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      Frequency distribution in intraoperative stimulation-evoked EMG responses during selective dorsal rhizotomy in children with cerebral palsy—part 1: clinical setting and neurophysiological procedure

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          Abstract

          Introduction

          Selective dorsal rhizotomy (SDR) consists of microsurgical partial deafferentation of sensory nerve roots (L1–S2). It is primarily used today in decreasing spasticity in young cerebral palsy (CP) patients. Intraoperative monitoring (IOM) is an essential part of the surgical decision-making process, aimed at improving functional results. The role played by SDR-IOM is examined, while realizing that connections between complex EMG responses to nerve–root stimulation and a patient’s individual motor ability remain to be clarified.

          Methods

          We conducted this retrospective study, analyzing EMG responses in 146 patients evoked by dorsal–root and rootlet stimulation, applying an objective response–classification system, and investigating the prevalence and distribution of the assessed grades. Part1 describes the clinical setting and SDR procedure, reintroduced in Germany by the senior author in 2007.

          Results

          Stimulation-evoked EMG response patterns revealed significant differences along the segmental levels. More specifically, a comparison of grade 3+4 prevalence showed that higher-graded rootlets were more noticeable at lower nerve root levels (L5, S1), resulting in a typical rostro-caudal anatomical distribution.

          Conclusions

          In view of its prophylactic potential, SDR should be carried out at an early stage in all CP patients suffering from severe spasticity. It is particularly effective when used as an integral part of a coordinated, comprehensive spasticity program in which a team of experts pool their information. The IOM findings pertaining to the anatomical grouping of grades could be of potential importance in adjusting the SDR-IOM intervention to suit the specific individual constellation, pending further validation.

          Trial registration

          ClinicalTrials.gov ID: NCT03079362

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          Most cited references48

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          Electrical stimulation of excitable tissue: design of efficacious and safe protocols.

          The physical basis for electrical stimulation of excitable tissue, as used by electrophysiological researchers and clinicians in functional electrical stimulation, is presented with emphasis on the fundamental mechanisms of charge injection at the electrode/tissue interface. Faradaic and non-Faradaic charge transfer mechanisms are presented and contrasted. An electrical model of the electrode/tissue interface is given. The physical basis for the origin of electrode potentials is given. Various methods of controlling charge delivery during pulsing are presented. Electrochemical reversibility is discussed. Commonly used electrode materials and stimulation protocols are reviewed in terms of stimulation efficacy and safety. Principles of stimulation of excitable tissue are reviewed with emphasis on efficacy and safety. Mechanisms of damage to tissue and the electrode are reviewed.
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            Development and reliability of a system to classify gross motor function in children with cerebral palsy.

            To address the need for a standardized system to classify the gross motor function of children with cerebral palsy, the authors developed a five-level classification system analogous to the staging and grading systems used in medicine. Nominal group process and Delphi survey consensus methods were used to examine content validity and revise the classification system until consensus among 48 experts (physical therapists, occupational therapists, and developmental pediatricians with expertise in cerebral palsy) was achieved. Interrater reliability (kappa) was 0.55 for children less than 2 years of age and 0.75 for children 2 to 12 years of age. The classification system has application for clinical practice, research, teaching, and administration.
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              Practice parameter: diagnostic assessment of the child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.

              The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society develop practice parameters as strategies for patient management based on analysis of evidence. For this parameter the authors reviewed available evidence on the assessment of a child suspected of having cerebral palsy (CP), a nonprogressive disorder of posture or movement due to a lesion of the developing brain. Relevant literature was reviewed, abstracted, and classified. Recommendations were based on a four-tiered scheme of evidence classification. CP is a common problem, occurring in about 2 to 2.5 per 1,000 live births. In order to establish that a brain abnormality exists in children with CP that may, in turn, suggest an etiology and prognosis, neuroimaging is recommended with MRI preferred to CT (Level A). Metabolic and genetic studies should not be routinely obtained in the evaluation of the child with CP (Level B). If the clinical history or findings on neuroimaging do not determine a specific structural abnormality or if there are additional and atypical features in the history or clinical examination, metabolic and genetic testing should be considered (Level C). Detection of a brain malformation in a child with CP warrants consideration of an underlying genetic or metabolic etiology. Because the incidence of cerebral infarction is high in children with hemiplegic CP, diagnostic testing for coagulation disorders should be considered (Level B). However, there is insufficient evidence at present to be precise as to what studies should be ordered. An EEG is not recommended unless there are features suggestive of epilepsy or a specific epileptic syndrome (Level A). Because children with CP may have associated deficits of mental retardation, ophthalmologic and hearing impairments, speech and language disorders, and oral-motor dysfunction, screening for these conditions should be part of the initial assessment (Level A). Neuroimaging results in children with CP are commonly abnormal and may help determine the etiology. Screening for associated conditions is warranted as part of the initial evaluation.
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                Author and article information

                Contributors
                simone.wolter@charite.de
                Journal
                Childs Nerv Syst
                Childs Nerv Syst
                Child's Nervous System
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                0256-7040
                1433-0350
                23 June 2020
                23 June 2020
                2020
                : 36
                : 9
                : 1945-1954
                Affiliations
                [1 ]Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
                [2 ]GRID grid.212340.6, ISNI 0000000122985718, Department of Molecular, Cellular, and Basic Medical Sciences, Center for Discovery and Innovation, , City University of New York School of Medicine, ; New York, NY USA
                [3 ]GRID grid.253482.a, ISNI 0000 0001 0170 7903, Neuroscience Program, , Graduate Center of the City University of New York, ; New York, NY USA
                [4 ]Division of Pediatric Neurosurgery, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
                [5 ]Center for Chronically Sick Children (SPZ), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
                [6 ]GRID grid.15090.3d, ISNI 0000 0000 8786 803X, Division of Pediatric Neurosurgery, , Universitätsklinikum Bonn, ; 53127 Bonn, Germany
                [7 ]GRID grid.14095.39, ISNI 0000 0000 9116 4836, Dahlem Research School, , Freie Universität Berlin, ; 14195 Berlin, Germany
                Author information
                https://orcid.org/0000-0001-7741-8761
                Article
                4734
                10.1007/s00381-020-04734-z
                7434802
                32577878
                c2f8891e-ae27-4855-8caa-41d98df0fbcb
                © The Author(s) 2020

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 5 June 2020
                : 8 June 2020
                Funding
                Funded by: Charité (3093)
                Categories
                Focus Session
                Custom metadata
                © Springer-Verlag GmbH Germany, part of Springer Nature 2020

                Neurology
                intraoperative neuromonitoring,sdr,threshold intensity,lumbosacral level differences,rostro-caudal anatomical distribution,stimulation-evoked emg response

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