Skip to main content

Advertisement

SpringerLink
Log in

Predictors of postoperative complications after selective dorsal rhizotomy

  • Original Article - Pediatric Neurosurgery
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Abbreviations

ASA:

American Society of Anesthesiologists

AUC:

area under the curve

BMI:

body mass index

CP:

cerebral palsy

CRP:

C-reactive protein

CSF:

Cerebrospinal fluid

EMG:

Electromyography

GMFCS:

Gross motor function classification system

MRI:

Magnetic resonance imaging

ROC:

Receiver operating characteristic

SDR:

Selective dorsal rhizotomy

SSI:

Surgical site infection

References

  1. Abdelsadg M, Kanodia AK, Badran K, Abdelsadig K, Mowle D (2017) Management of CSF leak following incidental durotomy during lumbar spinal surgery: is flat bed necessary? Neuro Open J 4:11–15

    Article  Google Scholar 

  2. Alriksson-Schmidt A, Hägglund G (2016) Pain in children and adolescents with cerebral palsy: a population-based registry study. Acta Paediatr 105:665–670. https://doi.org/10.1111/apa.13368

    Article  PubMed  PubMed Central  Google Scholar 

  3. Aquilina K, Graham D, Wimalasundera N (2015) Selective dorsal rhizotomy: an old treatment re-emerging. Arch Dis Child 100:798–802. https://doi.org/10.1136/archdischild-2014-306874

    Article  PubMed  Google Scholar 

  4. Barsotti MC, Losi P, Briganti E et al (2013) Effect of platelet lysate on human cells involved in different phases of wound healing. PLoS One 8:e84753. https://doi.org/10.1371/journal.pone.0084753

    Article  CAS  PubMed  Google Scholar 

  5. Blackwood BP, Gause CD, Harris JC et al (2017) Overweight and obese pediatric patients have an increased risk of developing a surgical site infection. Surg Infect 18:491–497. https://doi.org/10.1089/sur.2016.179

    Article  Google Scholar 

  6. Chan SH, Yam KY, Yiu-Lau BP, Poon CY, Chan NN, Cheung HM, Wu M, Chak WK (2008) Selective dorsal rhizotomy in Hong Kong: multidimensional outcome measures. Pediatr Neurol 39:22–32

    Article  Google Scholar 

  7. Cole TJ, Green PJ (1992) Smoothing reference centile curves: the LMS method and penalized likelihood. Stat Med 11:1305–1319. https://doi.org/10.1002/sim.4780111005

    Article  CAS  PubMed  Google Scholar 

  8. D’Aquino D, Moussa AA, Ammar A, Ingale H, Vloeberghs (2018) Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children. Acta Neurochir 160:811–821. https://doi.org/10.1007/s00701-017-3349-z

    Article  PubMed  Google Scholar 

  9. De la Garza RR, Nakhla J, Nasser R et al (2017) Effect of body mass index on surgical outcomes after spinal fusion for adolescent idiopathic scoliosis. Neurosurg Focus 43:E5. https://doi.org/10.3171/2017.7.FOCUS17342

    Article  Google Scholar 

  10. Duran I, Schulze J, Martakis K, Stark C, Schoenau E (2018) Diagnostic performance of body mass index to identify excess body fat in children with cerebral palsy. Dev Med Child Neurol 60:680–686

    Article  Google Scholar 

  11. Fasano VA, Broggi G, Barolat-Romana G, Sguazzi A (1978) A surgical treatment of spasticity in cerebral palsy. Child Brain 4:289–305

    CAS  Google Scholar 

  12. Foerster O (1908) Über eine neue operative Methode der Behandlung spastischer Lähmungen mittels Resektion hinterer Rückenmarkswurzeln. Z Orthop Chir 22:203–223

    Google Scholar 

  13. Foerster O (1910) Verhandlung der deutschen Gesellschaft für Chirurgie, Berlin, p 46

  14. Funk JF, Haberl H (2016) Monosegmental laminoplasty for selective dorsal rhizotomy—operative technique and influence on the development of scoliosis in ambulatory children with cerebral palsy. Childs Nerv Syst 32:819–825. https://doi.org/10.1007/s00381-016-3016-3

    Article  PubMed  Google Scholar 

  15. Golebiewska EM, Poole AW (2015) Platelet secretion: from haemostasis to wound healing and beyond. Blood Rev 29:153–162. https://doi.org/10.1016/j.blre.2014.10.003

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Gros C, Ouaknine G, Vlahovitch B, Frerebeau P (1967) La radicotomie selective posterieure dans le traitment neurochirurgical de I’ hypertonie pyramidale. Neurochirurgie 13:505–518

    CAS  PubMed  Google Scholar 

  17. Haberl H (2020) Chapter 39—selective dorsal rhizotomy. In: Deletis V, Shils JL, Sala F, Seidel K (eds) Neurophysiology in neurosurgery: a modern approach, Second edn. Academic Press, Elsevier, Amsterdam, pp 551–564. https://doi.org/10.1016/B978-0-12-815000-9.00039-3

