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The selective dorsal rhizotomy technique for spasticity in 2020: a review

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Rick Abbott
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Abstract

This review looks at the advances in the surgical technique, selective dorsal rhizotomy, used for the management of spasticity in children.
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FOCUS SESSION
The selective dorsal rhizotomy technique for spasticity
in 2020: a review
Rick Abbott
1
Received: 18 June 2020 / Accepted: 22 June 2020
#Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract
This review looks at the advances in the surgical technique, selective dorsal rhizotomy, used for the management of spasticity in
children.
Keywords Selective dorsal rhizotomy .Selective posterior rhizotomy .Cerebral palsy treatment .North America .Spasticity
In the mid-1980s, the selective dorsal rhizotomy (SDR) was
introduced to North America for the treatment of spasticity
and, in particular, the treatment of children with spastic cere-
bral palsy (CP). In the late 1980s, I was asked to write a review
of its history and its use [1]. At the time the favored technique
was based on Peacock’s[2,3]. It consisted of a L2 through L5
laminectomies wide enough to view the nerve roots as they
exited the dura, separation of the sensory from the motor nerve
root at each targeted level then electrical stimulation of the L2
through S1 sensory roots bilaterally. Interpretation of the re-
sponses was based on Fasano’s manuscript that described an
normal root response to an electrical stimulus train (1 stimu-
lus/s) as causing contraction of a single muscle or muscle
group that continued in a one-for-one pattern [4]. As the fre-
quency of stimuli in the train was increased, the observed
muscle contraction rapidly lessened in duration and ceased
when the train’s frequency of stimuli went above 20 Hz. He
also described a normal root’sresponseas“The responding
muscle groups are always the same, for each root being ex-
amined, whatever stimulation frequency is employed.”He
observed that the threshold for stimulation of normal nerve
roots was between 0.1 and 0.5 V. Fasano deemed a nerve root
as being abnormal when its response to stimulation varied
from the above description.
Peacock’s presentation of his technique and his reports on
his CP patients’outcome rapidly gained attention in North
America, both by its pediatric neurosurgeons and the public
at large. Much controversy was generated in the medical field
over the procedure and its efficacy. Surgeons employing the
technique were compelled to report their results in an increas-
ingly stringent manor. The result has been an evolution in the
methods used both surgically and for assessing the patients
undergoing SDR. This review will focus on this evolution and
how it has affected patient selection for treatment with SDRs,
the tools used for their assessment, the surgical technique, and
some of the complications that have been driving this
evolution.
Candidate selection
In his 1987 report on using SDR to treat “cerebral palsy spas-
ticity,”Peacock concluded that children with pure spasticity
that predominantly involves the legs benefited most from the
procedure and this became his ideal candidate [5]. The paper
also reported that “…athetoid and ataxic patients should not
undergo this form of surgery unless there is considerable
amount of coexisting spasticity.”Great attention was placed
on clearly defining spasticity as described by Lance (“…a
motor disorder characterized by a velocity-dependent increase
in tonic stretch reflexes (muscle tone) with exaggerated ten-
don jerks, resulting from hyperexcitability of the stretch re-
flex, as one component of the upper motor neuron syn-
drome.”)[6]. Peacock’s subsequent reports focused on the
results of using SDR to treat spastic diplegics. This, coupled
with the introduction of intrathecal baclofen, narrowed the
application of SDR to children in most centers by the late
1990s.
*Rick Abbott
rickabbott@me.com
1
Albert Einstein College ofMedicine, Montefiore Health System, 110
E. 210th St Bronx NY 10467 USA
https://doi.org/10.1007/s00381-020-04765-6
/ Published online: 9 July 2020
Child's Nervous System (2020) 36:1895–1905
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... SDR involves laminectomy and division of selective sensory nerve roots, which reduces afferent input into spinal reflex arcs to decrease spasticity. [7][8][9] Although SDR can be highly effective, it requires multilevel laminectomies that increase surgical risks, including CSF leaks, infection, hematomas, and spinal deformity. [9][10][11] The extensive dissection also leads to significant postoperative pain and a longer rehabilitation process. ...
