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SNI digital innovations in learning, in association with the UCLA Department of Neurosurgery, Lyndon the Owl, the chairwoman and its faculty, are both pleased to bring to you another in the UCLA
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Department 101 lecture series on neurosurgery and clinical and basic neuroscience.
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This series of lectures are provided free to bring the advances and clinical and basic neuroscience and physicians and patients everywhere. One out of every five people in the world suffer from a
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neurologically related disease.
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This neurosurgery and lecture and discussion will be on selective dorsal rhizotomy for spastic cerebral palsy. It'll be given by Warren Peacock.
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and his co-authors are Loretta Stout and Mark Noor.
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Dr. Peacock, or his professor of emeritus and neurologic surgery at the UCSF Wheel Institute of Neuroscience's in San Francisco, and also an emeritus professor of neurosurgery at the David Geffen
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School of Medicine at UCLA in Los Angeles. I'm playing in Toronto Hospital City And then we went back to South Africa as the first pediatric neurosurgery on the continent. I don't do that. And
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fortunately, before I lived, I trained the two of me. But I was very, very busy. And I've been there back there about one or two. When the pediatric neurologist spoke to me and said, You know,
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you can brain tumors and all these things. But what about the movement disorders in children? What about
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cerebral palsy? or anything like that. And he said, Okay, come to the clinics and we'll teach you. So I went to the clinics and I very rapidly learned about cerebral palsy. And I thought it was
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just something that affected the muscles and joints. But as they pointed out, it's actually called cerebral palsy. And
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it took a little bit of reading to find out that some work had been done And
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I decided that I would look into this. And I saw that the one thing in cerebral pals that we could treat was spasticity, the dystonia's and the other things, a little difficult to treat. But
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spasticity seemed to be something that one could develop a logical approach to. So I went to Christian Barnard. He was the guy who did the first heart transplant at the hospital in Penta, and I was
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just interned at the time he did it. But he said I could use his lab. And so we use baboons to try out a method of doing rhizotomy. And it didn't work initially because the anesthesiologists had
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given the patient muscle the baboon, muscle relaxants. And it, once
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we were able to reverse that, we could see the responses. And I developed a way of stimulating the nerve roots and seeing which responses indicated abnormality and those are the ones that we would
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cut So, what if I
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wanted to just run through the story of the logic behind it and then my story with my involvement? But the two people here at UCLA, Loretta Stauge, who's a PT and Mark Neuer, the neurologist were
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involved in every case that I did and
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they were extremely helpful in modifying even further once I got here.
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But I'm also very glad that I'm not doing plenty of New Jonesy, that was a terrifying disorder. I remember all those that I did, many of them with Marvin and the hemispherectomies, who are
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so stressful. And all I wanted now was to have a non-stressful job. So my patients are all dead now. So I'll make them any worse. What
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is cerebral therapy? Cerebral Pause is a movement disorder due to an insult to the development of the brain. And that's pretty much what it's all about.
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The incidence stood to 3, 000 live births at the moment here in LA, it's 27, which is quite high. But that's the way it's been, and why is it high? If it was so many of these are due to
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premature births and the premature birth rate is not going down.
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10, 000 children born every year with cerebral palsy in this country and 1, 000 in California. And the bulk of them are spastic. And so they're imminently treatable. And we were very busy here.
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And then when I was recruited to go out to UCSF, I started a clinic there which is still going. And I still go out there. The first Friday of the month, I fly up in the morning and come back in
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the evening And we see 12 to 20 patients in a day and operate on a lot of those. But the bulk of the kids with the folks here are born down in Southern California. And we're just not doing that. I
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think what it means is that the orthopedic surgeons are cutting the muscles, which are the poor, unfortunate victims. The muscles and joints are, it's a central nervous system problem and it
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should be dealt with by neurosurgeons.
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and I hope it will get started again.
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So the cause of cerebral palsy is mainly prematurity. There are other causes, but the vast majority, when I go to the clinic, I always want to get a history of the physical therapists, don't
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mystery, look at this, but the important thing is the birth history. And most of them are born under 32 weeks And the lower you go, the higher the incidence of cerebral palsy. And the different
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types of cerebral palsy is mainly spastic. 70, 80 of the kids with cerebral palsy have spastic cerebral palsy. There's a small group that have dystonia, but dystonia is really due to connectors,
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which we don't see anymore. The writhing movement disorders that
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we used to see with the ABO in compatibility.