    Chapter  Google Scholar 

  18. Hong JY, Suh SW, Park SY et al (2011) Analysis of dural sac thickness in human spine-cadaver study with confocal infrared laser microscope. Spine J 11:1121–1127. https://doi.org/10.1016/j.spinee.2011.11.001

    Article  PubMed  Google Scholar 

  19. Jankowitz BT, Atteberry DS, Gerszten PC et al (2009) Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery. Eur Spine J 18:1169–1174. https://doi.org/10.1007/s00586-009-0928-6

    Article  PubMed  PubMed Central  Google Scholar 

  20. Jeffery SMT, Markia B, Pople IK et al (2019) Surgical outcomes of single-level bilateral selective dorsal rhizotomy for spastic diplegia in 150 consecutive patients. World Neurosurg 125:e60–e66. https://doi.org/10.1016/j.wneu.2018.12.187

    Article  PubMed  Google Scholar 

  21. Katyal C, Grossman S, Dworkin A et al (2015) Increased risk of infection in obese adolescents after pedicle screw instrumentation for idiopathic scoliosis. Spine Deform 3:166–171. https://doi.org/10.1016/j.jspd.2014.07.007

    Article  PubMed  Google Scholar 

  22. Kaufman BA, Matthews AE, Zwienenberg-Lee M, Lew SM (2010) Spinal dural closure with nonpenetrating titanium clips in pediatric neurosurgery. J Neurosurg Pediatr 6:359–363

    Article  Google Scholar 

  23. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, Wei R, Curtin LR, Roche AF, Johnson CL (2002) 2000 CDC growth charts for the United States: methods and development. Vital Health Stat 11:1–190

    Google Scholar 

  24. Laurens N, Koolwijk P, de Maat MP (2006) Fibrin structure and wound healing. J Thromb Haemost 4:932–939

    Article  CAS  Google Scholar 

  25. Liu V, Gillis C, Cochrane D, Singhal A, Steinbok P (2014) CSF complications following intradural spinal surgeries in children. Childs Nerv Syst 30:299–305

    Article  Google Scholar 

  26. Liverman CT, Kraak VI (2005) Preventing childhood obesity: health in the balance. National Academic Press (US), Washington (DC)

  27. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline for prevention of surgical site infection. Hospital infection control practices advisory committee. Infect Control Hosp Epidemiol 20:250–278 [quiz 279-280]

    Article  CAS  Google Scholar 

  28. McLaughlin J, Bjornson K, Temkin N et al (2002) Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol 44:17–25

    Article  Google Scholar 

  29. McLaughlin JF, Bjornson KF, Astley SJ et al (1998) Selective dorsal rhizotomy: efficacy and safety in an investigator-masked randomized clinical trial. Dev Med Child Neurol 40:220–232

    Article  CAS  Google Scholar 

  30. Meng YB, He X, Huang YFM et al (2016) Multivariate analysis of risk factors for predicting incidental durotomy in lumbar surgery. Int J Clin Exp Med 9:20014–20019. https://doi.org/10.1097/BSD.0000000000000672

    Article  Google Scholar 

  31. Nordmark E, Josenby AL, Lagergen J, Andersson G, Strömblad LG, Westbom L (2008) Long-term outcomes five years after selective dorsal rhizotomy. BMC Pediatr 8:54

    Article  Google Scholar 

  32. Nurden AT, Nurden P, Sanchez M, Andia I, Anitua E (2008) Platelets and wound healing. Front Biosci 13:3532–3548

    PubMed  Google Scholar 

  33. Park TS, Johnston JM (2006) Surgical techniques of selective dorsal rhizotomy for spastic cerebral palsy. Technical note. Neurosurg Focus 21:e7

    Article  Google Scholar 

  34. Pascoe J, Thomason P, Graham HK, Reddihough D, Sabin MA (2016) Body mass index in ambulatory children with cerebral palsy: a cohort study. J Paediatr Child Health 52:417–421. https://doi.org/10.1111/jpc.13097

    Article  PubMed  Google Scholar 

  35. Peacock WJ, Arens LJ (1982) Selective posterior rhizotomy for the relief of spasticity in cerebral palsy. S Afr Med J 62:119–124

    CAS  PubMed  Google Scholar 

  36. Phillips LH, Park TS (1989) Electrophysiologic studies of selective posterior rhizotomy patients. In: Park TS, Phillips LH, Peacock WJ (eds) Neurosurgery: state of the art reviews: management of spasticity in cerebral palsy and spinal cord injury. Hanley & Belfus, Philadelphia, pp 459–469

    Google Scholar 

  37. Sethna NF, Clendenin D, Athiraman U, Solodiuk J, Rodriguez DP, Zurakowski D (2010) Incidence of epidural catheter-associated infections after continuous epidural analgesia in children. Anesthesiology 113:224–232. https://doi.org/10.1097/ALN.0b013e3181de6cc5

    Article  PubMed  Google Scholar 

  38. Sheean G (2002) The pathophysiology of spasticity. Eur J Neurol Suppl 1:3–9; discussion 53-61. https://doi.org/10.1046/j.1468-1331.2002.0090s1003.x

