| Objective:Cerebral palsy(CP)is the most common disabling disorder in childhood and a lifelong disorder which severely affected their daily life and brings a great burden of society and economic in the world.The standard of diagnosis and treatment for CP in China has not been established because of our unmatured CP registration system.Surgery is an effective treatment for CP children and the crucial of a successful surgery is the accuracy and objective evaluation on the operation comes with the clinical concepts of individualization and precision medicine.In order to evaluate the use of electromyography(EMG)in the selective obturator neurotomy(SON)and the recovery,we collected spastic CP samples who come to our hospital and accepted the surgery treatment.Use EMG during the selective obturator neurotomy was evaluated and the application of surface electromyography(sEMG)in surgical treatment and postoperative rehabilitation were also analyzed.Method:Spastic CP children who underwent SON at Department of Neurosurgery in our hospital were enrolled in the study.The selection criteria of cases are as following:(1)all patients met diagnostic criteria for spastic CP as determined by the international cerebral palsy congress in 2006.(2)Paralysis situation:the type of spastic CP was lower limb spastic cerebral palsy.The adductor muscle tension of the affected limb was significantly increased,Patients had obviously hip adduction deformity and their hip abduction angle less than 30 degrees,all of them were able to walk independently.(3)Intelligence status:normal level of the intelligence is necessary for these CP children,and that makes them have the ability to cooperate with clinical treatment and finish the clinical examinations.(4)Detailed and reasonable preoperative evaluation:All patients must take the X-ray examination to exclude the subluxation and luxation of the hip joint,make sure that there was no skeletal deformity and fractures before our SON.(5)Informed consent:the patients' parents have understood all aspects of the informed consent,and they were asked to sign an "informed consent form".The exclusive criteria are:(1)The patients who suffered from dystonia caused by encephalitis,meningitis,or other kinds of brain diseases caused by trauma.(2)Patients who could not be intolerant to this operation were excluded from the study.CP children who met the inclusion criteria underwent SON.The EMG of the adductor muscle on the affected side was monitored according to the compound muscle action potential(CMAP)during the operation,and the SON were conducted by the amplitude change of CMAP.Strict follow-up was performed at the other two timepoints,one is two weeks after surgery and the other is after 6 months'rehabilitation treatment according to different conditions of the patients.Modified Ashworth Scale(MAS),Holden functional ambulation classification score,hip abduction and surface electromyography(sEMG)were used to evaluate the patients' situation at the three timepoints:before the operation,2 weeks after operation and 6 months post-rehabilitation treatment.MAS and Holden functional ambulation classification score were grade variables and were descriptively analyzed and descripted the counting data to watch the change trend.Hip abduction and sEMG data including the integrated electromyography(iEMG)and root mean square(RMS)were analyzed in One-way analysis of variance of repeated measurement data.Statistical analysis was performed in GraphPad Prism 7.0 and IBM SPSS 25.0 software,p<0.05 was considered statistically significant.Results:1.The application of intraoperative EMG:the intramuscular CMAP of adductor muscle was recorded when it accepts the electronic stimulation during the operation,amplitude of CMAP would decrease when the nerve was narrowed.Reduction of 50%to 75%in triggered CMAP amplitudes was the major goal of our surgical treatment while the contraction shows a decrease in its strength.The utilization of intraoperation EMG can help clinicians to determine the degree of fascicular resection in SON and provide an objective evidence for surgical decision making.2.Evaluation of subjective scoring system:The adductor muscle tension was significantly reduced while gait was significantly improved 2 weeks after operation,and there were no symptoms of torso swing when walking.After 6 months of rehabilitation training,the patient's adductor muscle tension remained stable,and the gait was still coordinated,no spasticity reoccurrence was complained in these 18 CP children.The data of hip abduction were conversed by In(),it could be considered normal distribution judged by the histogram;as the variance covariance matrix moments of the dependent variables are not equal(p<0.01)by the Mauchly's spherical hypothesis test,the Greenhouse&Geisser correction ?=0.963 was given.The changes of hip abduction at the three timepoints were statistically significant(p<0.01).The hip abduction of 2 weeks after operation was significantly increased compared with pre-operation and the increases of hip abduction also make scene when 6 months after rehabilitation training compared to 2 weeks after operation(p<0.01).3.Evaluation of sEMG:The changes of iEMG and RMS in the patients'electromyograms were recorded at three timepoints and were expressed by meanąstandard.The data of iEMG and RMS were conversed by In(),it could be considered normal distribution judged by the histogram;as the variance covariance matrix moments of the dependent variables are not equal(p<0.01)by the Mauchly's spherical hypothesis test,the Greenhouse&Geisser correction ? was 0.804,0.805,0.376 and 0.778 respectively.The changes of EMG at three time points were statistically significant(p<0.01).Pairwise comparison showed that the iEMG and RMS of passive exercise at 2 weeks after surgery were significantly lower than those before surgery(p<0.01).The iEMG and RMS of passive and voluntary exercise at the third timepoint also decreased compared with the second timepoint,but it did not show significantly(p>0.05).Conclusion:1.Intraoperative EMG can be used to help the surgeon targeted nerve fascicles and avoid iatrogenic injury.The target nerve can be resected accuracy according to the change of CMAP amplitude,which can increase objectivity in the step of neurotomy.Utilization of intraoperative EMG in SON deserved be encouraged.2.Selective obturator nerve constriction has a significant effect on patients with spastic cerebral palsy whose main clinical manifestation is adductor muscle spasm.The muscle tension of the patients was obviously reduced,spasticity was significantly alleviated,and gait is obviously improved after the operation.The systematic rehabilitation training after the operation helps to improve the patient's limb balance ability and coordination,and should be recommended as an effective assistance therapy for CP children.3.Muscle function of patients can be quantified by EMG recording and reflect the changes in the patient's muscle tone objectively,which is better than the subjective assessment of the scale.EMG can be used as the main method for evaluating the effect of surgical treatment of cerebral palsy patients. |
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