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Um, so it is mainly specificity that we're dealing with and, uh, my picture cell, but, uh, yeah, I'm going to give it a sec. Uh, the, the basic physiology of muscle tone, you all know. And
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that is that the spinal reflex arc has a, um, an afferent coming from the muscle spindle in the dorsal root, in the posterior root Coming into the spinal cord and synapsing monosynaphically with
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the motor neuron going out to
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the muscle. What, what? So we said that many spastic, the stonic, um, and, um, the, the kids that I'd see at the clinic would be minimally involved and these, these kids walking up on their
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toes. And then the others more severely affected would be crossing their legs and having a great job and then the severely affected the spastic quadriplegic children, okay. The typical gate of a
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kid with spastic syrup was up on their toes and they're flexed at the knees and flexed at the hips and that's due to the
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spasticity and gastroc soleus, flex the hamstrings and sewers so that they're walking like this and this is a little girl here from New York who had a spastic diplegia and then so the cause of mainly
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prematurity and so it's an anoxic ischemic insult that occurs and what it produces is periventricular leukomelatia and sometimes interventricular hemorrhage and here is the periventricular
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leukomelatia that you can see which is so typical and that is what is the background to the movement disorder.
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So
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if you look at the spinal reflex arc, the muscle spindle efferent motor neuron coming around here like that and this is excitatory
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and the descending motor tracks have two functions, one is to inhibit muscle tone and the other one is to coordinate movement. So when there is damage, okay so let's summarize it, the descending
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tracks inhibit muscle tone and the muscle spindle efferent increases it.
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So when you lose descending tracks damaging to the descending tracks there are two effects, one is loss of inhibition which ends up with excess excitation and they have spasticity but the other thing
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which we all notice is the limb is not moved as well.
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But there's something else that happens. Here, if we look at a cross-section of the spinal cord, here's the corticospinal tract descending here. And with damage to that, this inhibitory influence
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is lost. And this synaptic site here is vacated. So what happens is the muscle spindle efferent develops an exonal
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outgrowth, which then occupies that vacated synaptic site. So it's not just loss of inhibition from the descending tract. There is an increase in spasticity as time goes by because of this factor
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here. So what can you do about cerebral palsy? Will they all get physical therapy? Some of them are given muscle reactions and they're not really very effective. By the time it is affected, the
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kid is so sleepy, It's not worthwhile. We use a lot of botulinum toxin in the clinic, orthopedic surgery, sorry. That is that kind of axonal growth or kind of, you know, like kind of setting up
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that synaptic pathway there. Is that a developmental thing? Is there an age at which that tends to slow or stop? You mean the axonal heart growth? Right. I think that's what we see in most
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patients with spasticity It increases with time and there's not any decrease in the descending tracts. And it goes on for a long time. And I think that's one
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of the great advantages of the rhizotomy that you're actually decreasing that as well.
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So orthopedic surgery and that's dealing with spastic muscles where they've been trapped in a real shortening of the muscle physical therapy doesn't really help with that and that is of course due to
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the specificity and then they have joint problems because they're in an abnormal pasture and ultimately dislocation at the hip is common. The intrathecal backlifen pump came in, Leland Albright in
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Pittsburgh, did a lot of that and
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we would often be together at a conference discussing the use of backlifen pump and using selective dorsal rhizotomy. So that is the one that we're really going to talk about.
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The botulinum toxin used for kids who are just walking up on their toes and maybe by relaxing gastroxolias, we can get them down onto their heels. And a lot of kids don't like the casts that they're
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given. It hurts. And if you give botulinum toxin, it decreases the tension in the the muscles and makes it a lot easier and also Some kids start walking up on their toes when they start getting a
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little older and using botulinum toxin helps with that. Inter-theacal batlofen, when it came out, sort of looked as if it was gonna take over completely, but the trouble with it is, it's like a
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shunt. It's fraught with problems. And at the clinic up at UCSF
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it's really used, but there are some patients where rhizotomy is just not the right thing to do, and we do sometimes use it.
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Now, what are the goals with rhizotomy? It's to reduce spasticity, which increases the range of motion. And when these kids are walking like that, their stride is very short. The range of motion
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at each of the joints is reduced. And hopefully by doing that we improve function.