    Article  Google Scholar 

  39. Sherrington CS (1898) Decerebrate rigidity, and reflex coordination of movements. J Physiol 22:319–332. https://doi.org/10.1113/jphysiol.1898.sp000697

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Sherrod BA, Arynchyna AA, Johnston JM, Rozzelle CA, Blount JP, Oakes WJ, Rocque B (2017) Risk factors for surgical site infection following nonshunt pediatric neurosurgery: a review of 9296 procedures from a national database and comparison with a single-center experience. J Neurosurg Pediatr 19:407–420

    Article  Google Scholar 

  41. Sin AH, Caldito G, Smith D, Rashidi M, Willis B, Nanda A (2006) Predictive factors for dural tear and cerebrospinal fluid leakage in patients undergoing lumbar surgery. J Neurosurg Spine 5:224–227

    Article  Google Scholar 

  42. Stabille DM, Diogo Filho A, Mandim BL et al (2015) Frequency of colonization and isolated bacteria from the tip of epidural catheter implanted for postoperative analgesia. Braz J Anesthesiol 65:200–206. https://doi.org/10.1016/j.bjane.2014.05.015

    Article  PubMed  Google Scholar 

  43. Steinbok P, Reiner AM, Beauchamp R, Armstrong RW, Cochrane DD, Kestle J (1997) A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy. Dev Med Child Neurol 39:178–184

    Article  CAS  Google Scholar 

  44. Steinbok P, Schrag C (1998) Complications after selective posterior rhizotomy for spasticity in children with cerebral palsy. Pediatr Neurosurg 28:300–313

    Article  CAS  Google Scholar 

  45. Summers J, Coker B, Eddy S et al (2019) Selective dorsal rhizotomy in ambulant children with cerebral palsy: an observational cohort study. Lancet Child Adolesc Health 3:455–462. https://doi.org/10.1016/S2352-4642(19)30119-1

    Article  PubMed  PubMed Central  Google Scholar 

  46. Van Schie PE, Vermeulen RJ, van Ouwerkerk WJ, Kwakkel G, Becher JG (2005) Selective dorsal rhizotomy in cerebral palsy to improve functional abilities: evaluation of criteria for selection. Childs Nerv Syst 21:451–457

    Article  Google Scholar 

  47. Wright FV, Sheil EM, Drake JM, Wedge JH, Naumann S (1998) Evaluation of selective dorsal rhizotomy for the reduction of spasticity in cerebral palsy: a randomized controlled trial. Dev Med Child Neurol 40:239–247

    Article  CAS  Google Scholar 

  48. Young RR (1989) Treatment of spastic paresis. N Engl J Med 320:1553–1555

    Article  CAS  Google Scholar 

Download references

Acknowledgments

We acknowledge Theodor Michael (MD, Neuropediatrician) for his assistance in patient selection in our outpatient consultation and his broad expertise in the field of spasticity.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany

    Johannes Wach, Ömer Can Yildiz, Sevgi Sarikaya-Seiwert, Hartmut Vatter & Hannes Haberl

Authors
  1. Johannes Wach
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ömer Can Yildiz
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sevgi Sarikaya-Seiwert
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hartmut Vatter
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hannes Haberl
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

H.H.: SDR surgeon, data interpretation, proof reading.

H.V.: Proof reading.

S.S.: Proof reading.

Ö.Y.: Proof reading, review of literature.

J.W.: Study design, data acquisition, data interpretation, writing.

Corresponding author

Correspondence to Johannes Wach.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed were in accordance with the ethical standards of the institutional and national research committee (Ethic committee of the Rheinische Friedrich Wilhelms University Bonn) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethical approval for this study was obtained from the ethic committee of the Rheinische Friedrich Wilhelms University Bonn.

Formal consent

For this type of study, formal consent is not required.

Additional information

Comments

This is an interesting study looking at the complication profile for SDR surgery. There has been a lot of historic discussion about the risks of SDR with a perception that this is high-risk surgery with a significant risk of neurological impairment afterwards, including a likelihood of bladder/bowel dysfunction. There have also been historic concerns about the risk of spinal deformity after SDR. This study demonstrates that SDR is in fact a generally safe procedure with a low risk of major complications. The use of intraoperative neurophysiology monitoring and a single-level technique for access for the SDR appear to be central to the safety of SDR as presented in this paper. The positive finding that obesity is linked to a greater incidence of wound infection is in line with other publications about SSI. Overall, this is a helpful paper which appears to demonstrate that SDR can be safe with low complication risks if an appropriate meticulous neurophysiology-guided technique is used.

John Goodden

Leeds, UK

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

PREVIOUS PRESENTATION AT A CONFERENCE

None

This article is part of the Topical Collection on Pediatric Neurosurgery

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wach, J., Yildiz, Ö.C., Sarikaya-Seiwert, S. et al. Predictors of postoperative complications after selective dorsal rhizotomy. Acta Neurochir 163, 463–474 (2021). https://doi.org/10.1007/s00701-020-04487-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-020-04487-3

Keywords

Search

Navigation