusion and exclusion criteria for a total of 1291 adult and 2263 patients. Etiologies in adult and pediatric populations varied substantially with multiple sclerosis, cerebral palsy, and trauma comprising the majority of causes for spasticity in adult patients. In pediatric patients, cerebral palsy was the predominant etiology of spasticity. While outcomes after SDR and ITB varied, both are effective for long-term tone reduction. SDR appeared to have a greater effect on function compared to baseline when comparing relatively similar subgroups. The complication rates for either intervention were significant; ITB had a much greater incidence of wound and hardware adverse events, whereas SDR was associated with a not insignificant incidence of new bladder or sensory deficit. CONCLUSION: ITB and SDR have demonstrated efficacy and utility for tone reduction in a variety of conditions. The selection of a specific intervention may have a variety of determining features including the etiology of spasticity, age of patient, as well as balancing benefit and complication profiles of each technique. Appropriate patient selection is essential for providing optimal patient outcomes.

Selective dorsal rhizotomy: short-term results and early experiences with a newly established surgical treatment in Slovenia.

BACKGROUND: Spasticity is characterised by an atypical increase of muscle tone, affecting normal movements and interfering with the patient quality of life. The medicines may limit the effects of the disease and selective dorsal rhizotomy (SDR) can be used for selected cases or cases refractory to medicine. We present the surgical technique and the short-term results of this newly established surgical treatment in Slovenia. METHODS: A retrospective analysis was performed of all patients that underwent the SDR from 2017 to 2019. The median follow-up was of 10 months. The following data have been collected: aetiology of spasticity, age at SDR, number of sectioned lumbar rootlets L1-S2, intraoperative disappearance of the H-reflex and intraoperative preservation of the bulbocavernosus reflex. The motor functions of all children have been classified by the Gross Motor Function Classification System (GMFCS) and Gross Motor Function Measure (GMFM-88). Twelve children underwent SDR, the median age at surgery was 9.6 years (min 3.9-max 16 years). RESULTS: A mean of 57.8% of dorsal rootlets L2-S1 have been cut, while at level L1 50% of the dorsal roots have been routinely sectioned. The median amount of S2 rootlets cut was 14.3%. Postoperatively, we observed a sudden decrease in muscle tone. In all patients, there was an improvement of the muscle tone and of the gait pattern. The GMFM improved from 187.8 to 208.3 after a follow-up of 6 months. CONCLUSIONS: There was no complication in terms of wound healing, cerebrospinal fluid fistula of neurological dysfunctions. Despite the relatively short follow-up, our early results confirm the efficacy of the SDR.

Clinical outcomes of partial sensory root rhizotomy on patients with recurrence of multiple sclerosing trigeminal neuralgia after percutaneous balloon compression.

OBJECTIVE: To investigate the clinical outcomes of partial sensory root rhizotomy (PSR) on patients with recurrence of multiple sclerosing trigeminal neuralgia(TN-MS) after percutaneous balloon compression (PBC). METHODS: 21 patients with recurrence of TN-MS after PBC were treated with PSR between January 2012 and July 2018. The visual analogue score (VAS) of participants before and after PBC/PSR were observed, and the postoperative recurrence rate of PBC/PSR were recorded, and the postoperative complications were also followed up. RESULTS: The VAS score reducing to 0-3 points after treatment was defined as effective and ≥4 points as invalid or recurrence. The effective rates of PSR at 1 day, 6 months, 12 months and 18 months after operation were 100%, 100%, 95% and 81%, respectively. The VAS scores of participants after PBC/PSR were significantly lower than those before PBC/PSR (all P<0.05), and the VAS scores at 1 day, 6 months, 12 months and 18 months after PSR were lower than those after PBC (all P<0.05). The postoperative recurrence rates at 6 months, 12 months and 18 months after PSR were significantly lower than those after PBC (all P<0.05). After PSR, all 21 patients had facial sensation loss, and one patient had intracranial infection, and none occurred decrease in masticatory muscle strength, weakened corneal reflex, intracranial hemorrhage, facial paralysis and cerebrospinal fluid leakage. CONCLUSION: PSR had a lower pain recurrence rate and a more significant reduction in VAS score compared with PBC, and it could be recommended to treat patients with recurrence of TN-MS after PBC.