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what the orthopedic surgeons are so frightened about, we reduce the need for orthopedic surgery. A lot of the kids who've already developed contractors still need to have the muscles lengthen, but
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it's much easier to do the surgery if you have less muscle tone. And so in the more severely affected, it improves comfort and makes it easier to handle the kids. So how do you select the patients?
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And this is the single most important thing. The surgery is pretty easy, but the selection of patients is where people go wrong. And there are still certain centers around the country where
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cerebral palsy means rhizotomy. And that really should not be the case. I have seen a lot of patients who have sent to me as spastic, they're not. A lot of patients who have sent us to Estonia,
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they're not as spastic And so that's the first thing that one really has to - identify spasticity.
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You want to be sure they don't have dystonia and dystonia you can see if they're hyper-extaining their wrist or there's a little rotation around the axis of the limb. Dystonia is then present and
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those kids don't do as well. There's something else going on. They need to have anti-gravity power because when
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you do a rhizotomy, they lose a little power for a while and that makes it very difficult to treat them but if they have good anti-gravity power, they'll do well. Good selective control is just
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telling you that they'll do better and they all need therapy because once they've had a rhizotomy, their limbs feel completely different and those who didn't have therapy didn't make us much
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improvement
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So, dystonia, as I say, for me, it's rotation around the and hyper-extension at the risk. As soon as you see that in the child, I'm very wary of going ahead with the rhizotomy.
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Regidity, we see almost every time a patient that's rigid. And these are usually the near drownings. Little kid of 18 months, two years, fell in the water, was pulled out blue and
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nearly brain dead. And they're left with rigidity And that is the lead pipe throughout the range of motion. It is
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rigid. And you may get brisk reflexes with it, but it is not muscle spindle dependent. So doing a rhizotomy does not help. It's something driven by the extra-paramidal system.
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So
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what do I sit down? usually have the kid on the parent's lap. And what am I looking for in spasticity, which you all know, but this is what I like to hear from the people when they call me about a
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kid. There's increased resistance to passive movement and a clasped knife filter to hit the resistance and then it gives. There are brisk reflexes and cloners. And that's pretty much what one sees
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with spasticity. Now, voluntary strength, if the kid is dependent on spasticity and you get them to go down and come up, it'll be a sudden thrust. And if they go to sit down, they collapse right
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down. What you want them to do is come up a little and stop, come up a little bit more and stop in the same going down so that they can break the movement. They have control of it. It isn't just a
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spastic thrust. And this is Lorena Stark, the physical therapist who worked with me.
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The other thing is looking at gluteus medius.
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I can show you here. If this
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person here standing on their left leg, the trunk is going to tilt to the side. And to prevent that, luteus medius contracts to stabilize the pelvis. And if those muscles are weak, they develop
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the Trendelenburg Gate walking like that. And if you do a rhizotomy, you'll make it worse.
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And you want to see that they can actually get up on their toes. If you do a rhizotomy and they cannot do that, they have great difficulty walking. And it's often associated with previous
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orthopedic surgery where they've overlaid them to the Achilles tendon.
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So the good candidate for the dorsal rhizotomy spastices, the main factor, good anti-gravity strength, good selective motor control, mild contractures. If the contractures are mild, they
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probably won't even need orthopedic surgery can be stretched out.
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You want someone who's motivated because they're gonna have to have physical therapy for a year. And if they don't, they just don't do as well. And they really need support from their families.
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So the rationale for our sodomy is decreased inhibition due to the descending tract damage and cutting the posterior roots decreases the excitation So there is a sort of balance between the two. The
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history of this, Sir Charles Sherrington, the great British neurologist, I
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don't know how he came about it, but he took a group of cats and divided their brain stems. And they developed spasticity. You could put them on the ground and they would stay standing. And he
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then opened up the spinal canal cut the dorsal roots and the spasticity went away. So, Otrad first day in Breslau, where Dr. Bathstorf comes from, performed Rizodomy on 89 children and he had
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very good results. But he cut the entire posterior roots from L2 down to S2. And
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the pictures are very good. These kids standing like this and sizzling and after the surgery, standing very well. But the problem was, cutting the entire posterior nerve root, except L4, which
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he left to give them some quadriceps strength, they lost sensation, they was lost of bowel and bladder control. So the operation fell into disrepute.
