#rhizotomy

Hi! I'm gonna talk about my mom in this post, about her illness and something that we just realized today, and it'd be nice if the medical side of tumblr could help

My mom is a 59 year old woman, who has an illness called syringomyelia (which basically means that she has cysts and cavities within her spinal cord). She was diagnosed like 15 years ago, and since then she has had 5 surgeries to help her "improve her day to day life"

After the first one, and a very long recovery, she was able to walk again, and she was able to have sensations on both her legs. Before the first surgery, she didn't feel anything from her waist to her feet. She was able to live her life normally for about 8 years after that, but around 2014-2015 she started falling, couldn't control her legs anymore, and went from walking without any help, to walking with canes, a walker, and then no walking at all

Since then, she's had at least one surgery per year for the past 4 years. She's had 4 laminectomies and 1 rhizotomy. The laminectomies only gave her hope, and after the surgery it was always worse. The cramps she got were awful, and she was in pain because of them for most of the day, having to take lots of pills to control them

The rhizotomy was this year, in August, and while it served its purpose, which was cutting a couple of nerves so her legs were more maleable and didn't get cramps as painful as before, she has also been a lot happier because after 4 months of recovery she has been able to move her legs and toes at will, little by little. She also gets neuropathic pains, which are really uncomfortable for her as well

Now, today, after her shower, i was applying some body cream to her legs, and while i was doing that, we realized that her right leg is mirror imaging the pain she doesn't feel on her left leg. I started pressing the gastrocnemius (i actually had to look up that term) in her left leg, and the right leg was the one that reacted and gave her pain

Neurosurgical Choice for Glossopharyngeal Neuralgia: A Benefit–Harm Assessment of Long-Term Quality of Life

Neurosurgery 88( 1) 2021: 131–139 Microvascular decompression (MVD) and vagoglossopharyngeal rhizotomy (VGR) are effective treatment for glossopharyngeal neuralgia (GN). However, surgical choice is controversial due to the need to maximize pain relief and reduce complications. OBJECTIVE: To retrospectively compare safety, efficacy, long-term quality of life (QOL), and global impression of change…

Nothing surprised to me more than reading this paper and finding out that folks that have had rhizotomies, which remove the afferent input from the dorsal horn and sensory information from the reflex loops in the cord, actually had better gait. Of course these children had severe spastic diplegia, which means they have lost descending inhibition from higher center's and most likely had increased flexor tone in the lower extremities. 

Remember that the fibers entering the dorsal horn not only go to the dorsal columns but also to the spinocerebellar pathways. When someone has spasticity, the feedback loops are skewed and flexor drive coming from the rostral reticular formation generally is increased are often kept in check by the cerebellar and vestibular feedback loops. Perhaps the interruption of this feedback loop and lack of information from type IA and II afferents of the muscle spindles as well as Ib afferents from the globe tendon organs modulated the tone sufficiently to improve gait. This study did a selective dorsal rhizotomy which means only a portion of it was ablated. 

The somatotopic organization  of the dorsal horn of the spinal cord (i.e.: certain areas of the dorsal horn correspond to certain body parts) is well documented in humans; It would make sense that the dorsal root itself (i.e.: the afferent fibers in the nerve going into the dorsal horn) would be as well, as they are that way in murines (2) and felines (3). 

So, how does this apply to gait? People with strokes, cortical lesions, diseases like cerebral palsy and even possibly increased flexor tone, may benefit from altered input into the dorsal horn. It would have been really cool to see if they increased extensor activity in this individuals, if they would be benefited further. 

 Abstract

OBJECTIVE: To identify factors associated with long-term improvement in gait in children after selective dorsal rhizotomy (SDR).

DESIGN: Retrospective cohort study SETTING: University medical center PARTICIPANTS: 36 children (age 4-13y) with spastic diplegia (gross motor classification system level I (n=14), II (n=15) and III (n=7) were included retrospectively from the database of our hospital. Children underwent selective dorsal rhizotomy (SDR) between January 1999 and May 2011. Patients were included if they received clinical gait analysis before and five years post-SDR, age >4 years at time of SDR and if brain MRI-scan was available.

INTERVENTION: Selective dorsal rhizotomy MAIN OUTCOME MEASURES: Overall gait quality was assessed with Edinburgh visual gait score (EVGS), before and five years after SDR. In addition, knee and ankle angles at initial contact and midstance were evaluated. To identify predictors for gait improvement, several factors were evaluated including: functional mobility level (GMFCS), presence of white matter abnormalities on brain-MRI, and selective motor control during gait (synergy analysis).

RESULTS: Overall gait quality improved after SDR, with a large variation between patients. Multiple linear regression analysis revealed that worse score on EVGS and better GMFCS were independently related to gait improvement. Gait improved more in children with GMFCS I & II compared to III. No differences were observed between children with or without white matter abnormalities on brain MRI. Selective motor control during gait was predictive for improvement of knee angle at initial contact and midstance, but not for EVGS.

CONCLUSION: Functional mobility level and baseline gait quality are both important factors to predict gait outcomes after SDR. If candidates are well selected, SDR can be a successful intervention to improve gait both in children with brain MRI abnormalities as well as other causes of spastic diplegia.

 1. Oudenhoven LM, van der Krogt MM, Romei M, van Schie PEM, van de Pol LA, van Ouwerkerk WJR, Harlaar Prof J, Buizer AI. Factors associated with long-term improvement of gait after selective dorsal rhizotomy. Arch Phys Med Rehabil. 2018 Jul 4. pii: S0003-9993(18)30442-8. doi: 10.1016/j.apmr.2018.06.016. [Epub ahead of print]

2. Wessels WJ1, Marani E. A rostrocaudal somatotopic organization in the brachial dorsal root ganglia of neonatal rats. Clin Neurol Neurosurg. 1993;95 Suppl:S3-11.