The impact of needle location on clinical outcome of radiofrequency rhizotomy for trigeminal neuralgia.

BACKGROUND: Radiofrequency thermocoagulation trigeminal rhizotomy (RT-TR) through the foramen ovale is a minimally invasive treatment for trigeminal neuralgia. Navigation of magnetic resonance imaging (MRI) and CT fusion imaging is a well-established method for cannulation of the Gasserian ganglion. In this study, we use the inline measurements from fusion image to analyze the anatomical parameters between the actual and simulation trajectories and compare the short- and intermediate-term outcomes according to determinable factors. METHODS: The study included thirty-six idiopathic neuralgia patients who had undergone RT-TR with MRI and CT fusion image as a primary modality or repeated procedures. RESULTS: Among thirty-six treated patients, the inline length of the trigeminal cistern was longer for the simulated trajectory (8.4 ± 2.4 versus 6.5 ± 2.8 mm; p < 0.05), and the predominant structure at risk extrapolated from the inline trajectory was the brainstem, which signified a more medially directed route, in contrast with the equal weighting of temporal lobe and brainstem for the actual trajectory. The preoperative visual analogue scale (VAS) was 9.3 ± 1.0, which decreased to 2.5 ± 2.6 and 2.9 ± 3.1 at first (mean, 3 months) and second (mean, 14 months) postoperative follow-up, respectively. The postoperative VAS scores at the two follow-ups were not statistically significant without a covariate analysis. After adjustment for covariate risk factors, the second follow-up sustained therapeutic benefit was evident in patients with no prior history of related treatment, an ablation temperature greater than 70 °C, and needle location within or adjacent to the trigeminal cistern. CONCLUSIONS: This preliminary study demonstrated that the needle location between cistern and ganglion also plays a significant role in better intermediate-term results.

Can fifth nerve mapping guide rhizotomy for recurrent trigeminal neuralgia? Case report.

INTRODUCTION: Microvascular decompression (MVD) is usually considered the first-line treatment for trigeminal neuralgia (TN) when medical treatments fail. Recurrence is rare and best treatment option is controversial. MVD was proposed as a feasible and effective technique for recurrent TN by many authors. Nevertheless, in a substantial number of cases, not any impingement or deterioration are found intraoperatively and partial selective rhizotomy is then advised. The rhizotomy site is mostly guided by anatomical landmarks, but variations due to scarring and adhesions are common pitfalls in these second surgeries. Intraoperative monitoring is infrequently used during MVD for trigeminal neuralgia. We describe the use of nerve mapping in a case of recurrence, revealing an unexpected rootlet distribution and thus safely guiding partial rhizotomy. CLINICAL PRESENTATION: A 53-year-old woman had suffered from bilateral trigeminal neuralgia for 10 years. Symptoms began on the right side. MVD resolved her symptoms but, after a few months, she developed left TN which persisted after left MVD, radiofrequency and radiosurgery. She was referred to our center for a second MVD on the left side. Intraoperative inspection detected no relevant findings, and nerve mapping followed by partial selective rhizotomy was performed. Complete pain relief was achieved. There were no complications. CONCLUSION: Rhizotomy is seldom employed for refractory trigeminal neuralgia. The effects of previous treatments can jeopardize anatomical landmarks. Nerve mapping seems a promising tool to improve results.

Efficacy and safety of radiofrequency in the treatment of trigeminal neuralgia: a systematic review and meta-analysis.