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But if you look at the posterior roots as they enter the spinal cord, they divide up into rootlets. And it depends which root you're looking at, how many rootlets there are L3 has about three
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rootlets. whereas S1 has eight to 11 rootlets. And it's just the amount of muscle that they are innovating. And so if instead of cutting the entire posterior root, just proximal to the dorsal root
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ganglid, you can actually find these little rootlets and stimulate
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or cut individual ones rather than the whole root
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So I met with Professor Fazano, who had started doing this. He realized that you could divide the roots into rootlets. And he did this by just doing an L1-2 laminectomy. And doing that, you're
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right down on the conus, very difficult to see. And he used intraoperative monitoring. And if there was a wild response, he would cut that root if there wasn't, he would leave it. But. I went
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to see him in Turin. And I'd done one case and the kid developed, couldn't initiate victory, lost bladder control. And I said to him, What about this? And he said, Yeah, we see that,
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frequently. And I said, Really? Does that not worry you? No, well, you know, that's the price you payfor having your spasticity taken away. And I must say, doing that little girl, I will
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never forget, it was very difficult. We had to catheterize her. And I thought, I just can't do this. But the result for the spasticity was very good, but I thought, I've got to do something
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about this. So I, oh, here we go. This is where it all happened. This is Cape Town, that's the city, that's Table Mountain, and down there is the South Pole This is the University of Cape Town
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over here. And this is the medical school down here. And this is where the first heart transplant took place in there. And this is now the big new hospital. And it's a pretty sophisticated place.
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The gold mines and the diamond mines put all their money into the medical schools. And so they are pretty well sorted out. And it's a very, very good medical school And I
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decided that I would do this on baboons first and managed to get the monitoring right. But I just felt exposing the conus was not adequate. And I went down in the autopsy room, smelly, cold, and
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awful place, no section. And I did this procedure on dead adults And I just know how earth am I going to get this right?
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So I took another level, another level, and it was like, catch up down there with all the blood running in and no suction. But, I know, I just don't, oh my God, I can see exactly where each
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nerve root is going on. And I took that back to the lab and we could check it out exactly where we were. And that's what I felt was the contribution that made it safe
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So here is a picture of doing it actually at surgery. We're able to get the level. So if I've opened there, I
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know the largest nerve root is gonna be S1. So I stimulate that and we should get plant deflection and knee flexion. And then I
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go down to S1, S2, and S2 will produce flexion of the toes So I know pretty sure where I am. And doing it that way, there was no further bowel or bladder loss. And we actually had very few
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complications at all. So this is a case here at UCLA doing the rhizotomy, patient prone on the operating table and a bolster under the chest and the pelvis to enable the abdominal wall to move
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freely. So we didn't have raised CSF pressure, incision marked out L5S1, the cross mark And we put electrodes, the Markneur would do this, electrodes into five muscle groups, quads, adductors,
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hamstrings, tibialis anterior and gastroxolias.
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And to be very certain, I was not going to get into any bowel or bladder trouble. We put an electrode into anal sphincter because that's got the same nerve supply as the bladder sphincter,
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pudendal nerve and the inferior rectal nerve, pudendal nerve going to the bladder as well. So if I stimulated a nerve root that caused anal sphincter contraction, an alarm would go off and we would
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definitely not cut that root lid.
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Here it is, opening
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the dura, always left the arachnoid intact until I was ready, there you can see the phylum and the nerve roots coming down on either side like that and this would be about L1 down to S1.
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And in children, this was a very quick procedure. Initially, I did laminectomies but then I did laminotomies. So I would then just make a little opening between L5 and S1, open the dura, open
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the ligament and flavor, and then I'd take a high-speed drill, cut up on either side and then divide the super spinous ligament between L5 and S1, and then flap that up and suture it back at the
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end. And a year or so later, if you took an x-ray, it looked as if there had not been anything done surgically.
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And at surgery, we would stimulate the nerve roots, firstly, to find the level there is the largest nerve root. That's the dorsal root of S1, and these are the electrodes here And
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then go down to
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S2. The neurologist monitors the leg at the lower end of the table and can tell exactly what is happening there. And he's also monitoring it
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electrically as well so that he can see the responses. Here we are stimulating each root in turn. And, you know, although the nerve, The dorsal root. is made up of rootlets, you can go on and
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on breaking it up, but it's fairly clear L1, just two or
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three rootlets there, you could make five or six, but if you just follow without trying to dissect it too much, you get the standard number of rootlets. Now, the response, the stimulus would be
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for one second, 60 hertz, and a normal response would be decrementable over that one second of stimulus, or squared off. But an abnormal response, we want it with incremental, clonic,
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multi-phasic, or sustained.
