Brachial plexus dorsal rhizotomy in the treatment of upper-limb spasticity

2000 ◽  
Vol 93 (1) ◽  
pp. 26-32 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Marcos Flavio Ghizoni ◽  
Adalberto Michels
Keyword(s):  
Brachial Plexus ◽  
Upper Limb ◽  
Dorsal Root ◽  
Functional Improvement ◽  
Content Type ◽  
Root Section ◽  
Dorsal Rhizotomy ◽  
Movement Ability ◽  
Limb Spasticity ◽  
Fine Print

Object. This study was conducted to evaluate the effects of dorsal rhizotomy on upper-limb spasticity, functional improvement, coordination, and hand sensibility.Methods. Fifteen spastic upper limbs in 13 patients were selected and prospectively studied. Brachial plexus dorsal rhizotomy was performed in which two, three, or four dorsal roots were completely sectioned. Patients were followed up for at least 12 months after surgery; the mean follow-up period was 15.6 months and the maximum period was 30 months. A remarkable relief of spasticity was observed in all cases. Recurrence was observed in only one patient and was caused by insufficient dorsal root section. Functional improvement was observed in all cases, and functional improvement in the hand was found to be related to the presence of active finger extension in the preoperative period. Even when extended dorsal root section was performed, no hand anesthesia, either total or partial, was observed. No patient lost movement ability in the postoperative period, and no ataxic limbs were observed.Conclusions. Brachial plexus dorsal rhizotomy is very effective as a treatment for upper-limb spasticity and results in functional improvement without loss of sensation in the hand.

Reliability of intraoperative electrophysiological monitoring in selective posterior rhizotomy

2001 ◽  
Vol 95 (1) ◽  
pp. 67-75 ◽  
Author(s):  
Sandeep Mittal ◽  
Jean-Pierre Farmer ◽  
Chantal Poulin ◽  
Kenneth Silver
Keyword(s):  
Dorsal Root ◽  
Medical Center ◽  
Electrophysiological Response ◽  
Content Type ◽  
Motor Responses ◽  
Dorsal Rhizotomy ◽  
Dorsal Roots ◽  
The Difference ◽  
Selective Posterior Rhizotomy ◽  
Fine Print

Object. Selective posterior rhizotomy is a well-established treatment for spasticity associated with cerebral palsy. At most medical centers, responses of dorsal rootlets to electrical stimulation are used to determine ablation sites; however, there has been some controversy regarding the reliability of intraoperative stimulation. The authors analyzed data obtained from the McGill Rhizotomy Database to determine whether motor responses to dorsal root stimulation were reproducible. Methods. A series of 77 patients underwent selective dorsal rhizotomy at a single medical center. The dorsal roots from L-2 to S-2 were stimulated to determine the threshold amplitude. The roots were then stimulated at 2 to 4 times the highest threshold with a 1-second 50-Hz train. A second stimulation run of the entire dorsal root was performed before it was divided into rootlets. Rootlets were individually stimulated and sectioned according to the extent of abnormal electrophysiological propagation. Motor responses were recorded by electromyography and were also assessed by a physiotherapist, and grades of 0 to 4+ were assigned. The difference in grades between the first and second stimulation trains was determined for 752 roots. Statistical analysis demonstrated a clear consistency in motor responses between the two stimulation runs, both in the electromyographic readings and the physiotherapist's assessment. More than 93% of dorsal roots had either no change or a difference of only one grade between the two trials. Furthermore, the vast majority of dorsal roots assigned a grade of 4+ at the first trial maintained the same maximally abnormal electrophysiological response during the second stimulation run. Conclusions. This study indicates that currently used techniques are reproducible and reliable for selection of abnormal rootlets. Intraoperative electrophysiological stimulation can be valuable in achieving a balance between elimination of spasticity and preservation of underlying strength.

Microsurgical lesioning in the dorsal root entry zone for pain due to brachial plexus avulsion: a prospective series of 55 patients

2005 ◽  
Vol 102 (6) ◽  
pp. 1018-1028 ◽  
Author(s):  
Marc P. Sindou ◽  
Eric Blondet ◽  
Evelyne Emery ◽  
Patrick Mertens
Keyword(s):  
Brachial Plexus ◽  
Dorsal Horn ◽  
Dorsal Root ◽  
Activity Level ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Content Type ◽  
Brachial Plexus Avulsion ◽  
Root Entry Zone ◽  
Fine Print

