Reading: Surgical Management of Spasticity

Question 1

Describe the mechanism of action for intrathecal baclofen

Answer 1

modulates the excitability of the reflex arc within the spinal cord

CNS depressant

Question 2

Describe the advantages of intrathecal baclofen

Answer 2

• dosage can be adjusted
• Safer for kids with GMFCS IV as it diminishes the intensity of dystonia.

Question 3

Describe the disadvantages of intrathecal baclofen

Answer 3

• possibility of withdrawal/overdose
• infection
• tube kinking
• pump failure

Question 4

Describe the mechanism of action for selective dorsal rhizotomy

Answer 4

• cut dorsal nerve rootlets that contribute to spasticity
• Reducing afferent input to the reflex arc. Normal sensation will not bring about a spastic response

Question 5

Describe the advantages of selective dorsal rhizotomy

Answer 5

• Permanent reduction in spasticity
• Cost per quality adjusted life year over time is low compared to intrathecal baclofen.
• No need for repeat visits to refill or replace pump
• Reduces soft tissue orthopedic surgery and bony surgery

Question 6

Describe the disadvantages of selective dorsal rhizotomy

Answer 6

• GMFCS IV patients with some walking ability may demonstrate a deterioration in walking ability post operatively
• Insufficient extensor strength and control is revealed after removal of spasticity
• Leads to higher level of dependency in the long term
• Scoliosis, kyphosis, and spondylolisthesis
• Obesity is often observed especially in children that walked most slowly were more liable to weight gain post op. Perhaps because they dont have sufficient strength or control to burn off the calories that are not normally being consumed by spastic muscle
• Unrefined control for complex movements

Question 7

Fill in the blank: Intrathecal baclofen treatment is quite effective in the management of ___________ , whereas selective dorsal rhizotomy in the presence of _______ allows ______ posturing to occur without the moderating restraint of spasticity.

Answer 7

dystonia

dystonia

dystonic

Question 8

define: dystonia

Answer 8

Dystonia is defined by involuntary maintained contraction of agonist and antagonist muscles yielding abnormal posturing, twisting and repetitive movements, or tremulous and can be initiated or worsened by attempted movement

Question 9

What are the general guidelines given in this paper related to GMFCS level and surgery?

Answer 9

In general, GMFCS IV and V children with severe spasticity are candidates for intrathecal baclofen and GMFCS grade II children with high levels of spasticity should be considered for selective dorsal rhizotomy.

GMFCS grade III children present the greatest challenge in terms of identifying the correct modality of surgical treatment.