选择性腰骶脊神经后根+前根切断术治疗混合型脑瘫

Selective lumbosacral posterior and anterior rhizotomy for mixed cerebral palsy

中文关键词:  脑性瘫痪  选择性脊神经后根切断术  选择性脊神经前根切断术  疗效

英文关键词:Cerebral palsy  Selective posterior rhizotomy  Selective anterior rhizotomy  Efficacy

中文摘要:

  【摘要】 目的：探讨选择性腰骶脊神经后根切断术（selective posterior rhizotomy，SPR）联合选择性脊神经前根切断术（selective anterior rhizotomy，SAR）治疗混合型脑瘫的疗效。方法：2004年1月~2010年1月，选择48例混合型脑瘫患者，其中男36例，女12例，年龄3～22岁，平均8.8岁，均以痉挛型为主，伴有下肢徐动，术前下肢肌张力均为3级（根据Ashworth 5级法），术前下肢功能情况：独立行走36例，简单介助行走8例，介助站立并有行走动作4例。采用SPR+SAR联合治疗，术中根据肢体痉挛程度切断部分脊神经后根，其中L5、S1后根38例，L4、L5、S1后根10例，后根切断比例为30%~50%；按徐动程度切断部分脊神经前根，其中L5前根28例，S1前根20例，切断比例为30%；术中尽可能保留椎板，以维持脊柱稳定性。结果：术后出现小腿或足底麻木感2例，下肢肌力下降3例，腰痛2例，腰部无力5例，小便控制差1例，经营养神经、康复锻炼、神经肌肉兴奋仪刺激等处理，6个月内症状基本消失。随访18个月。48例患者肌张力术后1周、6个月、18个月均较术前明显改善，痉挛缓解率100%。下肢徐动症状：术后1周时，1例症状加重，经联合应用镇静药物及巴氯芬3个月后恢复至术前，4例无变化，43例改善；术后6个月时，5例较术前无变化，43例改善，无加重病例；术后18个月时，44例明显改善，4例无明显变化，无加重病例。术后18个月随访时，术前介助行走的8例患者中，5例可独立行走，3例无变化；术前介助站立的4例患者中，1例可独立行走，2例可独自站立，1例无变化。结论：腰骶SPR+SAR治疗以痉挛型为主伴有下肢徐动的混合型脑瘫，能有效解除肢体痉挛，降低肌张力，而且能在一定程度上控制下肢徐动症状，是治疗此种混合型脑瘫比较合理的手术方法。

英文摘要:

  【Abstract】 Objectives: To investigate the efficacy of selective posterior rhizotomy(SPR) with selective anterior rhizotomy(SAR) for the treatment of mixed cerebral palsy. Methods: 48 patients with an average age of 8.8 years old（3-22 years） were reviewed retrospectively from January 2004 to January 2010. There were 36 males and 12 females. All cases had mixed cerebral palsy, and all patients presented with spasm compliacted with lower limb athetosis, the muscular tension according to Ashworth spasticity scale was grade 3. Preoperative lower limb dysfunction included: walking independently in 36 cases, walking with assistance in 8 cases and standing with assistance in 4 cases. SPR with SAR was applied in all cases. The L5 and S1 posterior roots in 38 cases and L4, L5 and S1 posterior roots in 10 cases were cut off partly in accordance with the degree of lower limb spasticity by preoperative physical exam. 30-50 percent of the posterior nerve roots were cut off. The L5 anterior roots in 28 cases and S1 anterior roots in 20 cases were cut off partly in accordance with the degree of athetosis. 30 percent of the anterior nerve roots were cut off. Laminae were maintained as far as possible so as not to violate the stability of spine. Results: Postoperative leg or foot numbness were noted in 2 cases, lower limb weakness in 3 cases, low back pain in 2 cases, lower back weakness in 5 cases, urine dysfunction in 1 case, all these were resolved by the corresponding intervention in six months. The average follow-up was 18 months, 48 cases with muscle tension at 1 week, 6 months, 18 months after operation improved significantly compared with preoperation, and the spasm relief rate reached 100%. As for the lower limb athetosis: after 1 week, deterioration was noted in 1 case, which was controlled satisfactively after administration of sedative drugs and baclofen; unchanged in 4, and excellent in 43 cases; after 6 months, unchanged in 5 cases and excellent in 43 cases, no case was noted deterioration; after 18 months, excellent in 44 cases, unchanged in 4，and no deterioration. After 18 months, 5 of 8 cases suffering from immobilization could walk independently, while 3 remained unchanged. 1 of 4 cases suffering standing difficulties could walk independently and 2 could stand up independently, while 1 remained unchanged. Conclusions: SAR and SPR are applicable to mixed cerebral palsy complicated with spasm and lower limb athetosis, which can not only decrease muscle tension, but also control lower limb athetosis to a certain degree.