Object. Most patients with preganglionic lesions after brachial plexus injuries suffer pain that is hard to control through medication or neuromodulation. Lesioning in the dorsal root entry zone (DREZ) is undeniably effective. Fifty-five patients who had undergone the so-called microsurgical DREZotomy (MDT) procedure were studied with the two following objectives: 1) to describe the anatomical lesions observed during MDT in correlation with sensory deficits and pain features; and 2) to analyze the results in the 44 patients who were followed for more than 1 year (mean 6 years). Methods. The observed lesions were severe: 79.6% of ventral and 78.2% of dorsal roots from C5—T1 were impaired. Damage extended to all five roots in 42% of patients. Strong arachnoiditis was present in 38.2%, pseudomeningoceles in 31%, spinal cord distortion and/or atrophy in 49%, and abundant gliotic tissue and/or microcavitations within the dorsal horn at the avulsed segments in 36.4% of cases. Sensory deficit corresponded to the entire territory of the dorsal root lesions in 52% of patients, but was larger in 30% most certainly due to the associated extrarachidian lesions. At the last evaluation after MDT, 66% of patients showed excellent (total relief without medication) or good (total relief with medication) pain relief and 71% experienced an improvement in activity level. Conclusions. Apart from other indications not addressed in this article, MDT can be performed to treat refractory pain due to brachial plexus avulsions. The long-term efficacy of this procedure strongly indicates that pain after brachial plexus avulsion originates from the deafferented (and gliotic) dorsal horn.

Reflex variability in selective dorsal rhizotomy

1993 ◽  
Vol 79 (3) ◽  
pp. 346-353 ◽  
Author(s):  
Ira P. Weiss ◽  
Steven J. Schiff
Keyword(s):  
Spinal Cord ◽  
Dorsal Root ◽  
Selection Method ◽  
Selective Dorsal Rhizotomy ◽  
Content Type ◽  
Reflex Responses ◽  
Dorsal Rhizotomy ◽  
Spatial Facilitation ◽  
Reflex Threshold ◽  
Fine Print

✓ The variability of reflex responses during selective dorsal rhizotomy was studied in eight children between the ages of 3 and 7 years. For a given dorsal root or rootiet, the electrical reflex threshold and response varied considerably when observed over several minutes. Changes in electrode pressure, mechanical dissection of the root, and reflex spatial facilitation were all found to contribute to the variability. Even when electrode pressure was held constant, intrinsic spinal cord reflex variability substantially weakened the predictability of the intraoperative selection method used during this surgery.

Peripheral selective neurotomy of the brachial plexus collateral branches for treatment of the spastic shoulder: anatomical study and clinical results in five patients

1997 ◽  
Vol 86 (4) ◽  
pp. 648-653 ◽  
Author(s):  
Philippe Decq ◽  
Paul Filipetti ◽  
Annaïk Feve ◽  
Michel Djindjian ◽  
Akim Saraoui ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Upper Limb ◽  
External Rotation ◽  
Anatomical Study ◽  
Pectoralis Major ◽  
Functional Improvement ◽  
Content Type ◽  
New Type ◽  
Selective Neurotomy ◽  
Teres Major

✓ A new type of peripheral selective neurotomy involving the collateral branches of the brachial plexus has been perfected for treatment of the spastic shoulder. Anatomical study of six cadaveric shoulders led to the specification of a surgical approach to the pectoralis major and teres major nerves, which innervate the main muscles implicated in shoulder spasticity. Between August 1994 and September 1995, five patients (four men and one woman) underwent two to four associated neurotomies of the upper limb, which included neurotomies of the pectoralis major (all five patients) and the teres major (two patients). The average follow-up period was 11 months, during which there were no local or general complications. The spasticity of the treated muscles resolved in all five patients (Held score range 3—0). The neurotomies led to statistically significant average amplitude increases in shoulder mobility, especially in abduction (+30°), antepulsion (+50°), retropulsion (+20°), and external rotation (+20°). The functionally useful active amplitude scores increased from 2.66 to 5.16/6. This functional improvement mainly involved the standing position and walking stability, as well as improvement in the range of motion of the lower limb. These results encourage the increasing use of this new type of neurotomy in treatment of the spastic upper limb.