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And also, if it's spread to the other side.
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So here's a stimulus, 50 hertz stimulus to L3-rootlet, rooted so else we root it on. The right should produce quads and
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adductors, femoral and obturated nerve. And here's what's happening. Right adductors, a decremental response, and that's a normal picture.
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So with that, we would just leave that nerve root behind, move on to the next one. Here is an abnormal response Oh, a 50 Hertz stimulus to the right S1 rootlet. We should get hamstrings and
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gastroxolias on that side, but we're also getting, here we go, gastroc hamstrings, but we're also getting to be aless anterior,
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right quadriceps, right adductors, and spreading to the opposite side. So that would be an abnormal rootlet and we would divide it.
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So, at the end of the procedure, because of the pathology of decreased inhibition from the descending tracts, we cut certain of the rootlets and the excitation and inhibition in our balanced and
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muscle tone returns normal
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So,
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people didn't like this. When I got here, I got into terrible trouble and
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the orthopedic surgeons tried to get me to stop doing it. But there was an article in the New York Times, Tuesday morning, the medical supplement about bold new surgery, and it was Sandy Blakesley,
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who was the New York Times reporter, came to see me and said, I hear one of my friends' child had cerebral palsy and you operated and the kid's doing so well. And with that, the New York Times is
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the best way to get your practice going. And I had to get another secretary because they were just getting calls from all over the place. And it then spread to one of the best medical journals with
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Rita's Digest.
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And so I was getting calls from India and Europe and Australia. And that's how my travel started. Instead of them coming here and paying exorbitant fees, I would go to India or China or Australia.
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And I had a very nice travel time, going to all these different places and teaching them how to do Rosotomy. But I had to prove that it actually worked. Does the Rosotomy reduce spasticity? Does
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it improve the range of movement and thereby improve function? So with the help of Loretta, it was very difficult to get a control group. So we use the patients as their own control. they would be
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assessed six months before surgery and then the day before surgery and then six months to a year after surgery. So that was a pretty reliable control. So here we're looking at the patients, looking
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at muscle tone six months before surgery and then
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the day before surgery. And here looking at them the day before surgery and after surgery And this is muscle tone, it was in all of them. This is not rigged, it was normal. And
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we looked at the range of motion and here it is before surgery, six months before and the day before and here it is six months to 12 months after surgery. And there's an increased range of motion in
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all the different muscle groups that were looked at Here's a little boy that we did. This is him sitting before the surgery, there he is after surgery.
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And looking at, so this is movement. So you want to monitor it with a gate analysis system. And here, if you look at this, this is the early gate analysis, a stick figure. Here is the left leg
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before surgery. You can see the major angle at the knee, and you look at the thigh angle there as well. And you can see post surgery, how that has increased And the same with the right leg, you
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can see the maximum angle there, and you can't hear. And the range of movement at the knee and the thigh was increased, stride length improved, speed of walking improved.
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Ah, now.
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So this is that same little girl, up on her toes, flexed at the hip, flexed at the knee, really unstable
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falling a lot.
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And this is after surgery,
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heel down, not normal, but pretty close to normal, and
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she could not get a heel down, now it's down, and her stride length is improved
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This is the boy operated on in Malaysia,
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very unstable, and
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the right leg's worse than the left.
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And this is him, I think it was a year after surgery, his right leg is still not as good, but he's got his heels down, he's walking pretty well, it's good straddling and he couldn't run before.
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Now he's able to run
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This is a little girl. You can see her toes drag underneath. She's scraping the toenails with that gate. And here she is, little girl from Wisconsin.
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Much better, much happier little girl after that.
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And then the last one, little boy, mainly a toe walker, but you can see not a great range of movement at the hip and the knee.
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The radar.
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So heels down, a nice stride, if you saw a kid like this at the shopping mall, you probably wouldn't think there was much wrong with him.
