Functional selective posterior spinal nerve rhizotomy (FSPR) is currently used in many hospitals in China and abroad to treat pediatric cerebral palsy. The mechanism by which this procedure relieves the limb spasm of the child is based on the experimental citation of physiology: the downstream conduction bundle of the spinal cord has an inhibitory effect on motor neurons, while the posterior root fibers entering the spinal cord have an excitatory effect. We comprehensively adjust the patient’s muscle tone by treating the posterior roots of the spinal nerves so that the muscle tone of the spastic muscles is as close to normal as possible. Intraoperatively, the posterior roots of the spinal nerve can be selectively cut to eliminate the intersegmental connection from the posterior roots of the lumbosacral nerve to the adjacent anterior horn motor neurons of the spinal cord, thereby attenuating the lower limb muscle spasm and improving the motor function of the limb of the sick child. One of the meanings of selectivity refers to the selection of spinal nerve branches with low threshold for severance. After incision of the dura mater, the anterior and posterior spinal nerve roots are carefully separated under a microscope or surgical magnification, and each posterior root nerve is divided into 4 to 10 bundles of small branches, and their thresholds are measured separately with an electrical stimulation instrument, usually by hooking each small bundle with a stimulation electrode and observing the threshold at the appearance of limb spasm after electrical stimulation. Generally, the severed posterior root nerve branches will be limited to 50% to avoid excessive severing to produce hypotonia after surgery.
Patients must undergo a rigorous preoperative surgical screening process and can be treated with FSPR if they meet the following criteria.
① those with simple spasticity and a muscle tone of grade 3 or higher
② no obvious fixed contracture deformity or only mild deformity.
③ preoperative spinal extremities with some motor ability.
④ normal or near normal intelligence, able to cooperate with postoperative rehabilitation training.
⑤ those with severe spasticity and stiffness that affect daily life, care and rehabilitation training
⑥Those with muscle strength of grade IV or above.
Patients should be bedridden for at least 3 weeks after surgery, and then undergo rehabilitation training with nursing support. Rehabilitation training is the key to the success of surgery, which is essential. If no postoperative training treatment is provided or postoperative care is not standardized and systematic, the surgery can also fail. In addition, orthopedic surgery can be performed if necessary, depending on the patient’s actual recovery after surgery.
FSPR surgery results and risks
FSPR surgery plays an important role in the treatment of pediatric cerebral palsy. The treatment of cerebral palsy should be carried out in a multidisciplinary approach, with active rehabilitation at an early stage under the premise of correct diagnosis. If the result is not good or the condition is recurrent, surgery should be performed promptly in order to release excessive muscle tone as early as possible, surgical release of spasticity, and necessary orthopedic treatment of deformity. Posterior spinal nerve root selective excision and peripheral nerve selective excision for spasticity should be performed before other surgeries, and orthopedic surgery should be performed in stages after posterior spinal nerve root selective excision according to the rehabilitation situation.
The FSPR procedure uses intraoperative electrophysiological monitoring techniques to ensure surgical results, reduce surgical risk, improve surgical efficacy, improve motor function, improve the patient’s quality of life and work ability, and achieve the goal of social reintegration of the disabled. This treatment route is also applicable to patients with cerebral hemorrhage, traumatic brain injury, and spastic paralysis state of limbs with sequelae of brain and spinal cord surgery, limb inflexibility and limb pain, and excellent results have been received after clinical application.
Therefore, the best treatment for children with spastic cerebral palsy to release spasticity is FSPR, which is minimally invasive, reversible, has no side effects, and can adjust stimulation parameters according to individual needs. In summary, the main objectives of FSPR treatment for cerebral palsy are to release muscle spasticity, balance muscle strength, correct deformities, adjust negative gravity lines of limbs, and improve motor function.
Notes on SPR surgery for spastic cerebral palsy
SPR is an electrical stimulation treatment based on the principle of spastic reflex, because the increased muscle tone and spasticity is a manifestation of the overactive detrusor reflex, whose receptor is the muscle shuttle. The principle of the procedure is to release the spasm of the limb by identifying the posterior spinal nerve root that causes the most pronounced spasm in the corresponding area, selectively cutting the afferent Class Ia fibers from the muscle shuttle, and blocking the r-loop in the spinal reflex.
