Surgical management of intractable spasticity

Spasticity is motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex, as one component of the upper motor neuron syndrome.

This study aimed at comparing between spinally based (dorsal rhizotomy) versus peripherally based (selective neurotomy) surgical procedures in management of hypertonia in the lower limbs of pediatrics.

Over a 3-year period, 50 children with intractable, lower limb spasticity were prospectively treated by selective neurotomy (group A, 35 patients) and dorsal rhizotomy (group B, 15 patients) with 6 months' follow-up period.

The operative duration was longer with dorsal rhizotomy with mean of 292.2 min versus 76.8 min with neurotomy (P = 0.001) and the hospital stay of dorsal rhizotomy was longer with mean of 6.2 days versus 1.7 days with neurotomy (P = 0.001). Muscles power exhibited significant improvement in 53.3% of the total rhizotomies (P = 0.001). Following neurotomies; muscle tone showed marked improvement in 69.3% muscles which had normal tone and 31.9% of muscles had mild spasticity (P = 0.001). The H/M ratio following dorsal rhizotomies showed marked reduction of the ratio, and the mean was 0.11 versus 0.58 preoperatively.

Both neurotomies and dorsal rhizotomies were safe surgical procedures and were provided with good improvement in respect of: muscle power, severity of spasticity, patient's ambulation, gait, range of joint movement, associated pain, functional disability, and nerve excitability with no significant difference between both procedures.