Abstract
Introduction
Risk of severe neurological complications after spinal reconstruction depends on the age of patient, plane, magnitude and rigidity of deformity; repeated operation and pre-op myelopathy increases the risk of complications up to 25% (L.G.Lenke, 2011). Reversibility of severe myelopathy is still under discussion. The purpose of study is to present method and outcomes of intensive post-surgery rehabilitation performed in 9 children with neurological complications of spine reconstruction.
Material and Methods
Design: prospective one-center observations study. 8 cases of post-op myelopathy were revealed after 112 multisegmental (two and more segments) spinal reconstructions in patients aged from 1 till 15 years during 2012–2015. One more patient was admitted from another hospital. Reconstruction was done in cervical-thoracic (3), thoracic (5) and lumbar (1) spine including TB spondylitis (5), neurofibromatosis NF1 (1), congenital abnormality (2), and aggressive hemangioma (1). Pedicle screw malposition caused complication in one case, no surgical mistake was found in others. Neurological deficit preexisted in 6 and appeared in 3 patients reaching after surgery type A (7), type B (1) and C (1) on Frankel scale. Rehabilitation was begun on the second/third weeks after surgery in 5, a month or later - in 4 patients. Course lasted 3 weeks (2), 5–10 weeks (6), and more (1). Neurological changes was assessed by Frankel, ASIA, Ashworth scales; excitability of spinal motoneurons - by H-reflex and posterior root polysegmental responses. Voluntary and stimulation-evoked movements were documented by video and EMG-records.
Results
The program included the spinal cord electrical stimulation (SCES) (except 2 patients with NF1 and hemangioma), apparatus-performed afferent stimulation of the foot supporting zone (“Korvit,” Russia), and muscle spindles activation by the rhythmic passive legs “stepping” (“KRV-4,” Russia). SCES was performed transcutaneously via two channels: 1) upper and lower to the damage zone, with cathode (−) at the C6–7 and anode (+) at the Th11 vertebrae level; 2) to the locomotor zone in lumbar enlargement, with (−) at Th12 and (+) on the abdomen, with rectangular pulse (0.5 milliseconds duration) by the rates 1 and 3–5 Hz, with power of 1.4 -1.8 MT (65–45mA), 40–60 minute per session (patent RU 2204423 C2). Motor program included tetra- and bipedal treadmill and ground walk, cycling and postural training with full and limited body weight support, with total duration 2–6 hours a day. All patients transferred from flaccid to spastic state, with increase of reflexes and muscle tone. Ability for tetrapedal stand and walk were reached in 9/9 cases, for supported stand in 7/9. The patient with incomplete paralysis improved from C to D on Frankel. Initially completely paralyzed patients restored locomotor ability up to overground and upstairs walk (A to D, 3 pts), supported treadmill walk (A to C, 2 pts), with ASIA motor scale increase to 14–18 points. Two patients transferred from A to B grade only.
Conclusions
SCES combined with afferent stimulation and intensive training being performed at early post-op period decrease neurological deficits and contribute to the motor recovery in children with neurological complications caused by spinal reconstruction.