To assess the effectiveness of radiofrequency (RF) versus other percutaneous strategies (balloon compression, glycerol rhizotomy [GR], and microvascular decompression [MVD]) in patients with trigeminal neuralgia. We systematically searched the electronic databases of PubMed, Embase, and the Cochrane Library to identify eligible studies throughout October 2020. The odds ratio (OR) with 95% confidence interval (CI) was applied to assess effect estimates using the random-effects model. Eighteen retrospective cohort studies that enrolled 6391 patients with trigeminal neuralgia were included. We noted that RF was associated with an increased incidence of immediate pain relief compared with GR (OR 2.65; 95% CI 1.29-5.44; P = 0.008). Moreover, RF was associated with an increased risk of pain recurrence compared with MVD (OR 3.80; 95% CI 2.00-7.20; P < 0.001). Furthermore, RF was associated with an increased incidence of postoperative anesthesia compared with GR (OR 3.01; 95% CI 1.11-8.13; P = 0.030) or MVD (OR 4.62; 95% CI 2.15-9.93; P < 0.001). This study found that RF was superior to GR for the improvement in immediate pain relief; whereas, RF yielded an excess risk of pain recurrence compared with MVD. Moreover, the incidence of postoperative anesthesia in patients treated with RF significantly increased compared with the incidence after treatment with GR and MVD.

Long-term effects of spasticity treatment, including selective dorsal rhizotomy, for individuals with cerebral palsy.

AIM: To understand the long-term effects of comprehensive spasticity treatment, including selective dorsal rhizotomy (SDR), on individuals with spastic cerebral palsy. METHOD: This was a pre-registered, multicenter, retrospectively matched cohort study. Children were matched on age range and spasticity at baseline. Children at one center underwent spasticity treatment including SDR (Yes-SDR, n=35) and antispastic injections. Children at two other centers had no SDR (No-SDR, n=40 total) and limited antispastic injections. All underwent subsequent orthopedic treatment. Participants returned for comprehensive long-term assessment (age ≥21y, follow-up ≥10y). Assessment included spasticity, contracture, bony alignment, strength, gait, walking energy, function, pain, stiffness, participation, and quality of life. RESULTS: Spasticity was effectively reduced at long-term assessment in the Yes-SDR group and was unchanged in the No-SDR group. There were no meaningful differences between the groups in any measure except the Gait Deviation Index (Yes-SDR + 11 vs No-SDR + 5) and walking speed (Yes-SDR unchanged, No-SDR declined 25%). The Yes-SDR group underwent more subsequent orthopedic surgery (11.9 vs 9.7 per individual) and antispastic injections to the lower limbs (14.4 vs <3, by design). INTERPRETATION: Untreated spasticity does not cause meaningful impairments in young adulthood at the level of pathophysiology, function, or quality of life.

Epidural analgesia for reduction of postoperative systemic opioid use following selective dorsal rhizotomy in children.

OBJECTIVE: Selective dorsal rhizotomy (SDR) requires significant postoperative pain management, traditionally relying heavily on systemic opioids. Concern for short- and long-term effects of these agents has generated interest in reducing systemic opioid administration without sacrificing analgesia. Epidural analgesia has been applied in pediatric patients undergoing SDR; however, whether this reduces systemic opioid use has not been established. In this retrospective cohort study, the authors compared postoperative opioid use and clinical measures between patients treated with SDR who received postoperative epidural analgesia and those who received systemic analgesia only. METHODS: All patients who underwent SDR at Boston Children's Hospital between June 2013 and November 2019 were reviewed. Treatment used the same surgical technique. Postoperative systemic opioid dosage (in morphine milligram equivalents per kilogram [MME/kg]), pain scores, need for respiratory support, vomiting, bowel movements, and length of hospital and ICU stay were compared between patients who received postoperative epidural analgesia and those who did not, by using the Wilcoxon rank-sum test or Fisher's exact test. RESULTS: A total of 35 patients were identified, including 18 females (51.4%), with a median age at surgery of 6.1 years. Thirteen patients received postoperative epidural and systemic analgesia and 22 patients received systemic analgesia only. Groups were otherwise similar, with treatment selection based solely on surgeon routine. Patients who received epidural analgesia required less systemic morphine milligram equivalents/kg on postoperative days (PODs) 0-4 (p ≤ 0.042). Patients who did not receive epidural analgesia were more likely to require respiratory support on POD 1 (45% vs 8%; p = 0.027). Reported pain scores did not differ between groups, although patients receiving epidural analgesia trended toward less severe pain on PODs 1 and 2. Groups did not differ with respect to postoperative vomiting or time to first bowel movement, although epidural analgesia use was associated with a longer hospital stay (median 7 vs 5 days; p < 0.001). CONCLUSIONS: Patients who received postoperative epidural analgesia required less systemic opioid use and had at least equivalent reported pain scores on PODs 1-4, and they required less respiratory support on POD 1, although they remained in the hospital longer when compared to patients who received systemic analgesia only. A larger prospective study is needed to confirm whether epidural analgesia lowers systemic opioid use in children, contributes to a safer postoperative hospital stay, and results in better pain control following SDR.

