Long-term outcomes five years after selective dorsal rhizotomy

<p>Abstract</p> <p>Background</p> <p>Selective dorsal rhizotomy (SDR) is a well accepted neurosurgical procedure performed for the relief of spasticity interfering with motor function in children with spastic cerebral palsy (CP). The goal is to improve function, but long-term outcome studies are rare. The aims of this study were to evaluate long-term functional outcomes, safety and side effects during five postoperative years in all children with diplegia undergoing SDR combined with physiotherapy.</p> <p>Methods</p> <p>This study group consisted of 35 children, consecutively operated, with spastic diplegia, of which 26 were Gross Motor Function Classification System (GMFCS) levels III–V. Mean age was 4.5 years (range 2.5–6.6). They were all assessed by the same multidisciplinary team at pre- and at 6, 12, 18 months, 3 and 5 years postoperatively. Clinical and demographic data, complications and number of rootlets cut were prospectively registered. Deep tendon reflexes and muscle tone were examined, the latter graded with the modified Ashworth scale. Passive range of motion (PROM) was measured with a goniometer. Motor function was classified according to the GMFCS and measured with the Gross Motor Function Measure (GMFM-88) and derived into GMFM-66. Parent's opinions about the children's performance of skills and activities and the amount of caregiver assistance were measured with Pediatric Evaluation Disability Inventory (PEDI).</p> <p>Results</p> <p>The mean proportion of rootlets cut in S2-L2 was 40%. Muscle tone was immediately reduced in adductors, hamstrings and dorsiflexors (p < 0.001) with no recurrence of spasticity over the 5 years. For GMFCS-subgroups I–II, III and IV–V significant improvements during the five years were seen in PROM for hip abduction, popliteal angle and ankle dorsiflexion (p = 0.001), capacity of gross motor function (GMFM) (p = 0.001), performance of functional skills and independence in self-care and mobility (PEDI) (p = 0.001).</p> <p>Conclusion</p> <p>SDR is a safe and effective method for reducing spasticity permanently without major negative side effects. In combination with physiotherapy, in a group of carefully selected and systematically followed young children with spastic diplegia, it provides lasting functional benefits over a period of at least five years postoperatively.</p

Postoperative Intrathecal Pain Treatment in Children

Selective dorsal rhizotomy (SDR) is an effective operations method that successfully decreased the degree of spasticity with long lasting beneficial effects for children with spastic diplegia. Children undergoing SDR are postoperatively in severe pain, a pain related to both the extensive surgical exposure with multilevel laminotomy and the nerve root manipulation. To give an optimal pain relief, pain measurement is a necessity in pain treatment, but it can be difficult in pre-school children. A worldwide survey was made (study I) to estimate the extent of SDR surgery, evaluate operation techniques and to clarify different centres pain management after SDR. A questionnaire comprise 8 questions was sent to 59 centres. 44 (75%) centres responded to the questionnaire. 33 centres constitute the study material. In a prospective study (study II), two IT different regimes was evaluated, continuous infusion versus inter-mittent, concerning pain killing and possible side effects. Intrathecal continuous infusion of bupivacaine and morphine was superior to intermittent morphine in the pain treatment after selective dorsal rhizotomy operations. To define an optimal dose (study III) of the continuous IT morphine and bupivacaine for severe pain treatment after SDR with regard to the analgesic effect and survey if they differed in side effects, we compared two different concentrations of morphine 0.4 ug/kg/h and 0.6 ug/kg/h in a fixed dose of bupivacaine 40 ug/kg/h. The Behavioural Observational Pain Scale (BOPS) was used to evaluate pain. Continuoues IT pain treatment with 0.6 ug/kg/h morphine and 40 ug/kg/h bupivacaine provides safe and good analgesia after major spinal operations. This is furthered strengthened by the fact that the adverse effect did not differ between the groups and was therefore not a drawback of the high-dose group. Effective pain management in infants and children starts with routine evaluation of pain and a clear documentation. This requires measurement of pain intensity and pain relief with reliable, valid and clinically sensitive assessment tools. Observation of behaviour can be an acceptable alternative when valid self-report is not possible. We evaluate (study IV) the validity and reliability of BOPS, as a postoperative pain measurement scale for children aged 1 - 7 years. The scale assess three variables of pain behaviours; facial expression, verbalization and body position. With BOPS the nurses can evaluate and document pain with high reliability and validity and thereby improve the postoperative pain treatment in preschool children. The simple scoring system makes BOPS easy to incorporate in a postoperative unit

Morphine with or without a local anaesthetic for postoperative intrathecal pain treatment after selective dorsal rhizotomy in children

