Selective Dorsal Rhizotomy: Analysis of two rootlet sectioning techniques

Selective Dorsal Rhizotomy: Analysis of two rootlet sectioning techniques | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Selective Dorsal Rhizotomy: Analysis of two rootlet sectioning techniques Beatriz Mantese, Christian G. Pirozzi Chiusa, Yamila Basilotta Márquez, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2990142/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Dec, 2023 Read the published version in Child's Nervous System → Version 1 posted 7 You are reading this latest preprint version Abstract Objective To analyze and compare the efficacy of two selective dorsal rhizotomy (SDR) techniques with intraoperative neurophysiological monitoring, using instrumented three-dimensional gait analysis. Introduction: SDR is a common, irreversible surgical treatment increasingly used to address gait disturbances in children with chronic non-progressive encephalopathy by reducing spasticity. Various techniques have been used, which mainly differ in the percentage of rootlets selected to be sectioned. A greater proportion of rootlets sectioned leads to a better reduction of spasticity; however, there is a potential risk of unwanted neurological effects of excessive deafferentation. While there is evidence of the short- and long-term benefits and complications of SDR, no studies have compared the effectiveness of each technique regarding gait function and preservation of the force-generating capacity of the muscles. Materials and methods Instrumented three-dimensional gait analysis was used to evaluate two groups of patients with spastic cerebral palsy treated by the same neurosurgeon in different time periods, initially using a classic technique (cutting 50% of the nerve rootlets) and subsequently a conservative technique (cutting no more than 33% the nerve rootlets). Results In addition to an increase in knee joint range of motion (ROM), in children who underwent SDR with the conservative technique a statistically significant increase (p = 0.04) in the net joint power developed by the ankle was observed. Patients who underwent SDR with the conservative technique developed a maximum net ankle power of 1.37 ± 0.61 [unit: W/BW], whereas those who were operated with the classic technique developed a maximum net joint power of the ankle of 0.98 ± 0.18 [unit: W/BW]. Conclusion Our results show that both techniques led to a reduction in spasticity with a positive impact on the gait pattern. In addition, patients treated with the conservative technique were able to develop greater net ankle joint power, leading to a better scenario for rehabilitation and subsequent gait. Rhizotomy Gait analysis Cerebral palsy Muscle power Spasticity Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION Spasticity is a motor disorder characterized by increased muscle tone that interferes with mobility and affects development and quality of life [ 1 ]. It also causes muscle shortening affecting bone growth and leading to deformities; therefore, its treatment is relevant in the management of children with cerebral palsy [ 2 ]. Treatment options are either surgical or nonsurgical. Selective dorsal rhizotomy (SDR) is a common, irreversible, surgical treatment to reduce spasticity [ 3 ]. The procedure is mainly performed at the lumbosacral level and consists of the interruption of the afferent stimulus of the monosynaptic stretch reflex. To preserve sensory and sphincter function, the dorsal root is divided into rootlets and only a part of these is sectioned [ 4 ]. ( Fig. 1 ) The surgery was first reported in 1888 by Robert Abbe in New York, who performed the posterior rhizotomy for the treatment of refractory pain, sectioning all the posterior roots. In 1908, Otfrid Foerster, a German neurologist and neurosurgeon, used the technique to reduce spasticity of the lower extremities to allow ambulation, relieve pain, and facilitate activities of daily living. He later observed that the intervention also produced a proprioceptive sensory deficit and significant weakness. In 1967, Gros revised the procedure described by Foerster, sparing one-fifth of the posterior root from L1 to S1 to preserve sensitivity, with poor functional results. In 1978, Fasano et al. reported the use of electrical stimuli to identify the roots involved in abnormal reflexes [ 5 , 6 ]. Peacock et al. modified Fasano's technique, changing from the conus medullaris to the cauda equina between L2-L5 and identifying the nerve roots to preserve sacral innervation [ 7 , 8 ]. In 1976, Edgardo Schijman reported a series of 25 patients who underwent surgery with the Peacock technique at the Instituto de Rehabilitación in Argentina. In 2005, the technique of limited rhizotomy from L4 to S2 under intraoperative neurophysiological monitoring, described by Jorge Lazareff [ 9 ] was used in eight patients at the Hospital Juan P. Garrahan, incorporating instrumented gait analysis at the Fleni Gait and Movement Laboratory before and after treatment. In 2007, SDR with intraoperative neurophysiological monitoring was introduced at the Fleni Institute following the Peacock technique [ 8 ] with bilateral L1 to S1 laminectomy and transection of 50% of the rootlets, regardless of the Gross Motor Function Classification System (GMFCS) level of the patient. As of 2015, the technique was modified and SDR was performed preserving the proximal roots and sectioning 20% of the L1 rootlets, 33% of the L2-L3-L4 rootlets, and eventually approximately 33 or 20% of the L5 rootlets, depending on the appearance of the soleus; 20% of the S1 rootlets are sectioned with special care of the plantar flexors. Rootlets involved in the innervation of muscles that contribute to standing (gluteus maximus, gluteus medius 25%, hamstrings 25%, and soleus 50%) are not cut. Extreme care is taken when sectioning S1 and S2 rootlets to avoid bladder injury and paralytic flatfoot [ 10 ]. This approach is based on the results presented by Dr. Molenaers and his team in Belgium, who treated patients with spastic diplegia and concluded that the treatment was more effective on the proximal muscles, resulting in a more efficient gait [ 11 ]. There is growing evidence that in the short term, SDR combined with physical therapy is effective at reducing spasticity and leads to significant changes in gait parameters and improvement in gross motor function in children with cerebral palsy [ 12 , 13 , 14 ]. Further long-term studies are needed to confirm whether these changes persist over time [ 15 , 16 ]. Currently, SDR is a standard surgical technique aimed at reducing spasticity in patients with cerebral palsy. Although, as described above, several surgical strategies have been reported, the differences in the functional effects produced by each have not been clearly demonstrated. Surgical techniques differ mainly in the number of rootlets that are selected for sectioning. Severing too many fibers may compromise useful muscle tone, while severing too few may result in insufficient effectiveness or possible recurrence. This seems to make sense, but so far the difference between a classic technique such as Peacock's technique and a more conservative approach such as that of the group of Molenaers has not been determined. The aim of this study was to evaluate the differences between the two SDR techniques performed in different periods of time by the Neurosurgery team at Fleni using instrumented three-dimensional gait analysis to assess the impact on functional gait of the patients. Instrumented three-dimensional gait analysis provides supporting evidence in the selection of the ideal candidate child for SDR and allows for the quantitative monitoring of outcome and postoperative management until skeletal maturity [ 17 ]. MATERIAL AND METHODS Patients This retrospective study was approved by the Fleni Ethics Committee. Patients with spastic cerebral palsy who met the following criteria were included in the study: (1) underwent RDS (all operated by the same neurosurgeon) between March 2009 and December 2019; (2) younger than 13 years at the time of SDR; (3) underwent at least one three-dimensional gait analysis study at no more than 21 months before SDR (considered the initial study) and one three-dimensional gait analysis study between 2 and 31 months after SDR (considered the follow-up study); (4) ambulatory at the time of the initial and follow-up three-dimensional gait study; (5) did not undergo any surgery other than SDR between the initial and follow-up study; and (6) consented to the use of their records for research purposes. All data were collected from the patients’ medical records. Two surgical techniques were performed from L1 to S1 bilaterally: in the first technique, all the rootlets were cut up to 50% (classic technique proposed by Peacock) and in the second technique, the rootlets were cut as follows: L1: 25%, L2, L3, and L4: 33%, L5: 25%, and S1: 15% (conservative technique proposed by Molenaers). In addition to gait studies, all patients underwent MRI of the brain and complete spine, urological examination, and pre- and post-voiding ultrasound; in case of abnormal findings on the latter, a urodynamic study was performed. All patients had intensive physical therapy rehabilitation 5 days a week for one year. Table 1 details the main patient characteristics, including age, sex, and GMFCS level [18] at the time of SDR, as well as surgical technique and the percentage of sectioned rootlets in each case. Table 1: General patient characteristics. PATIENT TECHNIQUE GMFCS AGE SEX APPROACH RIGHT LEFT L1 L2 L3 L4 L5 S1 L1 L2 L3 L4 L5 S1 1 CLASSICAL 1 13 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 2 12 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 0% 50% 50% 20% 10% 0% 0% 50% 50% 20% 10% 0% 3 6 M Incision D12 - S2 / Laminotomy L1 - L5 / Miniplate fixation 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 4 2 13 F Incision D12 - L3 / Laminotomy D12 - L2 / Miniplate fixation 50% 50% 50% 0% 0% 0% 50% 50% 50% 0% 0% 0% 5 13 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 30% 50% 50% 50% 50% 30% 30% 50% 66% 50% 50% 30% 6 5 F Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 7 13 F Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 50% 50% 33% 33% 33% 0% 50% 50% 33% 33% 33% 0% 8 5 M Incision D12 - S1 / Laminotomy L1 - L5 / Miniplate fixation 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 9 3 7 F Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 20% 50% 50% 50% 33% 20% 20% 50% 50% 50% 33% 20% 10 6 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 11 10 F Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 33% 50% 50% 50% 50% 33% 33% 50% 50% 50% 50% 33% 12 9 F Incision D12 - S1 / Laminotomy L1 - L5 / Miniplate fixation 20% 50% 50% 50% 50% 0% 20% 50% 50% 50% 50% 0% 13 7 F Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 14 6 F Incision D12 - L1 (single level) 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 1 CONSERVATIVE 1 37 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 0% 25% 25% 25% 0% 0% 0% 25% 25% 25% 0% 0% 2 7 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 25% 33% 33% 33% 33% 25% 25% 33% 33% 33% 33% 25% 3 2 9 F Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 25% 33% 33% 33% 33% 0% 25% 33% 33% 33% 33% 25% 4 9 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 20% 25% 25% 25% 25% 0% 20% 25% 25% 25% 25% 0% 5 6 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 0% 25% 25% 25% 25% 0% 0% 