The purpose of the procedure is to release or reduce muscle spasm, reduce excessive muscle tone, and restore and also improve muscle balance to facilitate active motor exercise, improve gait, and enhance daily living ability.
In the specific procedure, SPR surgery is performed under general anesthesia with the child in the prone position, a longitudinal incision is made along the spinous process of lumbar 2-sacral 1 to reveal the spinous processes and the vertebral plates of the lumbar spine, and the spinous processes of the vertebral plates from lumbar 2 to sacral 1 are removed in turn to reveal the dura mater. The posterior nerve roots from lumbar 2 to sacral 1 were freed by incising the dura mater, and the posterior roots were divided into several bundles, each bundle was electrically stimulated and its threshold was recorded, and the bundle with low threshold was selected and cut.
1. What kind of patients are suitable for SPR surgery?
The main effect of SPR surgery is to relieve the spasticity of the muscles. Therefore, patients with spastic cerebral palsy are suitable for this surgery. In general, spastic cerebral palsy is caused by prematurity at birth and mild asphyxia; in addition, post-traumatic brain injury and cerebral hemorrhage can also cause spasticity.
2. What are the risks, sequelae and trauma of SPR surgery?
After 15 years of clinical practice, it has been proved that SPR surgery has no significant complications as long as the indications are strictly controlled. There is a slight impact on spinal stability after lumbar surgery, but it does not lead to spinal instability, and the effect is long-lasting and stable, without spastic rebound.
3. What is the best time and age for surgery, and what other treatments should be used before and after surgery?
The best time for surgery is when the spasticity of the limb is stable and there is no obvious joint deformity; the best age is 3-8 years old. This is because the type of cerebral palsy in children with cerebral palsy is unstable up to the age of 3, and the symptoms may improve through rehabilitation, and they are too young to withstand the trauma of surgery. Since long-term muscle spasticity is likely to cause delayed muscle development and joint deformity, early surgery is likely to improve motor function more thoroughly through a single operation, and once joint deformity occurs, it often requires second-stage orthopedic surgery to deal with it. There is no requirement for the age of surgery if it is purely from the perspective of improving the spasticity. The treatment of cerebral palsy is a systematic project, and surgery should be performed at an appropriate time based on rehabilitation training, and surgery must be closely integrated with rehabilitation training.
4. Can cerebral palsy that is not spastic be treated? What are the components included?
Except for spastic cerebral palsy, other patients with cerebral palsy have increased muscle tone instability and involuntary muscle movements as the main manifestation, and mixed and tachycardic cerebral palsy with mainly balance and coordination dysfunction is relatively common. The main causes are moderate to severe asphyxia at birth and pathological jaundice. This type of cerebral palsy can undergo carotid sheath surgery to improve balance and coordination and improve motor status.
What is orthopedic surgery for cerebral palsy?
What is cerebral palsy orthopedic surgery? Orthopedic surgery for cerebral palsy is different from FSPR surgery, which is a second stage surgery performed by doctors after FSPR surgery to address conditions such as joint deformities and soft tissue contractures in patients with cerebral palsy.
FSPR is the intraoperative monitoring through multi-conductor electrophysiological technology to determine the proportion of the posterior spinal nerve roots to be removed, making the scope and proportion of sensory nerves to be removed more scientific and objective. The muscle tone of the patient is adjusted comprehensively so that the muscle tone of the spastic muscles is as close to normal as possible. The muscle spasm in cerebral palsy patients is not limited to a single muscle, but often manifests as spasm of multiple muscles or muscle groups, and the procedure can achieve a comprehensive adjustment of muscle tone, and can provide a long-term, stable and complete solution to the pain of muscle spasm in patients, providing the prerequisite for maximum recovery of their motor functions. It is worth mentioning that FSPR only selectively blocks part of the posterior nerve root fibers, without affecting the anterior nerve roots that govern muscle movement and motor function. The specific site of surgery, however, can depend on the patient’s specific condition: surgery in the lumbar spine can address lower extremity spasticity, and surgery in the cervical spine can address upper extremity spasticity. A set of scientific and reasonable individualized treatment plan should be established before surgery for each patient’s different conditions, including preoperative assessment and selection of appropriate methods, and long-term formal rehabilitation training should also be adhered to after the implementation of FSPR, so as to ensure the rehabilitation efficacy.