... [7][8][9] Although SDR can be highly effective, it requires multilevel laminectomies that increase surgical risks, including CSF leaks, infection, hematomas, and spinal deformity. [9][10][11] The extensive dissection also leads to significant postoperative pain and a longer rehabilitation process. ...
... 24 Given the often unsatisfactory results of conservative spasticity reduction, particularly in patients with significant motor impairments, more invasive methods such as SDR are widely used. [7][8][9][10] Despite advances in neurosurgical techniques and proven effectiveness in reducing spasticity, SDR remains a highly invasive surgical procedure involving laminectomy and selective irreversible destruction of spinal roots, leading to longer recovery times and higher risks compared with less invasive methods. Like any surgical operation, SDR carries a high risk of complications such as infection, bleeding, or nerve damage. ...
Percutaneous thermal radiofrequency rhizotomy of L2-S1 spinal nerve roots in children with cerebral palsy
Article
  • Jun 2024
  • Neurosurg Focus
OBJECTIVE This study presents the results of an evaluation of the effectiveness of percutaneous thermal radiofrequency (RF) ablation of spinal nerve roots to reduce spasticity and improve motor function in children with cerebral palsy (CP). METHODS A retrospective analysis was conducted on the surgical treatment outcomes of 26 pediatric patients with severe CP (Gross Motor Function Classification System levels IV–V). The assessment protocol included muscle tone assessment using the modified Ashworth scale (MAS), evaluation of passive and active range of motion, gait video recording, and locomotor status evaluation using the Gross Motor Function Measure (GMFM)–88 scale. Thermal RF rhizotomy (ablation of spinal nerve roots) was performed on all patients at the L2–S1 levels at 70°C for 90 seconds. The statistical data analysis was conducted using the t-test and Mann-Whitney U-test. A p value < 0.05 was considered statistically significant. RESULTS Before the operation, the average level of spasticity in the lower-limb muscles of all patients was 3.0 ± 0.2 according to the MAS. In the early postoperative period, the spasticity level in all examined muscle groups significantly decreased to a mean of 1.14 ± 0.15 (p < 0.001). In the long-term postoperative period, the spasticity level in the examined muscle groups averaged 1.49 ± 0.17 points on the MAS (p < 0.001 compared to baseline, p = 0.0416 compared to the early postoperative period). Despite the marked reduction of spasticity in the lower limbs, no significant change in locomotor status according to the GMFM-88 scale was observed in the selected category of patients. In the long-term period, during the control examination of patients, the GMFM-88 level increased on average by 3.6% ± 1.4% (from 22.2% ± 3.1% to 25.8% ± 3.6%). CONCLUSIONS The findings of this study offer preliminary yet compelling evidence that RF ablation of spinal nerve roots can lead to a significant and enduring decrease in muscle tone among children with severe spastic CP. Further studies and longer-term data of the impact on functionality and quality of life of patients with CP after spinal root RF ablation are needed.
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... Since the surgical application of Sherrington's pioneering work 1 by Foerster to treat spasticity, 2 lumbosacral dorsal rhizotomy has been widely used for children with spastic cerebral palsy (CP). 3,4 Foerster advocated interrupting the entire dorsal roots from L2 to S1 with the exception of the L4 root, prominent in antigravity and ambulatory function. 2 Later, to avoid producing excessive hypotonia and sensory disturbances, Gros developed partial rhizotomy, which consisted of sparing 20% of the rootlets of each of the L2 to S1 dorsal roots, then the sectorial modality, targeting the roots corresponding to the muscles harbouring harmful spasticity. ...