Clinical and electrophysiological expression of deafferentation pain alleviated by dorsal root entry zone lesions in rats

2002 ◽  
Vol 97 (6) ◽  
pp. 1402-1409 ◽  
Author(s):  
Marc Guenot ◽  
Jean Bullier ◽  
Marc Sindou
Keyword(s):  
Brachial Plexus ◽  
Dorsal Horn ◽  
Dorsal Root ◽  
Clinical Signs ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Content Type ◽  
Root Entry Zone ◽  
Healthy Side ◽  
Fine Print

Object. The aims of this study were to construct an animal model of deafferentation of the spinal cord by brachial plexus avulsion and to analyze the effects of subsequent dorsal root entry zone (DREZ) lesions in this model. To this end, the authors measured the clinical and electrophysiological effects of total deafferentation of the cervical dorsal horn in rats and evaluated the clinical efficacy of cervical DREZ lesioning. Methods. Forty-three Sprague—Dawley rats were subjected to total deafferentation of the right cervical dorsal horn by performing a posterior rhizotomy from C-5 to T-1. The clinical effects of this deafferentation, namely self-directed mutilations consisting of scraping and/or ulceration of the forelimb skin or even autotomy of some forelimb digits, were then evaluated. As soon as some of these clinical signs of pain appeared, the authors performed a microsurgical DREZ rhizotomy ([MDR], microincision along the deafferented DREZ and dorsal horn). Before and after MDR, single-unit recordings were obtained in the deafferented dorsal horn and in the contralateral (healthy) side. The mean frequency of spontaneous discharge from the deafferented dorsal horn neurons was significantly higher than that from the healthy side (36.4 Hz compared with 17.9 Hz, p = 0.03). After deafferentation, 81.4% of the rats developed clinical signs corresponding to pain following posterior rhizotomy. Among these animals, scraping was observed in 85.7% of cases, ulceration (associated with edema) in 37.1%, and autotomy in 8.5%. These signs appeared a mean 5.7 weeks (range 1–12 weeks) after deafferentation. Thirteen rats benefited from an MDR; nine (69%) experienced a complete cure, that is, a total resolution of scraping or ulceration (a mean 4.6 weeks after MDR). In contrast, only one of 11 sham-operated animals showed signs of spontaneous recovery (p = 0.01). Conclusions. These results emphasize the role of the spinal dorsal horn in the genesis of deafferentation pain and suggest that dorsal horn deafferentation by cervical posterior rhizotomy in the rat provides a reliable model of chronic pain due to brachial plexus avulsion and its suppression by MDR.

Atorvastatin reduction of intracranial hematoma volume in rats subjected to controlled cortical impact

2004 ◽  
Vol 101 (5) ◽  
pp. 822-825 ◽  
Author(s):  
Dunyue Lu ◽  
Asim Mahmood ◽  
Changsheng Qu ◽  
Anton Goussev ◽  
Mei Lu ◽  
...  
Keyword(s):  
Inflammatory Responses ◽  
Functional Improvement ◽  
Intracranial Hematoma ◽  
Imaging Device ◽  
Controlled Cortical Impact ◽  
Content Type ◽  
Tissue Sections ◽  
Male Wistar Rats ◽  
Cortical Impact ◽  
Fine Print

Object. Atorvastatin, a β-hydroxy-β-methylglutaryl coenzyme A reductase inhibitor, has pleiotropic effects such as improving thrombogenic profile, promoting angiogenesis, and reducing inflammatory responses and has shown promise in enhancing neurological functional improvement and promoting neuroplasticity in animal models of traumatic brain injury (TBI), stroke, and intracranial hemorrhage. The authors tested the effect of atorvastatin on intracranial hematoma after TBI. Methods. Male Wistar rats were subjected to controlled cortical impact, and atorvastatin (1 mg/kg) was orally administered 1 day after TBI and daily for 7 days thereafter. Rats were killed at 1, 8, and 15 days post-TBI. The temporal profile of intraparenchymal hematoma was measured on brain tissue sections by using a MicroComputer Imaging Device and light microscopy. Conclusions. Data in this study showed that intraparenchymal and intraventricular hemorrhages are present 1 day after TBI and are absorbed at 15 days after TBI. Furthermore, atorvastatin reduces the volume of intracranial hematoma 8 days after TBI.

Contralateral motor rootlets and ipsilateral nerve transfers in brachial plexus reconstruction

2004 ◽  
Vol 101 (5) ◽  
pp. 770-778 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Marcos Flávio Ghizoni
Keyword(s):  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Phrenic Nerve ◽  
Cranial Nerve ◽  
External Rotation ◽  
Elbow Flexion ◽  
Content Type ◽  
Nerve Transfers ◽  
Contralateral Motor ◽  
Fine Print

Object. The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion. Methods. Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90° and 92° in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70°. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3+ and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites. Conclusions. Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.