25% 25% 25% 25% 0% 6 13 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 50% 50% 33% 33% 33% 0% 50% 50% 33% 33% 33% 0% 7 6 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 20% 33% 33% 33% 25% 20% 20% 33% 33% 33% 25% 20% 8 5 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 20% 33% 33% 33% 33% 0% 20% 33% 33% 33% 33% 0% 9 7 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 20% 33% 33% 33% 25% 20% 20% 33% 33% 33% 25% 20% 10 6 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 15% 33% 33% 33% 33% 15% 15% 33% 33% 33% 33% 15% 11 12 F Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 0% 33% 40% 0% 25% 0% 0% 33% 40% 0% 25% 0% 12 3 9 F Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 25% 33% 33% 33% 33% 15% 25% 33% 33% 33% 33% 15% 13 37 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 33% 33% 33% 33% 0% 0% 33% 33% 33% 33% 0% 0% 14 23 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 20% 33% 33% 33% 25% 20% 20% 33% 33% 33% 25% 20% 15 11 F Incision L1 - S1 / Laminotomy L1 - L5 / Miniplate fixation 0% 33% 25% 33% 20% 0% 0% 33% 25% 33% 20% 0% 16 7 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 20% 25% 25% 25% 33% 20% 0% 25% 0% 25% 20% 10% 17 4 M Incision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation 25% 33% 33% 33% 33% 0% 25% 33% 33% 33% 33% 0% Physical examination Spasticity was assessed and classified during physical examination using the modified Ashworth scale [19] . No increase in muscle tone (0), slight increase in tone at the end of the movement (1), slight increase in muscle tone in the middle of the movement (1+), more marked increase in muscle tone (2), considerable increase in muscle tone with difficulty in passive movement (3), rigid limb (4). The same scale was used to evaluate five muscle groups: hip flexors, hip adductors, hamstrings, rectus femoris, and plantar flexors. For the same muscle groups, muscle strength was evaluated using the scale proposed by Kendall et al. [20] . Instrumented three-dimensional gait analysis Instrumented three-dimensional gait analysis is a functional diagnostic tool that provides useful information about the complexity of a subject’s gait an individual and how much their pattern deviates from a normal gait pattern [21] . Modern gait laboratories use different technologies to assess joint motion (kinematics), forces and how they manifest through moments of force and power (kinetics), and muscle contraction activity (surface electromyography). This multifactorial analysis, together with a physical examination, provides the medical team with objective information to discriminate muscle tone alterations and lever arm dysfunctions that affect the patient's gait in order to recommend adequate treatment for each individual case. (Figure 2) The gait analysis data consisted of three-dimensional kinematics and kinetics of the lower limbs (SMART XD BTS Bioengineering) and were processed using the standard BTS GAITLAB motion capture model. Kinematics of the sagittal plane, kinetics, and ankle joint force were extracted for further analysis. Net joint power is a kinetic quantity computed by multiplying the net joint moment by the difference in angular velocities of the adjoining segments, representing the net capacity of muscle groups to develop the joint dynamics of the movement. Surgical technique The surgical procedure consisted of the following steps: General anesthesia protocol (continuous administration for 72 hours): Balanced general anesthesia, sevoflurane MAC: 0.8 % Combination of remifentanil (0.2 - 0.5 µg/kg/hr) and propofol (1 - 10 mg / kg/hr) Postoperative analgesia with morphine 4 - 5 mg/kg/hr or Bupivacaine 0.125 %. Post-operative analgesia (48-hour pump): Clonidine 5 mcg/kg/day Ketamine 5 mg/kg/day Tramadol 3-5 mg/kg/day Dexamethasone Metoclopramide Dipyrone Electrode placement: Use of myotomes: bipolar needle electrodes were placed in the psoas, gluteus medius and gluteus maximus, adductors, hamstrings, quadriceps, calves, soleus, tibialis anterior, flexor hallux, and anal sphincter, as illustrated in Figure 3 . Laminotomy L1 to S1: Laminotomy was performed with an ultrasonic bone scalpel (Figure 4) . Fixation was performed with miniplates and 1.5 mm screws in those under 12 years of age, and with miniplates and 2.0 mm titanium screws in older children. Postoperatively, the children wore a bivalve TLSO brace lined with plastazote foam for 75 days. Intraoperative neurophysiological monitoring: dissectors-stimulation. (Figure 5) Determining the stimulation threshold Stimulus of 0.2 ms. Current intensity: high enough to stimulate, and low enough to avoid diffusion Whole dorsal root restimulation with two to four times supra-threshold intensity (from 0.1 mA to 1.5 mA) with a stimulus train of 1 second duration and 50 Hz frequency. Identification of the sensory roots Repeated stimulation of the dorsal root in the sensory or motor portions macroscopically identified by the neurosurgeon, with: Stimulus train of 1 second at a frequency of 50 Hz. Two to four times supra-threshold intensity. Sensory root: the root with the highest threshold of electrical current (this threshold is the basis for the tetanic stimulation of the rootlet). Rootlet division: Rootlet division was performed according to the protocol described below and as illustrated in Figure 5 : Macroscopic division into four to twelve rootlets (mean, six rootlets) aiming to achieve a multiplication of the percentage to be sectioned. Tetanic stimulation with the same supra-threshold characteristics as mentioned in the section above. Starting on the right side. Compound muscle action potentials (CMAP) are recorded using multichannel surface electromyography. Band-pass filters: low pass 10 Hz – high pass 1.5 KHz. Sweep at 100 msec. Depending on the surgical technique performed, 50% of all rootlets were sectioned (classic technique) or the rootlets were sectioned at L1: 25%, L2, L3 and L4: 33%, L5: 25%, and S1: 15% (conservative technique). Statistical analysis All statistical analysis was performed using Python 3.6. The mean and standard deviation of joint angles in the sagittal plane and net ankle joint force were calculated for each gait cycle for each patient. A representative gait cycle was obtained for each patient consisting of an average of six steps (three steps for the left limb and three steps for the right limb) [22] . A complete gait cycle is defined as the movement developed between two consecutive events of foot contact with the ground. To evaluate net ankle muscle force, the maximum power generation during the gait cycle was determined. Not all data were normally distributed. Therefore, to determine whether the estimates of net ankle power differed between groups (pre-operative, classic technique SDR, and conservative technique SDR), a randomized non-parametric permutation test was performed at the 95% significance level. RESULTS To assess changes in the gait patterns of patients with cerebral palsy undergoing rhizotomy surgery (both techniques), instrumented three-dimensional gait analysis was used, including subjective assessments recorded during the physical examination and objective assessments obtained by computer reconstruction of the patient's gait. Table 2 summarizes the results of the physical examination of the patients included in the study. Specifically, rhizotomy (both techniques) is shown to be efficient in reducing spasticity of the main muscle groups involved in gait. Table 2: Detailed data of the patients including muscle spasticity, muscle strength, and selective muscle control (SMC). For strength, spasticity, and SMC, number of legs/scale is indicated. General data Pre-operative Classic technique Conservative technique Weight 21.8 ± 6.9 Kg 27.9 ± 10.9 Kg 28.04 ± 7.7 Kg Height 1.15 ± 0.13 m 1.26 ± 0.17 m 1.27 ± 0.13 m Strength Hip flexion 2/3 11/3+ 1/4- 13/4 7/4+ 15/5 2/3+ 4/4- 5/4 4/4+ 8/5 1/3+ 1/4- 6/4 4/4+ 6/5 Prone hip extension (Staheli) 4/2 3/3- 7/3 5/3+ 9/4 2/5 1/2 3/3- 6/3 2/3+ 1/4- 2/4 1/4+ 4/5 3/2 2/3- 3/3 4/3+ 1/4- 5/4 4/4+ 1/5 Prone hip extension (flexed knee) 2/3- 8/3 3/3+ 4/4 1/3+ 1/4 4/4+ 6/3- 1/3 3/3+ 1/4- 4/4 1/4+ 1/5 Hip abduction with knee extended 13/2 7/3- 20/3 3/3+ 1/4- 5/4 2/5 1/2 2/2+ 3/3- 3/3 3/3+ 7/4 2/4+ 1/5 2/2 1/2+ 1/3- 3/3 4/4 4/4+ Hip abduction with knee flexed 1/2 3/4 2/5 - 2/3 3/3+ 1/4- 3/4 2/4+ Hip adduction 5/3 3/4- 17/4 7/4+ 18/5 1/4- 3/4 8/4+ 10/5 2/2 4/3+ 8/4 6/4+ 2/5 Maximum knee flexion 1/3- 5/3 1/3+ 7/4- 13/4 8/4+ 19/5 2/4- 6/4 12/4+ 2/5 2/2 1/4- 6/4 1/4+ 6/5 Prone knee flexion 1/1 1/2 12/3- 11/3 4/3+ 5/4- 8/4 1/4+ 7/5 2/3- 3/3 3/3+ 2/4- 3/4 5/4+ 4/5 2/2 1/3- 2/3 1/4- 5/4 2/4+ 5/5 Ankle dorsiflexion with knee at 90° 6/2 2/2+ 7/3- 8/3 4/3+ 8/4 3/4+ 4/5 1/1 1/2 1/2+ 1/3- 3/3 2/3+ 6/4 4/4+ 2/5 2/3- 5/3+ 7/4 4/4+ 2/5 Plantar flexion of the ankle 8/2 1/2+ 6/3- 4/3 3/3+ 2/4 1/1 2/2 1/2+ 1/3- 1/3 1/3+ 3/2 6/2+ 3/3- 1/3 5/4 SMC Hip flexion 56/2 22/2 16/2 Prone hip extension (Staheli) 9/1 23/2 7/1 13/2 5/1 11/2 Prone hip extension (flexed knee) 13/1 7/2 1/1 5/2 5/1 7/2 Hip abduction with extended knee 24/1 30/2 8/1 12/2 4/1 12/2 Hip abduction with flexed knee 2/1 4/2 - 2/1 8/2 Hip abduction 5/1 49/2 22/2 2/1 16/2 Maximum knee flexion 18/1 38/2 4/1 18/2 2/1 14/2 Prone knee flexion 33/1 20/2 9/1 11/2 3/1 12/2 Ankle dorsiflexion with knee at 90° 3/1 4/2 1/3 1/4 4/1 2/2 Plantar flexion of the ankle 2/1 4/2 - 2/1 2/2 Ashworth Hip flexion 9/0 9/1 12/1+ 2/2 8/0 1/1 1/1+ 7/0 2/1+ Adductors 1/0 9/1 20/1+ 13/2 10/0 7/0 1/1+ 1/2 Anterior rectus 7/0 11/1 11/1+ 11/2 8/0 1/1 7/0 2/1 Plantar flexors 4/1 13/1+ 15/2 12/3 6/0 3/1 2/1+ 2/0 3/1 1/1+ 1/2 1/3 Hamstrings 5/0 8/1 6/1+ 8/2 8/0 2/1 8/0 Tibialis anterior 14/0 6/1 5/1+ 7/0 1/1 10/0 Tibialis posterior 14/0 13/1 6/1+ 8/2 13/0 1/1+ 12/0 2/1 The results of the kinematic gait analysis are shown in Figure 6 . In the Figure, the sagittal plane is presented as range of motion (ROM) is greatest in that plane. Considering that ROM is defined as the amplitude between the maximum and minimum value of the angular displacement developed by a joint (hip, knee, or ankle) during gait, ROM increased in our patients with cerebral palsy after SDR, regardless of the surgical technique used (classic or conservative). This increase in ROM correlated with a decrease in the degree of muscle spasticity in patients post-operatively as shown in Table 2. The greatest benefits (changes in gait pattern) of SDR are seen in the knee joint, especially for the conservative technique. Specifically, improvements in gait patterns greater than 10° are considered clinically significant. In our patients, minimum knee flexion in the stance phase (i.e., the position in which the knee is in full extension) was the only measurement that was significantly different between the conservative technique and the classic technique, with a difference in flexion of 10°. When comparing pre- and post-operative joint patterns, knee extension at initial contact was found to have improved with both techniques; however, a greater improvement was seen for the conservative technique. Maximum knee flexion in the swing phase improved by approximately 10° for both surgical techniques. Net joint power indicates the rate at which energy is used or generated by the muscle groups crossing a joint. Figure 6 illustrates the maximum net joint power developed in the ankle by patients with cerebral palsy before and after SDR surgery. In addition to an increase in knee joint ROM, in children who underwent SDR with the conservative technique a