Excitability of the radiculo‐medullary circuitry in spastic cerebral palsy: An intraoperative neurophysiological study in children undergoing selective dorsal rhizotomy
Article
Full-text available
  • Jun 2022
  • DEV MED CHILD NEUROL
Aim To explore – through intraoperative neurophysiology mapping and recordings – the comparative distribution of the reflexive excitability of the L2 to S2 radiculo‐metameric segments of the spinal cord in a series of children with bilateral spastic cerebral palsy (CP) who underwent selective dorsal rhizotomy (SDR). Method Our series included 46 consecutive children (36 males, 10 females; aged 5–16 years, mean 8 years) who underwent SDR, using keyhole interlaminar dorsal rhizotomy. The procedure allowed access to all L2 to S2 roots independently, while preserving the posterior architecture of the lumbar spine. Dorsal roots were stimulated selectively to test reflexive excitability of the corresponding radiculo‐metameric levels. Stimulation parameters were identical for all roots for optimal comparison between root levels, with an intensity just above threshold to avoid excessive diffusion. The responses in the main muscular groups in each lower limb were clinically observed and electromyograms recorded. Degrees of excitability were quantified according to Fasano's scale. Results The difference between root levels was highly significant. Median values of excitability were 1, 2, 3, 3, 3, and 3 for the L2, L3, L4, L5, S1, and S2 levels respectively. Lower root levels exhibited significantly more excitability. Interpretation In addition to insight into the spasticity of children with CP, the profile of segmental excitability can be useful in establishing surgical planning when programming SDR. What this paper adds Keyhole interlaminar dorsal rhizotomy modality allowed selective stimulation of all L2–S2 dorsal roots for testing excitability. There were significant differences in reflexive excitability of L2–S2 radiculo‐medullary segments. Lower segments of L2–S2 medullary levels have higher excitability. Interindividual variability in excitability of lumbosacral segments justifies intraoperative neurophysiology. This original article is commented on by Young on pages 9–10 of this issue.
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White matter characteristics in children with cerebral palsy prior to selective dorsal rhizotomy: a multicenter diffusion tensor imaging study
Article
  • Jun 2024
  • J NEUROSURG-PEDIATR
OBJECTIVE The aims of this study were to 1) assess and quantify white matter (WM) microstructural characteristics derived from diffusion tensor imaging (DTI) in children with cerebral palsy (CP) prior to selective dorsal rhizotomy (SDR), and 2) investigate potential associations between WM diffusion properties and gross motor function and spasticity in children with spastic CP who underwent SDR. METHODS This study is a multisite study based on DT images acquired prior to SDR as well as postoperative outcome data. DTI data collected from two sites were harmonized using the ComBat approach to minimize intersite scanner difference. The DTI abnormalities between children with spastic CP and controls were analyzed and correlated with the severity of impaired mobility based on the Gross Motor Function Classification System (GMFCS). The improvement in gross motor function and spasticity after SDR surgery was assessed utilizing the Gross Motor Function Measure-66 (GMFM-66), the Modified Tardieu Scale (MTS), and the modified Ashworth scale (MAS). Alterations in these outcome measures were quantified in association with DTI abnormalities. RESULTS Significant DTI alterations, including lower fractional anisotropy (FA) in the genu of the corpus callosum (gCC) and higher mean diffusivity (MD) in the gCC and posterior limb of the internal capsule (PLIC), were found in children in the SDR group when compared with the age-matched control group (all p < 0.05). Greater DTI alterations (FA in gCC and MD in gCC and PLIC) were associated with lower mobility levels as determined based on GMFCS level (p < 0.05). The pre- to post-SDR improvement in motor function based on GMFM-66 was statistically significant (p = 0.006 and 0.002 at 6-month and 12-month follow-ups, respectively). The SDR efficacy was also identified as improving spasticity in lower-extremity muscle groups assessed with the MTS and MAS. Partial correlation analysis presented a significant association between pre- to post-SDR MTS alteration and DTI abnormalities. CONCLUSIONS The findings in the present study provided initial quantitative evidence to establish the WM microstructural characteristics in children with spastic CP prior to SDR surgery. The study generated data for the association between baseline DTI characteristics and mobility in children with CP prior to SDR surgery. The study also demonstrated SDR efficacy in improving motor function and spasticity based on the GMFM-66, MTS, and MAS, respectively, in association with DTI data.
