Selective dorsal rhizotomy: functional anatomy of the conus-cauda and essentials of intraoperative neurophysiology

Introduction Spasticity is the result of an exaggeration of the monosynaptic muscle stretch reflex due to lesions affecting the central nervous system, in particular an upper motor neuron lesion. Selective dorsal rhizotomy (SDR) is a surgical technique developed to treat spastic diplegia, one of the common forms of cerebral palsy, resulting from the lack of supraspinal inhibitory controls. The aim of SDR is to identify and cut a critical amount of the sensory rootlets, in particular those contributing the most to spasticity, in order to relieve the patient from lower limb spasticity while preserving motor strength and sphincter control. Various surgical techniques to perform SDR have been proposed over time. Similarly, intraoperative neurophysiology (ION)—first introduced by Fasano and colleagues in 1976—is a safe and effective tool to guide the surgeon in the procedure of SDR, but different ION strategies are used by different authors, and the value of ION itself has been questioned. Methods The purpose of this paper is to review the anatomo-physiological background of SDR, the historical development of the surgical technique, and the essential principles of ION. Results While some surgeons privilege a single-level approach and others a multi-level approach, nowadays, there are still neither agreement nor guidelines on the percentage of roots to be cut. Rather, a tailored approach based on both the preoperative functional status as well as intraoperative ION findings seems reasonable. ION is considered not essential to decide the percentage of roots to cut, but it assists to distinguish between ventral and dorsal roots, and to preserve sphincterial function, whenever S2 rootlets are included in SDR. Conclusions To optimize the balance between reduction of spasticity and preservation of motor strength while minimizing the neurological damage remains the main goal of SDR.