statistically significant increase (p=0.04) in the net joint power developed by the ankle was observed. Patients who underwent SDR with the conservative technique developed a maximum net ankle power of 1.37±0.61 [unit: W/BW], whereas those who were operated with the classic technique developed a maximum net joint power of the ankle of 0.98±0.18 [unit: W/BW], similar to that of all patients previous to surgery ( [unit: W/BW]). DISCUSSION In the literature, convincing short- and long-term evidence that rhizotomy reduces spasticity has been reported. However, strong data to support that this reduction leads to a significant benefit for individuals with cerebral palsy are lacking. A wide range of percentages of dorsal rootlet to be transected during SDR has been reported. In some centers, a rate of 50–70% is used [ 23 ]. The argument in favor of a higher rate of sectioning is a better reduction of spasticity. However, there is a potential risk of undesired neurological effects of excessive deafferentation, including weakness in the antigravity muscles and bowel and bladder problems. In studies evaluating long-term patient outcomes, spinal abnormalities such as scoliosis, kyphosis, lumbar lordosis, spondylolysis and spinal stenosis have been commonly described as complications after SDR using this technique [ 16 ]. Several authors, including Peacock and Aquilina, proposed to perform SDR from L2 to S1 because of the risk of spinal deformity, as to visualize the L1 root it is necessary to expose D12. Techniques such as limited posterior selective rhizotomy (Jorge Lazareff) lead to persistent spasticity in the L1, L2, and L3 roots, increasing the risk of hip dislocation. In other centers, a lower percentage (25–40%) of rootlet transection has been advocated and routinely used. The results suggest similar efficacy in tone reduction without adverse effects. In general, in these more conservative cases, the rootlets to be sectioned are selected based on a combination of preoperative examination and intraoperative electrophysiological mapping [ 15 ]. In addition to reducing spasticity in children with cerebral palsy, one of the main objectives of SDR is to maintain or improve gait and mobility. In this sense, our study shows that the impact of both techniques on gait function is similar with a generalized increase in ROM of the knee and ankle in the sagittal plane. A better performance in the knee joint was observed in patients that underwent SDR with the conservative technique, showing better knee flexion at initial contact and extension in mid-stance. Both techniques led to a positive change in the full knee flexion during swing. These data suggest that similar or even slightly better results can be achieved when a lower percentage of rootlets is sectioned in order to preserve the power-generating muscles that are essential for gait. The concept that a mono- or bi-articular muscle can transfer energy from one segment to another is physically significant and important for the execution of complex motor tasks. The redistribution of segmental energy occurs because the force generated by one muscle produces simultaneous accelerations and decelerations of segments throughout the body. Thus, a muscle can redistribute energy between segments regardless of whether the muscle is producing mechanical work (acting concentrically), dissipating energy by elongating (acting eccentrically), or maintaining a constant length (acting isometrically) [ 24 ]. Our results show that conservative SDR both improved joint ROM and led to a statistically significant increase in the net joint power of the ankle. These findings suggest that the conservative technique (as opposed to the classic technique) achieves optimal unblocking of the muscle groups that affect the ankle joint, avoiding excessive muscle weakness in these groups. This effect is extremely important for improved gait performance, considering that the soleus (uniarticular ankle plantar flexor) decelerates the thigh and tibia, and accelerates the trunk causing energy flow from the leg to the trunk during the mid-stance walking position (20–40% of the gait cycle). In addition, the soleus provides translational power to the trunk because its contribution to the intersegmental force of the hip has a component collinear with the velocity of translation of the trunk [ 24 ]. Achieving greater net joint power in the ankle after rhizotomy will allow patients to start the rehabilitation process with better and greater muscular capacity, leading to better results. Our findings suggest that the classic (a single cut of 50% of the rootlets) and conservative (a cut of the rootlets at L1: 25%, L2, L3 and L4: 33%, L5: 25% and S1: 15%) SDR techniques lead to very similar short-term functional gait results in terms of increased joint ROM. Modest differences in ankle kinematics during gait were observed, with a greater improvement in the classic SDR group. However, this putative improvement observed in the classic technique did not correlate with improvements in net muscle behavior. Conversely, it was observed that the conservative technique allows a better unblocking of the ankle muscle-joint complex, allowing important muscle groups that support the propulsion and advancement of the gait to develop greater muscle power, i.e., to more effectively transfer the forces generated by these muscles during gait. To our knowledge, this is the first research study to compare the effectiveness of two different SDR techniques, one of which was classic and the other conservative. The study allowed to evaluate whether a more conservative surgery has the potential to significantly reduce muscle spasticity while it also has the benefit of increasing net ankle joint power. This latter effect would be important because of the role of the plantar flexor muscles of the ankle in propulsion and stance during gait. Therefore, preserving or optimizing these muscle functions is of great value to achieve better results in the rehabilitation of children with cerebral palsy who underwent SDR to treat muscle spasticity. To assess the results quantitative parameters obtained by instrumented three-dimensional gait analysis were included. CONCLUSION This is the first study to comprehensively compare the short-term outcomes of a classic and a conservative SDR technique in a clinical cohort of ambulatory children with spastic cerebral palsy in Argentina. Using conventional gait modeling based on instrumented three-dimensional analysis, we found that SDR with sectioning of the nerve rootlets below 33% (the conservative technique) reduces muscle spasticity in patients with cerebral palsy by optimally unblocking the muscles that cross the ankle joint resulting in higher maximum net ankle joint power. Declarations Ethical approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of FLENI. Consent to participate Informed consent was obtained from all individual participants included in the study. Consent for publication Patients signed informed consent regarding publishing their data and photographs. Conflict of interest The authors do not present conflicts of interest. Funding No funding was received to assist with the preparation of this manuscript. Data availability The datasets generated during and/or analyzed during the current study are not publicly available due to the sensitive nature of the information and because the participants are underage but are available from the corresponding author on reasonable request. Author contribution All authors contributed to the study conception and design. Beatriz Mantese: Original idea, conceptualization, writing, original draft, supervision and project administration. Christian G. Pirozzi Chiusa: Data collection, review, image editing and visualization. Yamila Basilotta Marquez: Data collection, review, editing and visualization. María Pía Gotter Campo: Data collection, review, editing and visualization. Ricardo Nazar: Data collection, review, editing and visualization. Marcos Crespo: Methodology, data collection, writing, review, image editing and visualization. Alfredo Toledo: Data collection, review, editing and supervision. Emiliano Ravera: Methodology, supervision, review and editing. All authors read and approved the final manuscript. References Herzog W. Skeletal muscle mechanics: questions, problems and possible solutions. Journal of Neuroengineering and Rehabilitation. 2014; 14: 98. Aquilina K, Graham D, Wimalasundera N. Selective dorsal rhizotomy: an old treatment re-emerging. Arch Dis Child. 2015;100:798-802. Nahm NJ, Graham HK, Gormley ME Jr, Georgiadis AG. Management of hypertonia in cerebral palsy. Curr Opin Pediatr. 2018 Feb; 30(1):57-64. Grunt S, Fieggen AG, Vermeulen RJ, Becher JG, Langerak NG. Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature. Dev Med Child Neurol. 2014;56:302-12. Fasano VA, Broggie G, Barolat-Romana G, Sguazzi A. Surgical treatment of spasticity in cerebral palsy. Child Brain 1978;4:289-305. Fasano VA, Barolat-Romana G, Zeme S, Sguazzi A. Electrophysiological assesment of spinal circuits in spasticity by direct dorsal root stimulation. Neurosurgery 1979; 4:146- 151. Peacock WJ, Arens LJ, Berman B. Cerebral palsy spasticity. Selective posterior rhizotomy. Pediatr Neurosci 1987; 13:61- 66. Peacock WJ, Staoudt LA. Spasticity in cerebral palsy and the selective rhizotomy procedure. J Child Neurol 1990; 5:179- 185.1 J A Lazareff. Limited (L4-S1, L5-S1) selective dorsal rhizotomy for reducing spasticity in cerebral palsy. Acta Neurochir (Wien) 1999;141(7):743-51; discussion 751-2 Georgoulis G, Brînzeu A, Sindou M. Dorsal rhizotomy for children with spastic diplegia of cerebral palsy origin: usefulness of intraoperative monitoring. J Neurosurg Pediatr. 2018 Jul;22(1):89-101. doi: 10.3171/2018.1.PEDS17577. Epub 2018 Apr 13. PMID: 29652243. Huenaerts C. et al. Does decreased spasticity improve gait in children with cp after selective dorsal rhizotomy? Gait & Posture 42S (2015) S1–S90 McLaughlin J, BjornsonK, Temkin N, Steinbok P, Wright V, Reiner A, Roberts T, Drake J, O’Donnell M, Rosenbaum P, Barber J, Ferrel A. Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol. 2002 Jan;44(1):17-25 Engsberg JR, Ross SA, Collins DR, Park TS. Effect of selective dorsal rhizotomy in the treatment of children with cerebral palsy. J Neurosurg. 2006 Jul;105(1)(Suppl):8-15. [14] Crespo Marcos, Samara Eduardo, Toledo Alfredo, Duffy Clara, Segal Eduardo, Gotter María Pia, Couto Juan. Short-time kinematics changes after selective dorsal rhizotomy. Gait and Clinical Movement Analysis Society 2014 Annual Conference June 2014. DOI: 10.13140/2.1.3648.4804 Chen BP, Wang KK, Novacheck TF. Selective Dorsal Rhizotomy for the Treatment of Gait Dysfunction in Cerebral Palsy: A Critical Analysis Review. JBJS Rev. 2019 Nov;7(11):e3. doi: 10.2106/JBJS.RVW.19.00020. PMID: 31725025. Tedroff K, Hägglund G, Miller F. Long-term effects of selective dorsal rhizotomy in children with cerebral palsy: a systematic review. Dev Med Child Neurol. 2020 May;62(5):554-562. doi: 10.1111/dmcn.14320. Epub 2019 Jul 24. PMID: 31342516; PMCID: PMC7187377. Roberts A, Stewart C, Freeman R. Gait analysis to guide a selective dorsal rhizotomy program. Gait Posture. 2015 Jun;42(1):16-22. doi: 10.1016/j.gaitpost.2015.04.004. Epub 2015 Apr 20. PMID: 25979183. Oeffinger, D., Tylkowski, C., Davis, R. (2004) Gross Motor Function Classification System and outcome tools for assessing ambulatory cerebral palsy: a multicenter study. Dev. Med. Child Neurol. 