FSPR is unique in relieving muscle spasm, but it is difficult to correct joint deformation and soft tissue contracture. Therefore, in some cases, orthopedic surgeons need to perform second-stage orthopedic surgery such as selective peripheral nerve narrowing, tendon severance and joint capsule release, joint fusion or osteotomy after FSPR to receive the best treatment effect. Many scholars advocate that for patients with spastic cerebral palsy combined with fixed deformities, stage II orthopedic surgery 1 to 12 months after FSPR is a feasible option.
Joint contractures generally require stage II surgery. Mild deformities can be improved or corrected with training. For more severe deformities, come back to the hospital after at least six months of training after FSPR to determine which areas need stage II surgery.
Indications for carotid epicardial dissection
I. Indications for carotid epicardial dissection.
torsional spasm; language and intellectual impairment; tension spastic paralysis; spastic paralysis caused by nuclear jaundice; ataxia, hyperactivity, etc.
II. Treatment principle of carotid artery epicardial dissection
By doing “bilateral carotid artery epicardial dissection”, the blood supply and oxygen supply to the brain are improved to promote the growth and development of undamaged brain cells, so that the sensory-motor nerves can be completely released and the tense muscles of the whole body can be relaxed to improve a series of phenomena such as writhing, salivation, language, intelligence, hyperactivity, etc. At the same time, we should also combine the family’s At the same time, we also need to combine the family’s cooperation and good rehabilitation training with clinical guidance, so that patients can get scientific and reasonable treatment.
Postoperative rehabilitation of carotid artery dissection
Postoperative rehabilitation is a very important aspect. Rehabilitation refers to the integrated and concerted application of medical, social, educational and vocational measures to the patient to train and retrain him/her in order to restore his/her function to the highest possible level. The aim of rehabilitation is not only to train the patient to adapt to the environment, but also to involve him/her as a whole in the closest environment and society, so that the patient achieves self-sufficiency, becomes socially integrated, has a better quality of life and can realize his or her values.
In conclusion, bilateral carotid epicardial sympathectomy treatment improves the function of bilateral upper limb movement, speech, swallowing and chewing, and also improves the role of cerebral blood supply and oxygenation, which is then combined with rehabilitation training after the procedure.
Carotid artery epicardial sympathetic dissection for torsion spastic cerebral palsy
Prior to treatment, the ability of daily living movements of patients with torsional spasticity, tonic spasticity and tardive dyskinesia was rated using the PALCI system evaluation scale A (daily living movements): level 5 (fully supported), level 4 (fairly supported), level 3 (partially supported), level 2 (less supported), and level 1 (almost no support). Intelligent language impairment was assessed using the PALCI system evaluation scale C (language ability) and I (intelligence) grading; grade 5 (very severe), grade 4 (severe), grade 3 (moderate), and grade 2 (mild).
Intracranial vascular disease was excluded by cranial MRA examination before surgery. After intraoperative general anesthesia with tracheal intubation, the patient was placed in a supine position with shoulder pads and head tilted back. A longitudinal incision of approximately 3 cm in length was made on the medial border of the inferior and middle sternocleidomastoid muscles bilaterally. The skin, broad cervical muscle and anterior cervical fascia were incised, and the sternocleidomastoid muscle was pulled outward. The sternocleidomastoid muscle and sternocleidomastoid muscle were subconsciously separated, and the carotid artery sheath was medially retracted to expose the carotid artery sheath, and part of the carotid artery sheath was opened and excised; the common carotid artery was separated from the internal jugular vein gap, and special care was taken not to injure the vagus nerve between the two in this process. Then the outer membrane of the common carotid artery is circumcised under the microscope for 2-3 cm, and the vagus nerve is freed and the connective tissue around the nerve is excised. The hemorrhage is thoroughly stopped, the muscle is sutured in layers, and the skin incision is then glued with adhesive tape.
Through this surgical method, followed by the corresponding rehabilitation training, it has been outstandingly effective in improving the patient’s bilateral upper limb movement, speech, swallowing, chewing and other functions; it also improves the brain blood supply and oxygenation, etc. From the statistics of the surgeries performed, it is found that the efficiency of using carotid epicardial sympathetic dissection to treat torsional spasm and other diseases reaches more than 90%, and the apparent efficiency is more than 80%. After surgery with rehabilitation training, the symptoms have improved to different degrees.