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Dorsal Rhizotomy in the Pediatric Patient
Article
  • Feb 2024
The majority of cases of dorsal rhizotomy surgeries in children are done to improve the spasticity associated with cerebral palsy, and more recent techniques are selective in nature and referred to as selective dorsal rhizotomy (SDR). The techniques applied to selective dorsal rhizotomy surgery has changed since it was first described and continues to undergo modifications. Approaches to surgery and monitoring vary slightly among centers. This article provides a review of the rationale, variety of surgical approaches, and intraoperative neurophysiologic monitoring methods used along with discussion of the risks, complications and outcomes in these surgeries.
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Surgical procedures for treatment of spasticity
Article
  • Nov 2023
  • NERVENARZT
The causes of spasticity are various and include cerebral palsy, spinal cord injury, stroke, multiple sclerosis or other congenital or acquired lesions of the central nervous system (CNS). While there is often a partial functional component, spasticity also results in varying degrees of impairment of the quality of life. A review of surgical treatment options for spasticity. A systematic PubMed review of the literature on epidemiology and treatment options with a focus on neurosurgical interventions for spasticity and developments in the last 20 years as well as inclusion of still valid older landmark papers was carried out. Illustration of indications, technique, follow-up, and possible pitfalls of the different methods for the surgical treatment of spasticity. Depending on the affected region, the number of muscle groups, and the extent of spasticity, focal (selective peripheral neurotomy, nerve transfer), regional (selective dorsal rhizotomy), or generalized (baclofen pump) procedures can be performed. The indications are usually established by an interdisciplinary team. Conservative (physiotherapy, oral medications) and focally invasive (botulinum toxin injections) methods should be performed in advance. In cases of insufficient response to treatment or only short-term relief, surgical methods can be evaluated. These are usually preceded by test phases with, for example, trial injections. Surgical methods are a useful adjunct in cases of insufficient response to conservative treatment in children and adults with spasticity.
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Management of Spasticity
Chapter
  • May 2023
Spasticity has traditionally been considered a disease that can be medically managed with oral agents, botulinum injections, and serial casting. Medical management, while often effective, usually offers transient effects whose efficacy can wane over time with sustained use. In recent decades, surgical and technological advances have enabled the utility of an implanted intrathecal baclofen pump or laminectomy for selective dorsal rhizotomy for the treatment of pediatric spasticity. The surgical indications differ for each procedure. A baclofen pump can treat all types of spastic cerebral palsy while selective dorsal rhizotomy is confined to spastic diplegia in young, high-functioning patients. Each type of surgical intervention has provided patients with improved quality of life and control of their disease.KeywordsSpasticityToneCerebral palsyRhizotomyBaclofen pumpSpasticity surgery
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Spasticity Interventions
Article
  • Mar 2023
  • Pediatr Clin
Spasticity results from an abnormality of the central nervous system and is characterized by a velocity-dependent increase in muscle tone or stiffness. In children, it can cause functional impairments, delays in achieving developmental or motor milestones, participation restrictions, discomfort, and musculoskeletal differences. Unique to children is the ongoing process of a maturing central nervous system and body, which can create the appearance of worsening or changing spasticity. Treatment options include physical interventions such as stretching, serial casting, and bracing; oral and injectable medications; and neurosurgical procedures such as selective dorsal rhizotomy and intrathecal baclofen pump.
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Predicting the brain age of children with cerebral palsy using a two-dimensional convolutional neural networks prediction model without gray and white matter segmentation
Article
Full-text available
  • Nov 2022
Background Abnormal brain development is common in children with cerebral palsy (CP), but there are no recent reports on the actual brain age of children with CP. Objective Our objective is to use the brain age prediction model to explore the law of brain development in children with CP. Methods A two-dimensional convolutional neural networks brain age prediction model was designed without segmenting the white and gray matter. Training and testing brain age prediction model using magnetic resonance images of healthy people in a public database. The brain age of children with CP aged 5–27 years old was predicted. Results The training dataset mean absolute error (MAE) = 1.85, r = 0.99; test dataset MAE = 3.98, r = 0.95. The brain age gap estimation (BrainAGE) of the 5- to 27-year-old patients with CP was generally higher than that of healthy peers (p < 0.0001). The BrainAGE of male patients with CP was higher than that of female patients (p < 0.05). The BrainAGE of patients with bilateral spastic CP was higher than those with unilateral spastic CP (p < 0.05). Conclusion A two-dimensional convolutional neural networks brain age prediction model allows for brain age prediction using routine hospital T1-weighted head MRI without segmenting the white and gray matter of the brain. At the same time, these findings suggest that brain aging occurs in patients with CP after brain damage. Female patients with CP are more likely to return to their original brain development trajectory than male patients after brain injury. In patients with spastic CP, brain aging is more serious in those with bilateral cerebral hemisphere injury than in those with unilateral cerebral hemisphere injury.