46, 311–319. Bohannon RW, Smith MB (1987) Interrater Reliability of a Modified Asworth scale of muscle spasticity. Phys Ther 67 206-207. Kendall HO, Kendall FP, Wadsworth GE, editors (1971) Muscle Testing and Function, 2nd ed. London: Williams and Wilkins. James R. Gage, Michael H. Schwartz, Steven E. Koop, Tom F. Novacheck - The Identification and Treatment of Gait Problems in Cerebral Palsy (2009, Mac Keith Press). Chapter 3, p. 260 Kadaba MP, Ramakrishnan HK, Wootten ME, Gainey J, Gorton G, Cochran GV. Repeatability of kinematic, kinetic, and electromyographic data in normal adult gait. J Orthop Res. 1989;7(6):849-60. Nicolini-Panisson RD, Tedesco AP, Folle MR, Donadio MVF. Selective dorsal rhizotomy in cerebral palsy: selection criteria and postoperative physical therapy protocols. Rev Paul Pediatr. 2018 Jan 15;36(1):9. Zajac FE, Neptune RR, Kautz SA. Biomechanics and muscle coordination of human walking. Part I: introduction to concepts, power transfer, dynamics and simulations. Gait Posture. 2002 Dec;16(3):215-32. doi: 10.1016/s0966-6362(02)00068-1. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Dec, 2023 Read the published version in Child's Nervous System → Version 1 posted Editorial decision: Major revision 24 Jul, 2023 Reviews received at journal 18 Jun, 2023 Reviewers agreed at journal 01 Jun, 2023 Reviewers invited by journal 01 Jun, 2023 Editor assigned by journal 30 May, 2023 Submission checks completed at journal 30 May, 2023 First submitted to journal 27 May, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2990142","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":205194258,"identity":"957f7cfd-2500-4f11-a8a8-29ab39b41033","order_by":0,"name":"Beatriz Mantese","email":"","orcid":"","institution":"Pediatric Hospital J.P. Garrahan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Beatriz","middleName":"","lastName":"Mantese","suffix":""},{"id":205194259,"identity":"76dbc6cd-ec94-40b4-b277-b8dafca13f50","order_by":1,"name":"Christian G. Pirozzi Chiusa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIie2QMWrDMBSGZQzSouL1lZbmCjKBOFl6FouAJ6cUuhRaEoPAY7oaeglDodBNIOosPoCgXdJewBAoHUKorGS0m44d9A0/4sGH/vcQcjj+I75NQAx5GTKJAthPzv+mSKOcFlYGevQ31oZsH9oqqFeJyMl6/b0dD6IzJTbN9eXV8E2sPvT9mCKiXssOZSLIkAGF8GXJc5BsejN6r7hIK1OMJonu6qMwBgYQs9rLzS4+f9ZpKFJsFKCjXiVmVhGNZAv+VLTK7ogiY6tkppjiJRhllvcrE4H9MJMQlqYY1GzFC53wx9kSKO7ZJQoqz1xsPmA1+Wxut3f8oZjKTfo1vwiIqjqLdcwO4J75L4rD4XA4DvwADxRfqeCgBtEAAAAASUVORK5CYII=","orcid":"","institution":"Pediatric Hospital J.P. Garrahan","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Christian","middleName":"G. Pirozzi","lastName":"Chiusa","suffix":""},{"id":205194260,"identity":"f20b123c-32de-497a-9115-c8fbf24c15eb","order_by":2,"name":"Yamila Basilotta Márquez","email":"","orcid":"","institution":"Pediatric Hospital J.P. Garrahan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yamila","middleName":"Basilotta","lastName":"Márquez","suffix":""},{"id":205194261,"identity":"b4f61f39-a486-408c-a20f-5ca5e45a1372","order_by":3,"name":"María Pía Gotter Campo","email":"","orcid":"","institution":"FLENI","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"María","middleName":"Pía Gotter","lastName":"Campo","suffix":""},{"id":205194262,"identity":"ed74cd3a-2897-45f9-b638-ffad7d6ba2e9","order_by":4,"name":"Ricardo Nazar","email":"","orcid":"","institution":"FLENI","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ricardo","middleName":"","lastName":"Nazar","suffix":""},{"id":205194263,"identity":"3009ab97-63c3-48e7-9a6b-e6f72a061c36","order_by":5,"name":"Marcos Crespo","email":"","orcid":"","institution":"FLENI","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Marcos","middleName":"","lastName":"Crespo","suffix":""},{"id":205194264,"identity":"58b45c03-d823-4a32-a509-a8557811e97b","order_by":6,"name":"Alfredo Toledo","email":"","orcid":"","institution":"Maimonides University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alfredo","middleName":"","lastName":"Toledo","suffix":""},{"id":205194265,"identity":"49610253-80dc-4818-889a-c62eb504c4ac","order_by":7,"name":"Emiliano Ravera","email":"","orcid":"","institution":"Institute for Research and Development in Bioengineering and Bioinformatics (IBB), CONICET-UNER, Oro Verde","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Emiliano","middleName":"","lastName":"Ravera","suffix":""}],"badges":[],"createdAt":"2023-05-27 20:59:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2990142/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2990142/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00381-023-06247-x","type":"published","date":"2023-12-13T15:02:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":37850650,"identity":"2786719c-5203-4578-9568-03af22d62d1c","added_by":"auto","created_at":"2023-06-01 14:50:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45359,"visible":true,"origin":"","legend":"\u003cp\u003eA: Superior afferent and efferent nerve fibers. B: Section of the rootlets of the dorsal root. C: Muscle spindle. D: Mechanoreceptors. E: Golgi tendon organ. F: Skin receptors.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2990142/v1/4ba08cd79a5e3474a55de4c8.jpg"},{"id":37848743,"identity":"d686a341-efda-4d8c-925e-12f979c24e92","added_by":"auto","created_at":"2023-06-01 14:42:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":53337,"visible":true,"origin":"","legend":"\u003cp\u003eA: Patient walking in the gait laboratory, instrumented with markers and surface EMG electrodes. B: Model of the body segments used for the three-dimensional analysis. The ground reaction force used in the model to calculate net joint force is observed.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2990142/v1/d3002d26fc98be48829ecda7.jpg"},{"id":37850652,"identity":"ee186a11-4bd2-4452-92c0-1c441cdf43ac","added_by":"auto","created_at":"2023-06-01 14:50:01","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":58778,"visible":true,"origin":"","legend":"\u003cp\u003eA-C: The image shows the use of myotomes. Bipolar needle electrodes were placed in the psoas, gluteus medius and gluteus maximus, adductors, hamstrings, quadriceps, calves, soleus, tibialis anterior, flexor hallux, and anal sphincter.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2990142/v1/07a27dd14da318f488943087.jpg"},{"id":37848745,"identity":"2a78e8db-4109-464b-8f3e-95d92c49861b","added_by":"auto","created_at":"2023-06-01 14:42:01","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":90937,"visible":true,"origin":"","legend":"\u003cp\u003eA-E: Intraoperative images: L1-S1 laminotomy. F: Fixation was performed with miniplates.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2990142/v1/6856ed46696cff97cac4e9ff.jpg"},{"id":37851681,"identity":"245508c7-41a9-422c-87a3-773a385edd91","added_by":"auto","created_at":"2023-06-01 14:58:01","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":83513,"visible":true,"origin":"","legend":"\u003cp\u003eA-E: Intraoperative images: process of rootlet transection. F: Dissectors-stimulation probes used in intraoperative neurophysiological monitoring.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2990142/v1/cf1c7c0af33f1327773fefe3.jpg"},{"id":37851680,"identity":"e9b108ae-1e76-4a5c-ace1-ad405031d9de","added_by":"auto","created_at":"2023-06-01 14:58:01","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":86844,"visible":true,"origin":"","legend":"\u003cp\u003eA-C: Sagittal plane kinematics of the hip, knee, and ankle showing mean values and standard deviations over 100% of the gait cycle. D: Maximum net joint power of the ankle before and after SDR. The random permutations test with a significance level of 95% was used to evaluate statistical differences between the classic and the conservative technique. The results were normalized to body weight (BW).\u003c/p\u003e","description":"","filename":"Figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2990142/v1/3491c411b427a243cfc4dd39.jpg"},{"id":48401763,"identity":"3dd2dd1a-46ec-4a9f-baa3-ed7e380def19","added_by":"auto","created_at":"2023-12-18 15:11:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":703516,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2990142/v1/546d6d39-e362-4119-9ad5-8997a8c71e06.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Selective Dorsal Rhizotomy: Analysis of two rootlet sectioning techniques","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSpasticity is a motor disorder characterized by increased muscle tone that interferes with mobility and affects development and quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It also causes muscle shortening affecting bone growth and leading to deformities; therefore, its treatment is relevant in the management of children with cerebral palsy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTreatment options are either surgical or nonsurgical. Selective dorsal rhizotomy (SDR) is a common, irreversible, surgical treatment to reduce spasticity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The procedure is mainly performed at the lumbosacral level and consists of the interruption of the afferent stimulus of the monosynaptic stretch reflex. To preserve sensory and sphincter function, the dorsal root is divided into rootlets and only a part of these is sectioned [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe surgery was first reported in 1888 by Robert Abbe in New York, who performed the posterior rhizotomy for the treatment of refractory pain, sectioning all the posterior roots. In 1908, Otfrid Foerster, a German neurologist and neurosurgeon, used the technique to reduce spasticity of the lower extremities to allow ambulation, relieve pain, and facilitate activities of daily living. He later observed that the intervention also produced a proprioceptive sensory deficit and significant weakness. In 1967, Gros revised the procedure described by Foerster, sparing one-fifth of the posterior root from L1 to S1 to preserve sensitivity, with poor functional results.\u003c/p\u003e \u003cp\u003eIn 1978, Fasano et al. reported the use of electrical stimuli to identify the roots involved in abnormal reflexes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Peacock et al. modified Fasano's technique, changing from the conus medullaris to the cauda equina between L2-L5 and identifying the nerve roots to preserve sacral innervation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 1976, Edgardo Schijman reported a series of 25 patients who underwent surgery with the Peacock technique at the Instituto de Rehabilitaci\u0026oacute;n in Argentina. In 2005, the technique of limited rhizotomy from L4 to S2 under intraoperative neurophysiological monitoring, described by Jorge Lazareff [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] was used in eight patients at the Hospital Juan P. Garrahan, incorporating instrumented gait analysis at the Fleni Gait and Movement Laboratory before and after treatment.