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

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

Long term effects on epileptiform activity with vagus nerve stimulation in children.

Purpose: We report tong-term effects of vagus nerve stimulation (VNS) on epileptiform activity in 15 children, and how these changes are related to activity stage and to clinical effects on seizure reduction, seizure severity (NHS3) and quality of life (QOL). Methods: Initially, and after 3 and 9 months of VNS-treatment, 15 children were investigated with 24 h ambulatory EEG monitoring for spike detection. The number of interictal epiteptiform discharges (IEDs) and the inter spike intervals (ISIs) were analysed during 2 h in the awake state, and 1 h of rapid eye movement (REM)-, spindle- and delta-steep, respectively. Total number and duration of electrographic seizure episodes were also analysed. Results: At 9 months the total number of IEDs was significantly reduced (p = 0.04). There was a tendency of reduction in all activity stages, and significantly so in delta-steep (p = 0.008). Total etectrographic seizure number was significantly reduced in the 24 h EEG at 3 and 9 months (p = 0.03, 0.05). There was a significant concordance in direction of changes in epileptiform activity and etectrographic seizures at 9 months (p = 0.04). Concordance in direction of changes was seen in 9 of 15 children between clinical seizures and IED (p > 0.3), in 10 of 15 children between QOL and IED (p = 0.3) and in 8 of 15 children between NHS3 and IED (p > 0.3). There was no direct correlation between the extent of improvement in these clinical data and the degree of spike reduction. Conclusion: This study shows that VNS reduces IEDs especially in REM and delta steep, as well as the number of electrographic seizures. It also shows a concordance between reduction in IEDs and etectrographic seizures

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

Beneficial effects on sleep of vagus nerve stimulation in children with therapy resistant epilepsy.

The study purpose was to evaluate sleep structure following Vagus Nerve Stimulation (VNS) in 15 children with therapy resistant epilepsy and to correlate possible alterations with changes in epileptiform activity and clinical effects. Fifteen children were examined with ambulatory polysomnographic recordings initially, and after 3 and 9 months of VNS-treatment. Sleep parameters, all-night delta power activity and movement times (MTs), used to account for arousals were estimated. Epileptiform activity was evaluated by spike detection. Seizure frequency was recorded in a diary. The severity of the seizures was scored with the National Hospital Seizure Severity Scale (NHS3). Quality of life (QOL) was assessed by a visual analogue scale. Behaviour problems were quantified by using the total score of the Child Behaviour Checklist (CBCL). VNS induces a significant increase in slow wave sleep (SWS) and a decrease in sleep latency and in stage 1 sleep. The number and density of MTs during total night sleep were significantly increased. There was also a significant increase in the number of MTs immediately related to the VNS stimulation periods. Of the 14 children with increased MTs, 10 had a reduction in epileptiform activity, and in clinical seizures, all had an improvement in NHS3, and 11 in QOL. Of the 10 children with increased SWS, eight also improved in QOL and eight in behaviour. Our findings indicate that VNS counteracts known adverse effects of epilepsy on sleep and increases slow wave sleep. This possibly contributes to the reported improvement in well-being. We also see an increase in MTs. This arousal effect seems to be of minor importance for QOL and could possibly be related to the antiepileptic mechanisms in VNS

Vagus nerve stimulation in 15 children with therapy resistant epilepsy; its impact on cognition, quality of life, behaviour and mood.

PURPOSE: Vagus nerve stimulation (VNS) is a neurophysiologic treatment for patients with refractory epilepsy. There is growing evidence of additional quality of life (QOL) benefits of VNS. We report the effects of VNS on seizure frequency and severity and how these changes are related to cognitive abilities, QOL, behaviour and mood in 15 children with medically refractory and for surgery not eligible epilepsy. METHODS: Initially, and after 3 and 9 months of VNS-treatment, 15 children were investigated with Bayley Scales of Infant Development (BSID), Wechsler Preschool and Primary Scale of Intelligence (WPPSI-R), Wechlser Intelligence Scales for Children (WISC-III) depending on the child's level of functioning, a Visual Analogue Scale for validating QOL, Child Behaviour Checklist (CBCL) for quantifying behaviour problems, Dodrill Mood Analogue Scale and Birleson Depression Self-Rating Scale, and the National Hospital Seizure Severity Scale (NHS3). A diary of seizure frequency was collected. RESULTS: Six of 15 children showed a 50% or more reduction in seizure frequency; one of these became seizure-free. Two children had a 25-50% seizure reduction. Two children showed increased seizure frequency. In 13 of 15 children there was an improvement in NHS3. The parents reported shorter duration of seizure and recovery phase. There were no changes in cognitive functioning. Twelve children showed an improvement in QOL. Eleven of these also improved in seizure severity and mood and five also in depressive parameters. CONCLUSION: This study has shown a good anti-seizure effect of VNS, an improvement in seizure severity and in QOL and a tendency to improvement over time regarding behaviour, mood and depressive parameters. The improvement in seizure severity, QOL, behaviour, mood and depressive parameters was not related to the anti-seizure effect

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

Behandling av terapiresistent epilepsi - ett multiprofessionellt samarbete

Epilepsi är den vanligaste neurologiska sjukdomen efter stroke och huvudvärk, ca 60 000 personer har aktiv epilepsi i Sverige. Vi har idag tillgång till en rad mycket effektiva läkemedel, bara sedan 1989 har åtta nya epilepsimediciner registrerats. Trots den utvidgade behandlingsarsenalen bli bara två av tre patienter anfallsfria av läkemedel, för en tredjedel fortsätter anfallen att komma. Vid farmakologiskt terapiresistent epilepsi finns andra behandlingsalternativ