Predictors of postoperative complications after selective dorsal rhizotomy.

BACKGROUND: Selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy (CP). We analyzed potential preoperative predictors of complications after SDR via single-level laminectomy at the conus medullaris. METHODS: One hundred and forty SDRs performed in children (2-17 years) with CP were included in this retrospective study (March 2016 to July 2019). Of these children, 69% were ambulatory (Gross Motor Functional Classification System (GMFCS) II and III). Variables associated with wound dehiscence and infections, cerebrospinal fluid (CSF) leaks, and prolonged epidural pain management were analyzed statistically. RESULTS: Five children (3.6%) showed prolonged wound healing, which was associated with obesity (BMI z-score ≥ 1.64; odds ratio (OR) 24.4; 95% confidence interval (CI) 3-199; p = 0.003). Two cases (1.4%) had superficial surgical site infections (SSIs), which was associated with obesity (p = 0.004) and thrombocytopenia (< 180,000 G/l; p = 0.028). The area under the curve at ≥ 1.55 BMI z-score for SSI was 0.97 (95% CI 0.93-0.99, p = 0.024), with a sensitivity and specificity for SSI of 100 and 94.9%, respectively. CSF leaks occurred in four (2.9%) children, associated with age ≤ 5 years (p = 0.029). Fifteen (10.7%) children required prolonged (4-5 days) epidural pain treatment, which was associated with non-ambulatory GMFCS levels (IV and V) (OR 3.6; 95% CI 1.2-10.8; p = 0.008). CONCLUSIONS: SDR is safe for all GMFCS levels. Obesity predicts prolonged wound healing and SSI. Prolonged pain management via epidural pain catheter is safe, but care should be taken with non-ambulatory children.

Neurosurgical Choice for Glossopharyngeal Neuralgia: A Benefit-Harm Assessment of Long-Term Quality of Life.

BACKGROUND: Microvascular decompression (MVD) and vagoglossopharyngeal rhizotomy (VGR) are effective treatment for glossopharyngeal neuralgia (GN). However, surgical choice is controversial due to the need to maximize pain relief and reduce complications. OBJECTIVE: To retrospectively compare safety, efficacy, long-term quality of life (QOL), and global impression of change following MVD and VGR for treatment of GN. METHODS: Patient database reviews and telephone surveys were conducted to assess baseline characteristics and long-term outcomes. The effects of pain and complications on QOL were assessed using Brief Pain Inventory-Facial (BPI-Facial) questionnaire. Complication tolerance and surgery satisfaction were sorted using the global impression of change survey. RESULTS: Of 87 patients with GN, 63 underwent MVD alone, 20 underwent VGR alone, and 4 underwent VGR following a failed MVD. The long-term rate of pain relief was slightly, but not significantly, lower following MVD than VGR (83.6% vs 91.7%, P = .528). However, long-term complications occurred much more frequently following VGR (3.0% vs 50.0%, P < .001). The BPI-Facial, which evaluates pain and complications, showed that MVD had better postoperative QOL than VGR (P < .001). However, 91.7% of patients who underwent VGR experienced no or mild complications. There was no significant difference in the overall satisfaction rates between the groups (83.3% vs 83.6%, P > .99). CONCLUSION: Although VGR resulted in lower postoperative QOL due to a high complication rate, most of these complications were mild. The overall satisfaction rates for the 2 surgeries were similar.