\u003c/p\u003e \u003cp\u003eIn 2007, SDR with intraoperative neurophysiological monitoring was introduced at the Fleni Institute following the Peacock technique [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] with bilateral L1 to S1 laminectomy and transection of 50% of the rootlets, regardless of the Gross Motor Function Classification System (GMFCS) level of the patient. As of 2015, the technique was modified and SDR was performed preserving the proximal roots and sectioning 20% of the L1 rootlets, 33% of the L2-L3-L4 rootlets, and eventually approximately 33 or 20% of the L5 rootlets, depending on the appearance of the soleus; 20% of the S1 rootlets are sectioned with special care of the plantar flexors. Rootlets involved in the innervation of muscles that contribute to standing (gluteus maximus, gluteus medius 25%, hamstrings 25%, and soleus 50%) are not cut. Extreme care is taken when sectioning S1 and S2 rootlets to avoid bladder injury and paralytic flatfoot [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This approach is based on the results presented by Dr. Molenaers and his team in Belgium, who treated patients with spastic diplegia and concluded that the treatment was more effective on the proximal muscles, resulting in a more efficient gait [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is growing evidence that in the short term, SDR combined with physical therapy is effective at reducing spasticity and leads to significant changes in gait parameters and improvement in gross motor function in children with cerebral palsy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Further long-term studies are needed to confirm whether these changes persist over time [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, SDR is a standard surgical technique aimed at reducing spasticity in patients with cerebral palsy. Although, as described above, several surgical strategies have been reported, the differences in the functional effects produced by each have not been clearly demonstrated. Surgical techniques differ mainly in the number of rootlets that are selected for sectioning. Severing too many fibers may compromise useful muscle tone, while severing too few may result in insufficient effectiveness or possible recurrence. This seems to make sense, but so far the difference between a classic technique such as Peacock's technique and a more conservative approach such as that of the group of Molenaers has not been determined.\u003c/p\u003e \u003cp\u003eThe aim of this study was to evaluate the differences between the two SDR techniques performed in different periods of time by the Neurosurgery team at Fleni using instrumented three-dimensional gait analysis to assess the impact on functional gait of the patients. Instrumented three-dimensional gait analysis provides supporting evidence in the selection of the ideal candidate child for SDR and allows for the quantitative monitoring of outcome and postoperative management until skeletal maturity [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e"},{"header":"MATERIAL AND METHODS","content":"\u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Fleni Ethics Committee. Patients with spastic cerebral palsy who met the following criteria were included in the study: (1) underwent RDS (all operated by the same neurosurgeon) between March 2009 and December 2019; (2) younger than 13 years at the time of SDR; (3) underwent at least one three-dimensional gait analysis study at no more than 21 months before SDR (considered the initial study) and one three-dimensional gait analysis study between 2 and 31 months after SDR (considered the follow-up study); (4) ambulatory at the time of the initial and follow-up three-dimensional gait study; (5) did not undergo any surgery other than SDR between the initial and follow-up study; and (6) consented to the use of their records for research purposes. All data were collected from the patients\u0026rsquo; medical records.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo surgical techniques were performed from L1 to S1 bilaterally: in the first technique, all the rootlets were cut up to 50% (classic technique proposed by Peacock) and in the second technique, the rootlets were cut as follows: L1: 25%, L2, L3, and L4: 33%, L5: 25%, and S1: 15% (conservative technique proposed by Molenaers). \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to gait studies, all patients underwent MRI of the brain and complete spine, urological examination, and pre- and post-voiding ultrasound; in case of abnormal findings on the latter, a urodynamic study was performed. All patients had intensive physical therapy rehabilitation 5 days a week for one year.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e details the main patient characteristics, including age, sex, and GMFCS level \u003cstrong\u003e[18]\u003c/strong\u003e at the time of SDR, as well as surgical technique and the percentage of sectioned rootlets in each case.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e General patient characteristics.\u0026nbsp;\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"984\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.878048780487805%\" rowspan=\"2\"\u003e\n \u003cp\u003ePATIENT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.7926829268292686%\" rowspan=\"2\"\u003e\n \u003cp\u003eTECHNIQUE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.776422764227642%\" rowspan=\"2\"\u003e\n \u003cp\u003eGMFCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.776422764227642%\" rowspan=\"2\"\u003e\n \u003cp\u003eAGE\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.861788617886179%\" rowspan=\"2\"\u003e\n \u003cp\u003eSEX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.776422764227643%\" rowspan=\"2\"\u003e\n \u003cp\u003eAPPROACH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.06910569105691%\" colspan=\"6\"\u003e\n \u003cp\u003eRIGHT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.06910569105691%\" colspan=\"6\"\u003e\n \u003cp\u003eLEFT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eL1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eL2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eL3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eL4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eL5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eS1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eL1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eL2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eL3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eL4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eL5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eS1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.8681541582150105%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.780933062880324%\" rowspan=\"14\"\u003e\n \u003cp\u003eCLASSICAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.766734279918864%\" rowspan=\"3\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.766734279918864%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.71602434077079%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision D12 - S2 / Laminotomy L1 - L5 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.166846071044134%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.059203444564047%\" rowspan=\"5\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.059203444564047%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.53928955866523%\"\u003e\n \u003cp\u003eIncision D12 - L3 / Laminotomy D12 - L2 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision D12 - S1 / Laminotomy L1 - L5 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.166846071044134%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.059203444564047%\" rowspan=\"6\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.059203444564047%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.53928955866523%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision D12 - S1 / Laminotomy L1 - L5 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision D12 - L1 (single level)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.8681541582150105%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.780933062880324%\" rowspan=\"17\"\u003e\n \u003cp\u003eCONSERVATIVE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.766734279918864%\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.766734279918864%\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.71602434077079%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.8539553752535496%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.166846071044134%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.059203444564047%\" rowspan=\"9\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.059203444564047%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.53928955866523%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.166846071044134%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.059203444564047%\" rowspan=\"6\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.059203444564047%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.53928955866523%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.090419806243272%\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - L5 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.442176870748299%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.328798185941043%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.21995464852608%\"\u003e\n \u003cp\u003eIncision L1 - S1 / Laminotomy L1 - S1 / Miniplate fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.308390022675737%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical examination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpasticity was assessed and classified during physical examination using the modified Ashworth scale \u003cstrong\u003e[19]\u003c/strong\u003e. No increase in muscle tone (0), slight increase in tone at the end of the movement (1), slight increase in muscle tone in the middle of the movement (1+), more marked increase in muscle tone (2), considerable increase in muscle tone with difficulty in passive movement (3), rigid limb (4). The same scale was used to evaluate five muscle groups: hip flexors, hip adductors, hamstrings, rectus femoris, and plantar flexors. For the same muscle groups, muscle strength was evaluated using the scale proposed by Kendall et al. \u003cstrong\u003e[20]\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstrumented three-dimensional gait analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInstrumented three-dimensional gait analysis is a functional diagnostic tool that provides useful information about the complexity of a subject\u0026rsquo;s gait an individual and how much their pattern deviates from a normal gait pattern \u003cstrong\u003e[21]\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eModern gait laboratories use different technologies to assess joint motion (kinematics), forces and how they manifest through moments of force and power (kinetics), and muscle contraction activity (surface electromyography). This multifactorial analysis, together with a physical examination, provides the medical team with objective information to discriminate muscle tone alterations and lever arm dysfunctions that affect the patient\u0026apos;s gait in order to recommend adequate treatment for each individual case. \u003cstrong\u003e(Figure 2)\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe gait analysis data consisted of three-dimensional kinematics and kinetics of the lower limbs (SMART XD BTS Bioengineering) and were processed using the standard BTS GAITLAB motion capture model. Kinematics of the sagittal plane, kinetics, and ankle joint force were extracted for further analysis. Net joint power is a kinetic quantity computed by multiplying the net joint moment by the difference in angular velocities of the adjoining segments, representing