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A Cadaver Feasibility Study of Extradural Contralateral C7 Ventral Root Transfer Technique for Treating Upper Extremity Paralysis
Article
  • Jul 2022
Study design: A total of 6 formalin-fixed cadavers were included in the cadaver feasibility study. Objective: To ascertain the anatomical feasibility of extradural contralateral C7 ventral root transfer technique by cervical posterior. Summary of background data: Upper limb spastic hemiplegia is a common sequela after stroke. In our previous study, we established a method by transferring contralateral C7 dorsal and ventral roots to the corresponding C7 dorsal and ventral roots on the affected side in the cervical posterior. Methods: In the present study, six formalin-fixed cadavers were dissected to confirm the anatomical feasibility. Experimental anastomosis in cadavers was conducted. The pertinent lengths of the extradural nerve roots were measured. The tissue structures surrounding regions between the extradural CC7 nerve roots and the vertebral artery were observed. The cervical MRI scans of 60 adults were used to measure the distance between the donor and recipient nerves. Results: Experimental anastomosis showed that the distance between the donor and recipient nerves was approximately 1 cm; the short segment of the sural nerve needed bridging. The distance between both exit sites of the exit of the extradural dura mater was 33.57±1.55 mm. The length of the extradural CC7 ventral root was 22.00±0.98 mm. The ventral distance (vd) and the dorsal distance (dd) in males were 23.98±1.72 mm and 30.85±2.22 mm (P<0.05), while those in females were 23.28±1.51 mm and 30.03±2.16 mm, respectively. C7 vertebral transverse process, ligaments, and other soft tissues were observed between the vertebral artery and the extradural C7 nerve root. Conclusion: Under the premise of less trauma, our study shows that the extradural contralateral C7 ventral root transfer technique, , in theory, yields better surgical results, including better recovery of motor function and complete preservation of sensory function. Level of evidence: 5.
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Dorsal Rhizotomy for Children with Cerebral Palsy
Chapter
  • Jun 2022
As soon as the early twentieth century, dorsal rhizotomy (DRh) was known to alleviate spastic hypertonia. But it is only in the last 20 years that DRh became commonly used after refinements in surgical indications and in the selection of roots/rootlets on their topographic and/or functional responses to stimulation. Optimal timing for surgery is considered when spasticity becomes refractory to all conservative treatment and physical therapy, and before irreducible contractures and deformities appear. In children able to ambulate, the realistic goal is to improve gait, walk, and function. In children more severely affected, especially quadriplegic patients, the goal is to increase comfort, decrease pain, ease nursing cares, and diminish the overall emotional overactivity and parasite movements in upper limbs thanks to distant effects.