Selective dorsal rhizotomy is a surgical procedure with a selective division of posterior spinal nerve rootlets to treat spasticity in children. The extensive surgical procedure with multilevel laminectomies and the nerve root manipulation result in intense pain postoperatively. Two intrathecal (IT) regimes of pain treatment were compared in these children, concerning their pain relief and possible side-effects. In a prospective study, 12 children (3-6 years of age) with six in each group, received either intermittent IT morphine (5 microg x kg(-1) four times a day) or continuous infusion of a mixture of bupivacaine (40 microg x kg(-1) x h(-1)) and morphine (0.6 microg x kg(-1) x h(-1)). Pain score was lower in the bupivacaine/morphine group (0.2 +/- 1.1) compared to intermittent morphine (2 +/- 2.4) on a scale from 0 to 6 (P less than or = 0.0001). Bupivacaine/morphine resulted in a lower, but not significant, difference in pruritus and lower muscle spasm. Haemodynamic and ventilatory parameters did not differ between the groups. Intrathecal continuous infusion of bupivacaine and morphine was superior to intermittent morphine in the treatment of pain after selective dorsal rhizotomy operations

Postoperative continuous intrathecal pain treatment in children after selective dorsal rhizotomy with bupivacaine and two different morphine doses.

Heme proteins are a class of biological molecules that serve important roles throughout all forms of life. The protein studied in this research, CooA, is found in several bacteria such as Rhodospirillum rubrum (Rr) and Carboxydothermus hydrogenoformans (Ch). In nature, all forms of CooA sense a specific gas molecule, carbon monoxide, that allows the heme protein to bind DNA which activates the transcription process. Interestingly however, in the lab nitric oxide has also been found to activate DNA binding in Ch CooA, but it does not activate Rr CooA. It is hypothesized that a specific intermolecular interaction between amino acids within the heme environment is responsible for the different behavior of Ch CooA and Rr CooA. To test this hypothesis, the key amino acids that are proposed to be responsible for this interaction were mutated in both CooA proteins. Next, these variant CooA proteins will be reacted with carbon monoxide and nitric oxide, and the subsequent effects on DNA binding will be measured

Validity and reliability of the Behavioural Observational Pain Scale for postoperative pain measurement in children 1-7 years of age

Objective: Pain measurement is a necessity in pain treatment but can be difficult in young children. The aim of this study was to evaluate the validity and reliability of the Behavioural Observational Pain Scale (BOPS) as a postoperative pain measurement scale for children aged 1-7 yrs. The scale assesses three elements of pain behaviors: facial expression, verbalization, and body position. Design: A prospective study. Setting. A day surgery care unit for children and a neurosurgical postoperative care unit. Patients: Seventy-six children aged 1-7 yrs (4.5 +/- 1.8) undergoing elective surgical procedures were observed. Interventions. None. Measurements and Main Results. The study was divided into interrater reliability, concurrent validity, and construct validity. The interrater reliabilities of the observers were very good with a high agreement between the different nurses' BOPS scores. Each item of the BOPS scale ranged from kappa(w) 0.86 to 0.95. In the concurrent validity, BOPS and Children's Hospital of Eastern Ontario Pain Scale scores had a positive correlation indicating that both tools described similar behaviors (r(s) =.871, p <.001). In construct validity, the effect of analgesic Was tested before analgesic administration and at 15, 30, and 60 mins after analgesic administration. The differences in BOPS score between the time intervals were significant (p <.01) before administration of analgesia and at 15, 30, and 60 mins. There was also statistical significance in the BOPS score (p <.01) between 15 and 60 mins after administration of analgesia. Conclusions. With BOPS, the caretaker can evaluate and document pain with high reliability and validity and thereby improve postoperative pain treatment in preschool children. The simple scoring system makes BOPS easy to incorporate in a postoperative unit

Cerebral Blood Flow and Transcranial Doppler Sonography Measurements of CO(2)-Reactivity in Acute Traumatic Brain Injured Patients.

BACKGROUND: Cerebral blood flow (CBF) measurements are helpful in managing patients with traumatic brain injury (TBI), and testing the cerebrovascular reactivity to CO(2) provides information about injury severity and outcome. The complexity and potential hazard of performing CBF measurements limits routine clinical use. An alternative approach is to measure the CBF velocity using bedside, non-invasive, and transcranial Doppler (TCD) sonography. This study was performed to investigate if TCD is a useful alternative to CBF in patients with severe TBI. METHOD: CBF and TCD flow velocity measurements and cerebrovascular reactivity to hypocapnia were simultaneously evaluated in 27 patients with acute TBI. Measurements were performed preoperatively during controlled normocapnia and hypocapnia in patients scheduled for hematoma evacuation under general anesthesia. MAIN FINDING AND CONCLUSION: Although the lack of statistical correlation between the calculated reactivity indices, there was a significant decrease in TCD-mean flow velocity and a decrease in CBF with hypocapnia. CBF and TCD do not seem to be directly interchangeable in determining CO(2)-reactivity in TBI, despite both methods demonstrating deviation in the same direction during hypocapnia. TCD and CBF measurements both provide useful information on cerebrovascular events which, although not interchangeable, may complement each other in clinical scenarios