the net capacity of muscle groups to develop the joint dynamics of the movement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe surgical procedure consisted of the following steps:\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eGeneral anesthesia protocol (continuous administration for 72 hours):\u0026nbsp;\u003cul class=\"decimal_type\" style=\"list-style-type: circle;\"\u003e\n \u003cli\u003eBalanced general anesthesia, sevoflurane MAC: 0.8 %\u003c/li\u003e\n \u003cli\u003eCombination of remifentanil (0.2 - 0.5 \u0026micro;g/kg/hr) and propofol (1 - 10 mg / kg/hr)\u003c/li\u003e\n \u003cli\u003ePostoperative analgesia with morphine 4 - 5 mg/kg/hr or Bupivacaine 0.125 %. \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003ePost-operative analgesia (48-hour pump):\u003cul style=\"list-style-type: circle;\"\u003e\n \u003cli\u003eClonidine 5 mcg/kg/day\u003c/li\u003e\n \u003cli\u003eKetamine 5 mg/kg/day\u003c/li\u003e\n \u003cli\u003eTramadol 3-5 mg/kg/day\u003c/li\u003e\n \u003cli\u003eDexamethasone\u003c/li\u003e\n \u003cli\u003eMetoclopramide\u003c/li\u003e\n \u003cli\u003eDipyrone\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eElectrode placement:\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eUse of myotomes: bipolar needle electrodes were placed in the psoas, gluteus medius and gluteus maximus, adductors, hamstrings, quadriceps, calves, soleus, tibialis anterior, flexor hallux, and anal sphincter, as illustrated in \u003cstrong\u003eFigure 3\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eLaminotomy L1 to S1:\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eLaminotomy was performed with an ultrasonic bone scalpel \u003cstrong\u003e(Figure 4)\u003c/strong\u003e. Fixation was performed with miniplates and 1.5 mm screws in those under 12 years of age, and with miniplates and 2.0 mm titanium screws in older children. Postoperatively, the children wore a bivalve TLSO brace lined with plastazote foam for 75 days.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eIntraoperative neurophysiological monitoring: dissectors-stimulation. \u003cstrong\u003e(Figure 5)\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eDetermining the stimulation threshold\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eStimulus of 0.2 ms.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCurrent intensity:\u0026nbsp;\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003ehigh enough to stimulate, and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003elow enough to avoid diffusion\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWhole dorsal root restimulation with two to four times supra-threshold intensity (from 0.1 mA to 1.5 mA) with a stimulus train of 1 second duration and 50 Hz frequency.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eIdentification of the sensory roots\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRepeated stimulation of the dorsal root in the sensory or motor portions macroscopically identified by the neurosurgeon, with:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eStimulus train of 1 second at a frequency of 50 Hz. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTwo to four times supra-threshold intensity.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSensory root: the root with the highest threshold of electrical current (this threshold is the basis for the tetanic stimulation of the rootlet). \u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eRootlet division:\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eRootlet division was performed according to the protocol described below and as illustrated in \u003cstrong\u003eFigure 5\u003c/strong\u003e:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eMacroscopic division into four to twelve rootlets (mean, six rootlets) aiming to achieve a multiplication of the percentage to be sectioned. Tetanic stimulation with the same supra-threshold characteristics as mentioned in the section above.\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eStarting on the right side.\u003c/li\u003e\n \u003cli\u003eCompound muscle action potentials (CMAP) are recorded using multichannel surface electromyography.\u003c/li\u003e\n \u003cli\u003eBand-pass filters: low pass 10 Hz \u0026ndash; high pass 1.5 KHz.\u003c/li\u003e\n \u003cli\u003eSweep at 100 msec. \u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eDepending on the surgical technique performed, 50% of all rootlets were sectioned (classic technique) or the rootlets were sectioned at L1: 25%, L2, L3 and L4: 33%, L5: 25%, and S1: 15% (conservative technique).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analysis was performed using Python 3.6. The mean and standard deviation of joint angles in the sagittal plane and net ankle joint force were calculated for each gait cycle for each patient. A representative gait cycle was obtained for each patient consisting of an average of six steps (three steps for the left limb and three steps for the right limb) \u003cstrong\u003e[22]\u003c/strong\u003e. A complete gait cycle is defined as the movement developed between two consecutive events of foot contact with the ground. To evaluate net ankle muscle force, the maximum power generation during the gait cycle was determined.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot all data were normally distributed. Therefore, to determine whether the estimates of net ankle power differed between groups (pre-operative, classic technique SDR, and conservative technique SDR), a randomized non-parametric permutation test was performed at the 95% significance level.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eTo assess changes in the gait patterns of patients with cerebral palsy undergoing rhizotomy surgery (both techniques), instrumented three-dimensional gait analysis was used, including subjective assessments recorded during the physical examination and objective assessments obtained by computer reconstruction of the patient\u0026apos;s gait. \u003cstrong\u003eTable 2\u003c/strong\u003e summarizes the results of the physical examination of the patients included in the study. Specifically, rhizotomy (both techniques) is shown to be efficient in reducing spasticity of the main muscle groups involved in gait.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Detailed data of the patients including muscle spasticity, muscle strength, and selective muscle control (SMC). For strength, spasticity, and SMC, number of legs/scale is indicated.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-operative\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eClassic technique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eConservative technique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWeight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.8 \u0026plusmn; 6.9 Kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27.9 \u0026plusmn; 10.9 Kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.04 \u0026plusmn; 7.7 Kg\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHeight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.15 \u0026plusmn; 0.13 m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.26 \u0026plusmn; 0.17 m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.27 \u0026plusmn; 0.13 m\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStrength\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHip flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/3 11/3+ 1/4- 13/4 7/4+ 15/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/3+ 4/4- 5/4 4/4+ 8/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/3+ 1/4- 6/4 4/4+ 6/5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProne hip extension (Staheli)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4/2 3/3- 7/3 5/3+ 9/4 2/5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/2 3/3- 6/3 2/3+ 1/4- 2/4 1/4+ 4/5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3/2 2/3- 3/3 4/3+ 1/4- 5/4 4/4+ 1/5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProne hip extension \u0026nbsp;(flexed knee)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/3- 8/3 3/3+ 4/4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/3+ 1/4 4/4+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6/3- 1/3 3/3+ 1/4- 4/4 1/4+ 1/5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHip abduction with knee extended\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13/2 7/3- 20/3 3/3+ 1/4- 5/4 2/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/2 2/2+ 3/3- 3/3 3/3+ 7/4 2/4+ 1/5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/2 1/2+ 1/3- 3/3 4/4 4/4+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHip abduction with knee flexed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/2 3/4 2/5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/3 3/3+ 1/4- 3/4 2/4+\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHip adduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5/3 3/4- 17/4 7/4+ 18/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/4- 3/4 8/4+ 10/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/2 4/3+ 8/4 6/4+ 2/5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaximum knee flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/3- 5/3 1/3+ 7/4- 13/4 8/4+ 19/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/4- 6/4 12/4+ 2/5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/2 1/4- 6/4 1/4+ 6/5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProne knee flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/1 1/2 12/3- 11/3 4/3+ 5/4- 8/4 1/4+ 7/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/3- 3/3 3/3+ 2/4- 3/4 5/4+ 4/5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/2 1/3- 2/3 1/4- 5/4 2/4+ 5/5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnkle dorsiflexion with knee at 90\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6/2 2/2+ 7/3- 8/3 4/3+ 8/4 3/4+ 4/5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/1 1/2 1/2+ 1/3- 3/3 2/3+ 6/4 4/4+ 2/5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/3- 5/3+ 7/4 4/4+ 2/5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlantar flexion of the ankle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8/2 1/2+ 6/3- 4/3 3/3+ 2/4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/1 2/2 1/2+ 1/3- 1/3 1/3+\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3/2 6/2+ 3/3- 1/3 5/4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSMC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHip flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProne hip extension (Staheli)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9/1 23/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7/1 13/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5/1 11/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProne hip extension (flexed knee)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13/1 7/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/1 5/2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5/1 7/2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHip abduction with extended knee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24/1 30/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8/1 12/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4/1 12/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHip abduction with flexed knee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/1 4/2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/1 