Dorsal root entry zone lesions to control central pain in paraplegics

1981 ◽  
Vol 55 (3) ◽  
pp. 414-419 ◽  
Author(s):  
Blaine S. Nashold ◽  
Elizabeth Bullitt
Keyword(s):  
Dorsal Root ◽  
Central Pain ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Content Type ◽  
Root Entry Zone ◽  
Cord Injury ◽  
Fine Print

✓ Thirteen patients with intractable long-term pain following spinal cord injury and paraplegia were treated with dorsal root entry zone lesions placed at the level just above the transection. Pain relief of 50% or more was achieved in 11 of the 13 patients, with follow-up periods ranging from 5 to 38 months. A previous report showed that central pain from brachial plexus avulsion could be relieved by dorsal root entry zone lesions, and this technique has been extended to the central pain phenomena associated with spinal trauma and paraplegia.

Intramedullary ependymoma of the spinal cord

1990 ◽  
Vol 72 (4) ◽  
pp. 523-532 ◽  
Author(s):  
Paul C. McCormick ◽  
Roland Torres ◽  
Kalmon D. Post ◽  
Bennett M. Stein
Keyword(s):  
Spinal Cord ◽  
Mr Imaging ◽  
Tumor Recurrence ◽  
Neurological Deficits ◽  
Functional Improvement ◽  
Consecutive Series ◽  
Intramedullary Spinal Cord ◽  
Content Type ◽  
Fine Print

✓ A consecutive series of 23 patients underwent operative removal of an intramedullary spinal cord ependymoma between January, 1976, and September, 1988. Thirteen women and 10 men between the age of 19 and 70 years experienced symptoms for a mean of 34 months preceding initial diagnosis. Eight patients had undergone treatment prior to tumor recurrence and referral. Mild neurological deficits were present in 22 patients on initial examination. The location of the tumors was predominantly cervical or cervicothoracic. Radiological evaluation revealed a wide spinal cord in all cases. Magnetic resonance (MR) imaging was the single most important radiological procedure. At operation, a complete removal was achieved in all patients. No patient received postoperative radiation therapy. Histological examination revealed a benign ependymoma in all cases. The follow-up period ranged from 6 to 159 months (mean 62 months) with seven patients followed for a minimum of 10 years after surgery. Fourteen patients underwent postoperative MR imaging at intervals ranging from 8 months to 10 years postoperatively. No patient has been lost to follow-up review and there were no deaths. No patient showed definite clinical or radiological evidence of tumor recurrence during the follow-up period. Recent neurological evaluation revealed functional improvement from initial preoperative clinical status in eight patients, no significant change in 12 patients, and deterioration in three patients. The data support the belief that long-term disease-free control of intramedullary spinal ependymomas with acceptable morbidity may be achieved utilizing microsurgical removal alone.

Use of intercostal nerves for neurotization of the musculocutaneous nerve in infants with birth-related brachial plexus palsy

2001 ◽  
Vol 94 (3) ◽  
pp. 386-391 ◽  
Author(s):  
Hidehiko Kawabata ◽  
Toru Shibata ◽  
Yoshito Matsui ◽  
Natsuo Yasui
Keyword(s):  
Brachial Plexus ◽  
Muscle Power ◽  
Musculocutaneous Nerve ◽  
Biceps Muscle ◽  
Brachial Plexus Palsy ◽  
Content Type ◽  
Age At Surgery ◽  
The Mean ◽  
Intercostal Nerves ◽  
Fine Print

Object. The use of intercostal nerves (ICNs) for the neurotization of the musculocutaneous nerve (MCN) in adult patients with traumatic brachial plexus palsy has been well described. However, its use for brachial plexus palsy in infants has rarely been reported. The authors surgically created 31 ICN—MCN communications for birth-related brachial plexus palsy and present the surgical results. Methods. Thirty-one neurotizations of the MCN, performed using ICNs, were conducted in 30 patients with birth-related brachial plexus palsy. In most cases other procedures were combined to reconstruct all upper-extremity function. The mean patient age at surgery was 5.8 months and the mean follow-up period was 5.2 years. Intercostal nerves were transected 1 cm distal to the mammary line and their stumps were transferred to the axilla, where they were coapted directly to the MCN. Two ICNs were used in 26 cases and three ICNs in five cases. The power of the biceps muscle of the arm was rated Grade M4 in 26 (84%) of 31 patients. In the 12 patients who underwent surgery when they were younger than 5 months of age, all exhibited a grade of M4 (100%) in their biceps muscle power. These results are better than those previously reported in adults. Conclusions. Neurotization of the MCN by surgically connecting ICNs is a safe, reliable, and effective procedure for reconstruction of the brachial plexus in patients suffering from birth-related palsy.

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