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So that to me, the actual video, it's all about movement and that's what shows how it works. So I presented this stuff at the American Academy of Cerebral Palsy meeting in Boston the year after I
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got here. And there were 1, 500 people in the audience, though at the end of my talk, the lines of the microphone were unending This is unethical. How dare you do this? Operating on children's
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spines. Who do you think you are? You're a neurosurgeon. What do you know about Cerebral Palsy? And I remember standing there. This is the president of the. Why do you cut the motor roots? It's
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not really. It was. And they were just so rude I've got a few letters of apologies to our police, but it was really terrible. I nearly thought of giving up, but I. went back to the drawing board
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and in fact, the work that I've showed you was what came out then. And I
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went, four years later, the meeting was in San Francisco and I was the invited, yes. And when I was called up to come and give my presentation, they stood up and tapped before I even gave the
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talk because I'd been publishing the stuff and it really worked And they had been so prejudiced, it was such a relief to actually be accepted again. And so we've followed these kids. I thought if
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you're introducing a new procedure, you should follow them. We've followed them every five years, but I won't go through each other. Here's that little boy you saw, here he is before, here he is
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after, here he is 20 years later. That's the long-term results in Cape Town the 27 patients are operated on 1985.
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And here, Barbara Van der Wiel and Mark Neuer looked at 105 consecutive cases that I did and looking at complications. And the complications that we had was fever, post-operative fever in
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many of the patients for 48 hours. Well, I wouldn't really have considered that a complication No saturation in nine out of 105, post-catheterization, all of them had catheters in. And there were
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six females, four males who got cystitis and
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constipation. They were on morphine and they got a fleet enema on the fifth day that solved the problem. But that's what there was. And there was no wound breakdown, no CSF leakage, no wound
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infections, and no interference with bowel and bladder
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So I think we did prove that Rosotomy. does improve function with long-lasting results, and it can have a very low complication rate. We're coming out, I think it's just been accepted, the
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Journal of Neurosurgery, our 30-year follower of those same patients, and they're all doing well. I go back to South Africa every year, and we get together, they're married, and they've got kids,
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and their improvement has been maintained, and they haven't developed any long-term complications. Rose, aren't
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we? How could you do this operation?
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I thought I was going to read you a very quick question. Why aren't you doing that? How much can you get? As you know, there's groups out there that are just saying, send us videos, and we're
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going to assess, but, and obviously you need to do a physical examination, but how much can you tell by just looking at the game, whether or not you're likely a good
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candidate? Part of it I was going to be sharing some other pictures of.
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what I would choose to do with it. But
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there are a few subtle things that is, you know, if you see a kid with big shoulder muscles, you know that they've got weak legs. They're using their walk out or they're using
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painless. And just subtle things that you pick up that I wouldn't want to miss because they look at it, they're going to spastic that feature, but they've got big shoulders and there's a giveaway.
40:08
Little things like that you want to see that you wouldn't see in a video and also coming up on their toes and being able to stand on one leg and being able to break their movements as they come up and
40:23
down so that it's not just a spastic thrust because if you're not careful there'll be weaker after you've started and
40:32
I think it does help to really get the history and see the patient.
40:39
Great, great, great talk, Dr. Pico. I have a question about these abnormal root lids. Is it one root lid per muscle or were they so aberrant that other root lids potentially had taken over that
40:51
function of that muscle so that when you cut something up, there's like other compensatory takeover. I don't, or teach us this. I think the answer to the question, but what I assume is the case
41:02
that the anterior bone cell pool is differentially disinhibited So whichever rootlet you're getting, those anterior bone cells have lost more inhibitory fibers than the rootlets lower down or higher
41:17
up, in the same root that have normal amount of inhibition. It does work. And when you go through the rootless, even if you repeat it, you get pretty much the same picture each time you do it.
41:35
Um, thank you. That was wonderful. Uh, it seems like right off the bat, you seem to have really good outcomes. I'm just curious, like, over time, did you have tweak anything or change
41:46
anything and prove on anything? I'm like, oh, but I'll be. Yeah, I had tried all the time to make this case better than the last one, but, um, you get to a point where the team Selecting
41:59
selecting the right face. That's probably the single most important thing. And the second thing is to have Mark newer or someone like that. In the room doing the case, because it's how do you
42:11
select these Notice in the end, it would just be cut. Don't cut. Don't cut. It wouldn't go over what it was done. And
42:19
I knew that he was actually reliable and Loretta used to come to the OR as well. And she would just go back on that again that the helical is much tighter on that side and
42:34
It's the teamwork that really brings it together. You're just the pattern, not the pattern.