8/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHip abduction\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5/1 49/2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/1 16/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaximum knee flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18/1 38/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4/1 18/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/1 14/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProne knee flexion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33/1 20/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9/1 11/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3/1 12/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnkle dorsiflexion with knee at 90\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3/1 4/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/3 1/4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4/1 2/2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlantar flexion of the ankle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/1 4/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/1 2/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAshworth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHip flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9/0 9/1 12/1+ 2/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8/0 1/1 1/1+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7/0 2/1+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAdductors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1/0 9/1 20/1+ 13/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7/0 1/1+ 1/2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnterior rectus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7/0 11/1 11/1+ 11/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8/0 1/1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7/0 2/1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlantar flexors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4/1 13/1+ 15/2 12/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6/0 3/1 2/1+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/0 3/1 1/1+ 1/2 1/3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHamstrings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5/0 8/1 6/1+ 8/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8/0 2/1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8/0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTibialis anterior\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14/0 6/1 5/1+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7/0 1/1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10/0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTibialis posterior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14/0 13/1 6/1+ 8/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13/0 1/1+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12/0 2/1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe results of the kinematic gait analysis are shown in \u003cstrong\u003eFigure 6\u003c/strong\u003e. In the Figure, the sagittal plane is presented as range of motion (ROM) is greatest in that plane. Considering that ROM is defined as the amplitude between the maximum and minimum value of the angular displacement developed by a joint (hip, knee, or ankle) during gait, ROM increased in our patients with cerebral palsy after SDR, regardless of the surgical technique used (classic or conservative). This increase in ROM correlated with a decrease in the degree of muscle spasticity in patients post-operatively as shown in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe greatest benefits (changes in gait pattern) of SDR are seen in the knee joint, especially for the conservative technique. Specifically, improvements in gait patterns greater than 10\u0026deg; are considered clinically significant. In our patients, minimum knee flexion in the stance phase (i.e., the position in which the knee is in full extension) was the only measurement that was significantly different between the conservative technique and the classic technique, with a difference in flexion of 10\u0026deg;. When comparing pre- and post-operative joint patterns, knee extension at initial contact was found to have improved with both techniques; however, a greater improvement was seen for the conservative technique. Maximum knee flexion in the swing phase improved by approximately 10\u0026deg; for both surgical techniques.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNet joint power indicates the rate at which energy is used or generated by the muscle groups crossing a joint. \u003cstrong\u003eFigure 6\u003c/strong\u003e illustrates the maximum net joint power developed in the ankle by patients with cerebral palsy before and after SDR surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition to an increase in knee joint ROM, in children who underwent SDR with the conservative technique a statistically significant increase (p=0.04) in the net joint power developed by the ankle was observed. Patients who underwent SDR with the conservative technique developed a maximum net ankle power of 1.37\u0026plusmn;0.61 [unit: W/BW], whereas those who were operated with the classic technique developed a maximum net joint power of the ankle of 0.98\u0026plusmn;0.18 [unit: W/BW], similar to that of all patients previous to surgery ( [unit: W/BW]).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn the literature, convincing short- and long-term evidence that rhizotomy reduces spasticity has been reported. However, strong data to support that this reduction leads to a significant benefit for individuals with cerebral palsy are lacking.\u003c/p\u003e \u003cp\u003eA wide range of percentages of dorsal rootlet to be transected during SDR has been reported. In some centers, a rate of 50\u0026ndash;70% is used [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The argument in favor of a higher rate of sectioning is a better reduction of spasticity. However, there is a potential risk of undesired neurological effects of excessive deafferentation, including weakness in the antigravity muscles and bowel and bladder problems. In studies evaluating long-term patient outcomes, spinal abnormalities such as scoliosis, kyphosis, lumbar lordosis, spondylolysis and spinal stenosis have been commonly described as complications after SDR using this technique [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral authors, including Peacock and Aquilina, proposed to perform SDR from L2 to S1 because of the risk of spinal deformity, as to visualize the L1 root it is necessary to expose D12. Techniques such as limited posterior selective rhizotomy (Jorge Lazareff) lead to persistent spasticity in the L1, L2, and L3 roots, increasing the risk of hip dislocation.\u003c/p\u003e \u003cp\u003eIn other centers, a lower percentage (25\u0026ndash;40%) of rootlet transection has been advocated and routinely used. The results suggest similar efficacy in tone reduction without adverse effects. In general, in these more conservative cases, the rootlets to be sectioned are selected based on a combination of preoperative examination and intraoperative electrophysiological mapping [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to reducing spasticity in children with cerebral palsy, one of the main objectives of SDR is to maintain or improve gait and mobility. In this sense, our study shows that the impact of both techniques on gait function is similar with a generalized increase in ROM of the knee and ankle in the sagittal plane. A better performance in the knee joint was observed in patients that underwent SDR with the conservative technique, showing better knee flexion at initial contact and extension in mid-stance. Both techniques led to a positive change in the full knee flexion during swing. These data suggest that similar or even slightly better results can be achieved when a lower percentage of rootlets is sectioned in order to preserve the power-generating muscles that are essential for gait.\u003c/p\u003e \u003cp\u003eThe concept that a mono- or bi-articular muscle can transfer energy from one segment to another is physically significant and important for the execution of complex motor tasks. The redistribution of segmental energy occurs because the force generated by one muscle produces simultaneous accelerations and decelerations of segments throughout the body. Thus, a muscle can redistribute energy between segments regardless of whether the muscle is producing mechanical work (acting concentrically), dissipating energy by elongating (acting eccentrically), or maintaining a constant length (acting isometrically) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our results show that conservative SDR both improved joint ROM and led to a statistically significant increase in the net joint power of the ankle. These findings suggest that the conservative technique (as opposed to the classic technique) achieves optimal unblocking of the muscle groups that affect the ankle joint, avoiding excessive muscle weakness in these groups.\u003c/p\u003e \u003cp\u003eThis effect is extremely important for improved gait performance, considering that the soleus (uniarticular ankle plantar flexor) decelerates the thigh and tibia, and accelerates the trunk causing energy flow from the leg to the trunk during the mid-stance walking position (20\u0026ndash;40% of the gait cycle). In addition, the soleus provides translational power to the trunk because its contribution to the intersegmental force of the hip has a component collinear with the velocity of translation of the trunk [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Achieving greater net joint power in the ankle after rhizotomy will allow patients to start the rehabilitation process with better and greater muscular capacity, leading to better results.\u003c/p\u003e \u003cp\u003eOur findings suggest that the classic (a single cut of 50% of the rootlets) and conservative (a cut of the rootlets at L1: 25%, L2, L3 and L4: 33%, L5: 25% and S1: 15%) SDR techniques lead to very similar short-term functional gait results in terms of increased joint ROM. Modest differences in ankle kinematics during gait were observed, with a greater improvement in the classic SDR group. However, this putative improvement observed in the classic technique did not correlate with improvements in net muscle behavior. Conversely, it was observed that the conservative technique allows a better unblocking of the ankle muscle-joint complex, allowing important muscle groups that support the propulsion and advancement of the gait to develop greater muscle power, i.e., to more effectively transfer the forces generated by these muscles during gait.\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first research study to compare the effectiveness of two different SDR techniques, one of which was classic and the other conservative. The study allowed to evaluate whether a more conservative surgery has the potential to significantly reduce muscle spasticity while it also has the benefit of increasing net ankle joint power. This latter effect would be important because of the role of the plantar flexor muscles of the ankle in propulsion and stance during gait. Therefore, preserving or optimizing these muscle functions is of great value to achieve better results in the rehabilitation of children with cerebral palsy who underwent SDR to treat muscle spasticity. To assess the results quantitative parameters obtained by instrumented three-dimensional gait analysis were included.