摘要： 目的 分析选择性脊神经后根切断术（SDR）治疗痉挛型脑瘫患儿临床疗效及影响因素。方法 纳入2015年9月至2019年6月在上海市儿童医院行SDR的131例痉挛型脑瘫患儿，采用粗大运动功能分级系统（GMFCS）和粗大运动功能评分-66项（GMFM-66）评价术前及末次随访时粗大运动功能、改良Ashworth肌张力分级评价双下肢目标肌群痉挛程度，单因素和多因素前进法Logistic回归分析筛查GMFM-66评分改善的影响因素。结果 与术前相比，术后下肢目标肌群双侧内收肌（Z=-8.164，P=0.000；Z=-8.304，P=0.000）、双侧腘绳肌（Z=-7.424，P=0.000；Z=-7.123，P=0.000）、双侧腓肠肌（Z=-9.328，P=0.000；Z=-9.605，P=0.000）、双侧比目鱼肌（Z=-9.349，P=0.000；Z=-9.543，P=0.000）肌张力不同程度下降，术后GMFCS分级总体改善率为34.35%（45/131），无一例GMFCS分级升高。不同GMFCS分级患儿手术前后GMFM-66评分差异有统计学意义（F=215.030，P=0.000），GMFCS分级Ⅰ级（t=4.379，P=0.000）、Ⅱ级（t=3.686，P=0.000）、Ⅲ级（t=3.198，P=0.002）患儿GMFM-66评分改善程度优于Ⅳ级患儿，且Ⅰ级患儿评分优于Ⅲ级（t=2.170，P=0.032）。Logistic回归分析显示，手术年龄3~6岁（OR=4.917，95% CI：1.554~15.557；P=0.007）和术前GMFCS分级Ⅰ~Ⅲ级（OR=10.294，95% CI：3.522~30.092；P=0.000）是ΔGMFM-66 ≥ 6.55分的有利因素。结论 SDR可有效降低痉挛型脑瘫患儿下肢目标肌群肌张力、改善粗大运动功能，尤以双下肢肌张力增高且能够配合康复训练患儿（GMFCS分级Ⅰ~Ⅲ级）术后疗效良好，严重脑瘫患儿（GMFCS分级Ⅳ~Ⅴ级）为便于生活护理也可行SDR治疗。

关键词: 脑性瘫痪, 脊髓切断术, 肌张力, 运动, 儿童

Abstract: Objective To analyze clinical efficacy rhizotomy (SDR) for treatment of spastic cerebral palsy (SCP) in children. Methods Total 131 children with SCP who underwent SDR at Shanghai Children's Hospital between September 2015 and June 2019 were included in the study. The Gross Motor Function Classification System (GMFCS) and Gross Motor Function Measure-66 Items (GMFM-66) were used to evaluate the gross motor function before surgery and at the last follow-up. The modified Ashworth Scale was used to assess the degree of spasticity in the target muscle groups of the lower limbs. Univariate and multivariate Logistic regression analyses were performed to identify the influencing factors of the improvement in GMFM-66 score. Results Compared to preoperative values, there was a significant decrease in muscle tonus in the target muscle groups of the lower limbs after surgery, including bilateral adductors muscles (Z=-8.164, P=0.000; Z=-8.304, P=0.000), bilateral hamstrings muscles (Z=-7.424, P=0.000; Z=-7.123, P=0.000), bilateral gastrocnemius muscles (Z=-9.328, P=0.000; Z=-9.605, P=0.000), and bilateral tibialis anterior muscles (Z=-9.349, P=0.000; Z=-9.543, P=0.000). The overall improvement rate of GMFCS classification after surgery was 34.35% (45/131), and there were no cases of GMFCS classification worsening. There were statistically significant differences in GMFM-66 scores before and after surgery among different GMFCS levels (F=215.030, P=0.000). The improvement in GMFM-66 score was greater in GMFCS level Ⅰ (t=4.379, P=0.000), Ⅱ (t=3.686, P=0.000) and Ⅲ (t=3.198, P=0.002) compared to level Ⅳ, and level Ⅰ had better score than level Ⅲ (t=2.170, P=0.032). Logistic regression analysis showed that surgery performed at the age of 3-6 years (OR=4.917, 95%CI:1.554-15.557; P=0.007) and preoperative GMFCS level Ⅰ-Ⅲ (OR=10.294, 95%CI:3.522-30.092; P=0.000) were favorable factors for a ΔGMFM-66 score improvement of ≥ 6.55 score. Conclusions SDR effectively reduces muscle tonus in the target muscle groups of the lower limbs and improves gross motor function in children with SCP. The treatment outcome is particularly favorable for children with increased muscle tonus in both lower limbs who can cooperate with rehabilitation training (GMFCS level Ⅰ -Ⅲ). SDR can also be considered for children with severe cerebral palsy (GMFCS level Ⅳ-Ⅴ) to facilitate daily care.

Key words: Cerebral palsy, Cordotomy, Muscle tonus, Motion, Child