Highly selective dorsal rhizotomy

Highly selective spinal nerve dorsal rhizotomy is used for spastic paralysis. Spastic sputum is one of the types of cerebral palsy (referred to as cerebral palsy), accounting for 30% to 50% of cerebral palsy. Surgical treatment of cerebral palsy is mainly for the treatment of spastic paralysis, and surgery is not the main treatment for cerebral palsy. It is impossible to recover from severe cerebral palsy, but it is important to develop a reasonable comprehensive treatment plan. The so-called comprehensive treatment plan should include psychological training, language training, occupational therapy, physical therapy, special education and orthopedic treatment. Generally, starting from non-surgical therapy, after the child is mature, surgery is used to correct deformity, balance muscle strength, adjust muscle strength, stabilize joints, and restore a reasonable negative gravity line. The purpose of comprehensive treatment is to help bedridden patients to sit still, to enable them to move to society, and to use wheelchairs and walking aids. However, each treatment training program must face reality and be formulated according to the actual condition. Whether the treatment training program can be achieved depends on whether the objective conditions are met, such as the patient's mood, psychological state, social status, and economic conditions, but it is directly related to the treatment effect. Severe compound brain damage, any treatment method is also difficult to work, can only maximize the improvement on the original basis, the ability to improve. The main principles of orthopedic surgery in the treatment of cerebral palsy patients are to correct deformity, balance and adjust muscle strength, stabilize joints, and restore limb strength. Correction of static deformity should be placed first. The tendon extension and lysis, joint capsule incision, fascia cutting and osteotomy were used to correct bone and joint deformities. The correction of dynamic malformation mainly depends on balancing muscle strength and adjusting muscle strength, but it is difficult to balance muscle strength in cerebral palsy patients to achieve ideal results. Because there are many factors affecting muscle transposition: 1 self-control muscle function damage; 2 slow movement of autonomic movement; 3 low stretch reflex; 4 joint receptor loss; 5 antagonistic muscle group unsynchronized uncoordinated; 6 voluntary tendon Shrink and so on. Therefore, after the muscle transposition, special training is required, and sometimes the muscle motor nerve branching with excessive muscle strength can be used to achieve the antagonistic balance. However, the effect of neurotomy is not long-lasting and easy to relapse. This should be noted. Three-joint fixation can also be used, and the sub-articular external fixation can be used to stabilize the foot. Before the treatment, a careful treatment plan should be prepared, and the cooperation between the patient and his family should be obtained to complete the treatment plan. Treatment of diseases: abnormal muscle tone Indication Highly selective spinal nerve dorsal rhizotomy is suitable for: 1. Severe multiple tendon and increased muscle tone, Ashworth IV or above, and a minor over 5 years of age. 2. Severe paralysis with limb stiffness affects daily life and rehabilitation trainers. 3. The trunk muscles and limb muscles have certain functions. 4. The intelligence is normal or close to normal, and can be used in conjunction with rehabilitation training. Contraindications 1. Low muscle tone, poor muscle strength, and poor motor function. 2. Fixed bone and joint deformity and contracture. 3. Those with low intelligence and no motor function. 4. The spine has obvious deformity and dysplasia. 5. Patients with bronchospasm and epilepsy. Surgical procedure Incision and exposure Take the midline incision from the waist 2~1, separate the muscles, expose the lumbar 2~5 lamina, expose the dura mater and cut it longitudinally, and lift the edge with a mosquito clamp or lift the wire to prevent the cerebrospinal fluid from overflowing. Locate the lumbar 2~1 nerve at the exit of the intervertebral foramen, and find the confluence point of the anterior and posterior anterior and posterior branches, ie, the dural hole. The nerve root near the dorsal side of the dura mater is the posterior root. . When looking for, pay attention to the fact that the anterior root and the posterior root are not connected in the dural cavity. When they go out from the dural sac, they gradually come together. When the dural sac is worn out, the anterior root is below and then The root is on. They are separated by a thin film, and the outer surface is covered with a total sheath. When reaching the intervertebral foramen, a large part (spine ganglion) containing cell components appears in the posterior root, from which the posterior root and the surrounding area are worn. The sensory fibers of the nerves are then joined together to form the spinal nerve roots. The thickened part of the ganglion can be used as a marker of the posterior root. In the neck surgery, the prolapsed neck and neck flexion position is taken, and the posterior median longitudinal incision is made. The laminae of the affected side of the neck 4-7 are exposed and the dura of the semi-vertebral lamina is incision, and the neck 4 to chest 1 are exposed. After the nerve roots are small bundles, the threshold is low and the small bundles of the posterior roots are cut off proportionally. Generally, the neck 5 is 35%, the neck 6 is 56%, the neck 7-8 is about 55%, and the chest 1 is about 40%. 2. Electrical stimulation and selective cutting of the posterior roots of each nerve Under the operating microscope or magnifying glass, each of the posterior root bundles is bluntly separated by a microsurgical instrument. The number of small bundles of each rear root is not the same, generally 5 to 7 bundles. Carefully separate the small bundles, lift them with nerve hooks or rubber membranes, and use an electrical stimulator (electromyograph or pulse electrical stimulator) to stimulate the small bundles of the posterior roots to induce tendon. Threshold values of each small bundle-induced tendon were measured by electromyography or by limbometry and marked and recorded one by one, and the posterior root beamlets with low threshold were selected to be cut proportionally. In addition to the low threshold, these small beams are accompanied by a small range of continuous clonic. The posterior root beamlets with a low threshold are cut proportionally to block the r-loop of spinal cord reflexes to reduce muscle tone and relieve tendon. The posterior root beamlets with high thresholds should be preserved to prevent postoperative sensory disturbances. 3. The ratio of nerve root cutting There are different reports and there is no uniform standard. The average is about 35%. According to most reports, the lumbosacral 2 posterior root resection is 20% to 25%, the lumbar 3 posterior root resection is 15% to 20%, the lumbar 4 posterior root resection is 10% to 15%, and the lumbar 5 resection is 25% to 30%. Excision 25% to 30%. However, it should be based on muscle tone and muscle strength. If the muscle tension is high, the cutting ratio of the muscle strength can be higher, and vice versa. 4. Close the incision Thoroughly stop bleeding and tightly suture the dural incision to prevent postoperative cerebrospinal fluid leakage. In the dural cavity, appropriate saline can be injected to supplement the amount of cerebrospinal fluid loss, which can prevent postoperative adhesion of the cauda equina. When the dural has been swelled and there is no cerebrospinal fluid leakage, the surgical incision is closed according to the layer, and the rubber is placed in the incision. Drainage strip to prevent epidural hematoma. complication Early postoperative fever, urinary retention, cerebrospinal fluid leakage, bronchospasm, hematuria, abdominal pain, etc., the late stage is mainly spinal instability, spinal deformity and hip dislocation, muscle weakness and so on.

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