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis is the first study to comprehensively compare the short-term outcomes of a classic and a conservative SDR technique in a clinical cohort of ambulatory children with spastic cerebral palsy in Argentina. Using conventional gait modeling based on instrumented three-dimensional analysis, we found that SDR with sectioning of the nerve rootlets below 33% (the conservative technique) reduces muscle spasticity in patients with cerebral palsy by optimally unblocking the muscles that cross the ankle joint resulting in higher maximum net ankle joint power.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of FLENI.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients signed informed consent regarding publishing their data and photographs.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors do not present conflicts of interest.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received to assist with the preparation of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are not publicly available due to the sensitive nature of the information and because the participants are underage but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Beatriz Mantese: Original idea, conceptualization, writing, original draft, supervision and project administration. Christian G. Pirozzi Chiusa: Data collection, review, image editing and visualization. Yamila Basilotta Marquez: Data collection, review, editing and visualization. Mar\u0026iacute;a P\u0026iacute;a Gotter Campo: Data collection, review, editing and visualization. Ricardo Nazar: Data collection, review, editing and visualization. Marcos Crespo: Methodology, data collection, writing, review, image editing and visualization. Alfredo Toledo: Data collection, review, editing and supervision. Emiliano Ravera: Methodology, supervision, review and editing. All authors read and approved the final manuscript.\u003cstrong\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHerzog W. Skeletal muscle mechanics: questions, problems and possible solutions. Journal of Neuroengineering and Rehabilitation. 2014; 14: 98.\u003c/li\u003e\n\u003cli\u003eAquilina K, Graham D, Wimalasundera N. Selective dorsal rhizotomy: an old treatment re-emerging. Arch Dis Child. 2015;100:798-802.\u003c/li\u003e\n\u003cli\u003eNahm NJ, Graham HK, Gormley ME Jr, Georgiadis AG. Management of hypertonia in cerebral palsy. Curr Opin Pediatr. 2018 Feb; 30(1):57-64.\u003c/li\u003e\n\u003cli\u003eGrunt S, Fieggen AG, Vermeulen RJ, Becher JG, Langerak NG. Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature. Dev Med Child Neurol. 2014;56:302-12.\u003c/li\u003e\n\u003cli\u003eFasano VA, Broggie G, Barolat-Romana G, Sguazzi A. Surgical treatment of spasticity in cerebral palsy. Child Brain 1978;4:289-305. \u003c/li\u003e\n\u003cli\u003eFasano VA, Barolat-Romana G, Zeme S, Sguazzi A. Electrophysiological assesment of spinal circuits in spasticity by direct dorsal root stimulation. Neurosurgery 1979; 4:146- 151. \u003c/li\u003e\n\u003cli\u003ePeacock WJ, Arens LJ, Berman B. Cerebral palsy spasticity. Selective posterior rhizotomy. Pediatr Neurosci 1987; 13:61- 66.\u003c/li\u003e\n\u003cli\u003ePeacock WJ, Staoudt LA. Spasticity in cerebral palsy and the selective rhizotomy procedure. J Child Neurol 1990; 5:179- 185.1\u003c/li\u003e\n\u003cli\u003eJ A Lazareff. Limited (L4-S1, L5-S1) selective dorsal rhizotomy for reducing spasticity in cerebral palsy. Acta Neurochir (Wien) 1999;141(7):743-51; discussion 751-2\u003c/li\u003e\n\u003cli\u003eGeorgoulis G, Br\u0026icirc;nzeu A, Sindou M. Dorsal rhizotomy for children with spastic diplegia of cerebral palsy origin: usefulness of intraoperative monitoring. J Neurosurg Pediatr. 2018 Jul;22(1):89-101. doi: 10.3171/2018.1.PEDS17577. Epub 2018 Apr 13. PMID: 29652243.\u003c/li\u003e\n\u003cli\u003eHuenaerts C. et al. Does decreased spasticity improve gait in children with cp after selective dorsal rhizotomy? Gait \u0026amp; Posture 42S (2015) S1\u0026ndash;S90\u003c/li\u003e\n\u003cli\u003eMcLaughlin J, BjornsonK, Temkin N, Steinbok P, Wright V, Reiner A, Roberts T, Drake J, O\u0026rsquo;Donnell M, Rosenbaum P, Barber J, Ferrel A. Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol. 2002 Jan;44(1):17-25\u003c/li\u003e\n\u003cli\u003eEngsberg JR, Ross SA, Collins DR, Park TS. Effect of selective dorsal rhizotomy in the treatment of children with cerebral palsy. J Neurosurg. 2006 Jul;105(1)(Suppl):8-15. \u003c/li\u003e\n\u003cli\u003e[14] Crespo Marcos, Samara Eduardo, Toledo Alfredo, Duffy Clara, Segal Eduardo, Gotter Mar\u0026iacute;a Pia, Couto Juan. Short-time kinematics changes after selective dorsal rhizotomy. Gait and Clinical Movement Analysis Society 2014 Annual Conference June 2014. DOI: 10.13140/2.1.3648.4804\u003c/li\u003e\n\u003cli\u003eChen BP, Wang KK, Novacheck TF. Selective Dorsal Rhizotomy for the Treatment of Gait Dysfunction in Cerebral Palsy: A Critical Analysis Review. JBJS Rev. 2019 Nov;7(11):e3. doi: 10.2106/JBJS.RVW.19.00020. PMID: 31725025.\u003c/li\u003e\n\u003cli\u003eTedroff K, H\u0026auml;gglund G, Miller F. Long-term effects of selective dorsal rhizotomy in children with cerebral palsy: a systematic review. Dev Med Child Neurol. 2020 May;62(5):554-562. doi: 10.1111/dmcn.14320. Epub 2019 Jul 24. PMID: 31342516; PMCID: PMC7187377.\u003c/li\u003e\n\u003cli\u003eRoberts A, Stewart C, Freeman R. Gait analysis to guide a selective dorsal rhizotomy program. Gait Posture. 2015 Jun;42(1):16-22. doi: 10.1016/j.gaitpost.2015.04.004. Epub 2015 Apr 20. PMID: 25979183.\u003c/li\u003e\n\u003cli\u003eOeffinger, D., Tylkowski, C., Davis, R. (2004) Gross Motor Function Classification System and outcome tools for assessing ambulatory cerebral palsy: a multicenter study. Dev. Med. Child Neurol. 46, 311\u0026ndash;319.\u003c/li\u003e\n\u003cli\u003eBohannon RW, Smith MB (1987) Interrater Reliability of a Modified Asworth scale of muscle spasticity. Phys Ther 67 206-207.\u003c/li\u003e\n\u003cli\u003eKendall HO, Kendall FP, Wadsworth GE, editors (1971) Muscle Testing and Function, 2nd ed. London: Williams and Wilkins. \u003c/li\u003e\n\u003cli\u003eJames R. Gage, Michael H. Schwartz, Steven E. Koop, Tom F. Novacheck - The Identification and Treatment of Gait Problems in Cerebral Palsy (2009, Mac Keith Press). Chapter 3, p. 260 \u003c/li\u003e\n\u003cli\u003eKadaba MP, Ramakrishnan HK, Wootten ME, Gainey J, Gorton G, Cochran GV. Repeatability of kinematic, kinetic, and electromyographic data in normal adult gait. J Orthop Res. 1989;7(6):849-60. \u003c/li\u003e\n\u003cli\u003eNicolini-Panisson RD, Tedesco AP, Folle MR, Donadio MVF. Selective dorsal rhizotomy in cerebral palsy: selection criteria and postoperative physical therapy protocols. Rev Paul Pediatr. 2018 Jan 15;36(1):9. \u003c/li\u003e\n\u003cli\u003eZajac FE, Neptune RR, Kautz SA. Biomechanics and muscle coordination of human walking. Part I: introduction to concepts, power transfer, dynamics and simulations. Gait Posture. 2002 Dec;16(3):215-32. doi: 10.1016/s0966-6362(02)00068-1. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Rhizotomy, Gait analysis, Cerebral palsy, Muscle power, Spasticity","lastPublishedDoi":"10.21203/rs.3.rs-2990142/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2990142/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo analyze and compare the efficacy of two selective dorsal rhizotomy (SDR) techniques with intraoperative neurophysiological monitoring, using instrumented three-dimensional gait analysis.\u003c/p\u003e\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eSDR is a common, irreversible surgical treatment increasingly used to address gait disturbances in children with chronic non-progressive encephalopathy by reducing spasticity. Various techniques have been used, which mainly differ in the percentage of rootlets selected to be sectioned. A greater proportion of rootlets sectioned leads to a better reduction of spasticity; however, there is a potential risk of unwanted neurological effects of excessive deafferentation. While there is evidence of the short- and long-term benefits and complications of SDR, no studies have compared the effectiveness of each technique regarding gait function and preservation of the force-generating capacity of the muscles.\u003c/p\u003e\u003ch2\u003eMaterials and methods\u003c/h2\u003e \u003cp\u003eInstrumented three-dimensional gait analysis was used to evaluate two groups of patients with spastic cerebral palsy treated by the same neurosurgeon in different time periods, initially using a classic technique (cutting 50% of the nerve rootlets) and subsequently a conservative technique (cutting no more than 33% the nerve rootlets).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn addition to an increase in knee joint range of motion (ROM), in children who underwent SDR with the conservative technique a statistically significant increase (p\u0026thinsp;=\u0026thinsp;0.04) in the net joint power developed by the ankle was observed. Patients who underwent SDR with the conservative technique developed a maximum net ankle power of 1.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61 [unit: W/BW], whereas those who were operated with the classic technique developed a maximum net joint power of the ankle of 0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18 [unit: W/BW].\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur results show that both techniques led to a reduction in spasticity with a positive impact on the gait pattern. In addition, patients treated with the conservative technique were able to develop greater net ankle joint power, leading to a better scenario for rehabilitation and subsequent gait.\u003c/p\u003e","manuscriptTitle":"Selective Dorsal Rhizotomy: Analysis of two rootlet sectioning techniques","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-01 14:41:56","doi":"10.21203/rs.3.rs-2990142/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-07-25T00:57:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-06-18T07:44:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7661e48a-2191-4855-8955-83c66744c990","date":"2023-06-01T12:59:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-06-01T12:46:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-05-30T11:45:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-05-30T11:45:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child's Nervous System","date":"2023-05-27T20:57:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"37ad9ec5-7376-4323-8911-9a18dc12fc51","owner":[],"postedDate":"June 1st, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-12-18T15:08:21+00:00","versionOfRecord":{"articleIdentity":"rs-2990142","link":"https://doi.org/10.1007/s00381-023-06247-x","journal":{"identity":"childs-nervous-system","isVorOnly":false,"title":"Child's Nervous System"},"publishedOn":"2023-12-13 15:02:05","publishedOnDateReadable":"December 13th, 2023"},"versionCreatedAt":"2023-06-01 14:41:56","video":"","vorDoi":"10.1007/s00381-023-06247-x","vorDoiUrl":"https://doi.org/10.1007/s00381-023-06247-x","workflowStages":[]},"version":"v1","identity":"rs-2990142","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2990142","identity":"rs-2990142","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}