Clinical factors associated with intracranial complications after pediatric traumatic head injury: an observational study of children submitted to a neurosurgical referral unit

Background: Clinically validated guidelines for the management of head injury in children do not exist, and the treatment is often based upon adult management routines. In order to examine the safety of this procedure, an analysis of clinical factors associated with complications after pediatric head injury was attempted. Method: We performed a descriptive retrospective study, including patients who received any S06 diagnosis during treatment in the Neurointensive Care Unit at Lund University Hospital between 2002 and 2007. One hundred children were included during the 6 years. Results: During 6 years, 100 children with head injury needed neurointensive care or neurosurgery for their injury in southern Sweden. Traffic accidents (50%) were the main cause of head trauma, followed by falls (36%). Thirty-two percent of all children were injured in bicycle and motorcycle accidents. Both loss of consciousness and amnesia were absent in 23% of the children with intracranial injury. Seven children with intracranial injury, 6 of them requiring neurosurgery, were classed as having minimal head injury according to the Head Injury Severity Scale (HISS). Interesting differences in intracranial injuries between helmet users and nonusers were observed. Conclusion: Children with minimal head injuries (according to HISS) may develop intracranial complications and may even require neurosurgical intervention. Hence, the HISS classification, as well as other risk classifications based upon unconsciousness and amnesia, are unreliable in children

Selective dorsal rhizotomy and postoperative pain management. A worldwide survey.

Background: Selective dorsal rhizotomy (SDR) is an operation method that decreases the degree of spasticity with long-lasting beneficial effects for children with spastic diplegia. Children undergoing SDR are postoperatively in severe pain, a pain related to both the extensive surgical exposure with multilevel laminectomy and the nerve root manipulation. Various pain management strategies for children undergoing SDR have been published. The postoperative pain treatment is a vital part of the management. The aim of this study was to estimate the number of centers performing SDR, the frequency of SDR surgery and to investigate pain management of the different centers. Methods: A questionnaire comprising 7 questions was sent by mail and/or e-mail to a total of 59 potential centers performing SDR, centers that have published material concerning SDR or centers that have been recommended. Forty-seven (80%) centers responded to the questionnaire; 11 of them do not presently perform SDR surgery, and the remaining 36 centers constitute the material of the present study. Results: 23 of the 36 centers use Peacock's operation technique and 8 centers use Park's technique. Continuous intravenous infusion of opioids for postoperative pain treatment is used by 17 (47%) of the centers. Seven (19%) centers use the epidural (ED) approach for treating postoperative pain and 6 (17%) centers use intrathecal (IT) pain treatment. The duration of intravenous ED or IT pain relief ranged from 24 h up to 7 days. To evaluate pain relief, 25 (70%) centers used some form of pain scale. Conclusion: The most common operation techniques in use today are described by Peacock or by Park, with an estimated number of procedures of more than 487/year in 36 centers. The majority of the centers seem to have a satisfactory pain management strategy. These centers administer continuous infusions of opioids, with an intravenous, ED or IT approach, and incorporate the use of a pain assessment tool to evaluate pain relief. Copyright (c) 2007 S. Karger AG, Base

The Experience of Care at Nurse-Led Rheumatology Clinics.

OBJECTIVE: To describe how people with rheumatoid arthritis (RA) experience the care provided by Swedish nurse-led rheumatology outpatient clinics. METHODS: Eighteen adult people with a diagnosis of RA who had had at least three documented contact sessions with a nurse-led clinic were interviewed. The interviews were analysed with qualitative content analysis. RESULTS: Care was expressed in three categories: social environment, professional approach and value-adding measures. A social environment including a warm encounter, a familial atmosphere and pleasant premises was desired and contributed to a positive experience of care. The nurses' professional approach was experienced as empathy, knowledge and skill, as well as support. The care was described as person centred and competent, as it was based on the individual's unique experience of his/her disease and needs. The nurses' specialist knowledge of rheumatology and rheumatology care was highly valued. The offered care represented added value for the participants, instilling security, trust, hope and confidence. It was perceived as facilitating daily life and creating positive emotions. The nurse-led clinics were reported to be easily accessible and provided continuity of the care. These features were presented as fundamental guarantees for health care safety. CONCLUSION: The experiences emphasized the need for a holistic approach to care. In this process, the organization of care and the role and skills of the nurse should be focused on the individual's needs and perspectives. The social environment, professional approach and value-adding measures are particularly relevant for optimal care at nurse-led rheumatology outpatient clinics. Copyright © 2012 John Wiley & Sons, Ltd