Dorsal Rhizotomy, Keyhole interlaminar approach and intraoperative neuromonitoring for spastic diplegia/ quadriplegia in children with cerebral palsy

OBJECTIVE: Dorsal rhizotomy is considered the gold standard for treating spastic diplegia/quadriplegia in children with cerebral palsy, when rehabilitation programs reveal insufficient to control excess of spasticity. We present the entire surgical technique along with its specific intraoperative neuromonitoring. METHODS: The Keyhole Interlaminar Dorsal rhizotomy (KIDr) modality has been developed to access – individually – all L2-S2 roots, intradurally at the corresponding dural sheath, and preserve the posterior spine architecture. Intraoperative neuromonitoring consists of stimulating each ventral root (anatomical mapping), to verify its myotomal innervation, and dorsal roots (physiological testing), to explore their reflexive muscular responses in order to help determination of the proportion of rootlets to be cut. RESULTS: In all children, excess of spasticity was reduced. This modality offered tailored accuracy. CONCLUSION: KIDr offers direct intradural access to each of the ventral/dorsal roots, thus maximizing reliability of anatomical mapping and allowing individual physiological testing of all targeted roots. Interlaminar approach minimizes invasiveness by respecting the posterior spine structures.