Novel Intradural Endoscopic Lumbosacral Ventral-Dorsal Rhizotomy: A Technical Note With Operative Video.

background and importanceMovement disorders in children, particularly medically refractory hypertonia caused by cerebral palsy, often require surgical intervention. Lumbosacral ventral-dorsal rhizotomy (VDR), which includes sectioning both ventral and dorsal nerve roots, is a viable treatment for dyskinesias like dystonia. However, severe scoliotic spinal rotation can make traditional open rhizotomy and other minimal access approaches technically impractical. We report the first endoscopic VDR, offering a minimal access and non-destabilizing alternative for patients with severe spinal rotation. CLINICAL PRESENTATION: We present a 21-year-old nonambulatory male with spastic, dystonic cerebral palsy, neuromuscular rotatory kyphoscoliosis, and spinal fusion who was nonrespondent to intrathecal baclofen bolus test dose of 100 μg. Severe spinal rotation and a large fusion mass made open and radiofrequency ablation approaches infeasible; we performed a 233-minute endoscopic VDR using flexible neuroendoscopy, mechanical nerve stimulation with free running electromyography, fluoroscopy, and bugbee electrocautery. Lessons learned include visualization, root selection, and extent of ablation. Postoperative modified Ashworth Scale was reduced to 0 in all muscle groups, and physical examination video shows improved sitting position with neutral spinal alignment and enhanced sitting balance.

conclusionThis first-ever endoscopic VDR demonstrates a safe and effective tone reduction methodology for patients without alternative surgical options. We are encouraged by these results and hope that this operative technique may be expanded through continued surgical innovation.