42:42
Yeah, it worked. This brings back great memories. Seeing the intrap photos and the videos and everything, and it was such a wonderful time for all of us who trained with you to have you. And it
42:54
just brings back great memories. And I'm glad that although the residents now didn't get the experience we did with you, operate and they at least get part of it And to be able to share this
43:02
knowledge, it is outstanding. And I just wanted to thank you for coming and hearing that. And I'll tell you, if you guys look at the pictures, you saw there was like no blood in the field, it
43:12
was perfectly clean, perfectly dry, cotton weights perfectly aligned, everything was perfect. And that's such a great way to do the surgery and work really influence a lot of us. So you do get
43:23
some of the benefit of him teaching through me and Marvin and Linda in some ways. be as good as original, but at least you get some of it. And the Dural Sutra Mind perfectly stitched. Everything
43:36
looks great. No CSF leaks, just really good, clean surgery. And so I'm just so happy you're able to share that with everybody. Thank you so much, thanks to the area. It's a very rewarding thing
43:47
to do.
43:50
I'm now 30 years out on these kids more actually in South Africa. I go back and we're great friends It's made such a difference to their lives and even more so to their parents. But my question to
44:06
you is,
44:07
and I guess I didn't know it at the time when we were a resident. I mean, we were a national referral center for this particular procedure, right? And I guess how has the field developed and what
44:18
others, 'cause you talked about UCSF does this, but why is it that now we don't do it as much? And then there are other centers that have evolved other ways and enjoy. I think here in California
44:32
they go to UCSF because the parents spread the word around most of them but you know whenever anybody takes over an operation they're always modified a little bit so it's their operation and it's been
44:46
modified. Some people don't do the complete laminating labanotomy. We had no problems from that. We've actually had all those spines 30 years later and there hasn't been a problem but people do
44:60
modify it in Boston. They do it a different way from Salt Lake City and
45:06
it's just a pity it's not being done here. You guys are all busy but it is a very rewarding thing to do and you know Southern California probably has 600-700 born a year and most of them are spastic.
45:23
The orthopedic surgeons are cutting their muscles and they're cutting them again and cutting them again because they remain spastic It.
45:30
would be nice. But I guess if this is a better procedure, you would think of climate-related wall to be more widely used than this petting fossil. So I guess, and there could be other reasons,
45:43
right, that why certain things don't develop, you know, not necessarily just, you know. Yeah CPT, goes and things like that. So I guess I'm just trying to figure out, you know. Yeah,
45:56
and I think the hope there is improvement, but we did have pretty much zero, neuro-social complication rate with it. And I think if it's damn careful, you can be
46:16
my day. Thank you. Mark. You're such a stard. Didn't I see what the Academy Awards are? One. With my wife. That's his wife, yeah. He literally was at the Academy Awards, because his wife
46:25
wanted the Academy Award for us. Yeah, yeah with the chronicles of Narnia, right? Still doing that, you know, he's sitting up there typing away, yeah. There was just a great pleasure to come
46:36
to the people who are very bothered, and as this is a neurosurgery procedure, I hate to say the orthopedic surgeons to go there.
46:45
Oh, I'll ask you a picture of me with my background. It's a remarkable that you were able to develop this. Do you think you could actually do it again today? You and I talked about how it was so
46:56
instrumental to have a readily available, inexpensive, large animal model to develop the surgery on. And this was like a product of you being in Cape Town at the time that you were. How would you
47:08
do it again today?
47:11
It'd be a hell of a job because I had access to primates, which in South Africa is no longer available. And I had worked with Chris Barnard who allowed me to use the lab. It would be very difficult
47:28
today to do that. very difficult today to introduce a procedure like that. You'd get criticized very, very quickly, but I was fortunate in South Africa, you could pretty much do what you like,
47:42
and when I came here, you could do, you know, introduce a new procedure and it was advertised very nicely about the New York Times. I'd
47:54
have to start it again I think one of the things you have to do, you have to, like, develop something for an
48:03
unsolved problem, right? Like, something that, like, has no other, like, legit treatment, you know?
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