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Feasibility and effectiveness of a newly modified protocol-guided selective dorsal rhizotomy via single-level approach to treat spastic hemiplegia in pediatric cases with cerebral palsy
Article
Full-text available
  • Nov 2019
  • CHILD NERV SYST
Purpose It still remains challenging to treat CP cases with spastic hemiplegia using SDR via a single-level approach when guided by the traditional EMG response grading system. Our aim was to assess the feasibility and effectiveness of a newly modified protocol-guided single-level laminectomy SDR to treat such pediatric patients. Methods A retrospective cohort review was conducted in the CP cases with spastic hemiplegia undergone our newly modified protocol-guided single-level approach SDR since May 2016 to October 2017, and followed by intensive rehabilitation program for at least 12 months in both Shanghai Children’s Hospital and Shanghai Rehabilitation and Vocational Training Center for the Disabled. Inclusion and exclusion criteria were set for the selection of patients in the current study. Our study focused on the setup, EMG recording interpretation, and outcome measures for this newly modified rhizotomy scheme. Results Eleven cases were included in the current study. Based on our new rhizotomy protocol, a total of 34 rootlets over our 11 cases were cut (2 in 4, 3 in 4, 4 in 1, and 5 rootlets in 2 cases, respectively). After SDR and the following rehabilitation program at a mean duration of 19 months, muscle tone of those “target muscles” in affected lower extremities which identified during pre-op assessment decreased by a mean of 1.4 degrees (Modified Ashworth Scale) in our cases. Strength of those target muscles and ROM of joints involved in their lower limbs were reported to have improved significantly as well. All cases showed major progress with regard to their motor function. A mean of about 10-point increase of GMFM-66 score was reported, and five of six cases who were with GMFCS level II preoperatively improved their GMFCS level at the last assessment. Kinematics of joints of hip, knee, and ankle on the affected side in our cases demonstrated a major correction, along with improvement of their foot pressure patterns to the ground during their gait cycles. Surgery-related complications, such as cerebral–spinal fluid leak/infection, long-term hypoesthesia, or urinary/bowel incontinence were not recorded in the current study. Conclusion Single-level SDR when guided by our simplified rhizotomy protocol is feasible and effective to treat pediatric CP cases with spastic hemiplegia.
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Selective dorsal rhizotomy in ambulant children with cerebral palsy: an observational cohort study
Article
Full-text available
  • Apr 2019
Background Selective dorsal rhizotomy (SDR) is an irreversible surgical procedure involving the division of selected sensory nerve roots, followed by intensive physiotherapy. The aim is to improve function and quality of life in children with cerebral palsy and a Gross Motor Function Classi cation System (GMFCS) level of II or III (walks with or without assistive devices, respectively). We assessed gross motor function before and after SDR and postoperative quality of life in a study commissioned by NHS England. Methods We did a prospective observational study in ve hospitals in England who were commissioned to perform SDR on children aged 3–9 years with spastic diplegic cerebral palsy. The primary outcome was score changes in the 66-item Gross Motor Function Measure (GMFM-66) and seven domains of the Cerebral Palsy Quality of Life Questionnaire ([CP-QoL] social wellbeing and acceptance, feelings about functioning, participation and physical health, emotional wellbeing and self-esteem, access to services, family health, and pain and impact of disability) from before to 24 months after SDR. Findings From Sept 4, 2014, to March 21, 2016, 137 children underwent SDR. The mean age was 6·0 years (SD 1·8). The mean GMFM-66 score increased after SDR with an annual change of 3·2 units (95% CI 2·9 to 3·5, n=137). Of the seven CP-QoL domains, ve showed signi cant improvements over time: feelings about functioning mean annual change 3·0 units (95% CI 2·0 to 4·0, n=133), participation and physical health 3·9 units (2·5 to 5·3, n=133), emotional wellbeing and self-esteem 1·3 units (0·2 to 2·3, n=133), family health 2·0 units (0·7 to 3·3, n=132), and pain and impact of disability –2·5 units (–3·9 to –1·2, n=133). 17 adverse events were reported in 15 children, of which none were severe and 15 (88%) resolved. Interpretation SDR improved function and quality of life in the 24 months after surgery in children with cerebral palsy classi ed as GMFCS levels II and III. On the basis of these ndings, an interim national policy decision was made that SDR would be funded for eligible children in England from 2018. Funding National Institute for Health and Care Excellence, National Institute for Health Research Biomedical Research Centre, NHS England.
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Selective dorsal rhizotomy: Current state of practice and the role of imaging
Article
Full-text available
  • Mar 2018
Spastic diplegic cerebral palsy (CP) is the most common form of CP. A specific goal-oriented approach, tailored to the child, is essential to management in all forms of CP. Selective dorsal rhizotomy (SDR) is a neurosurgical procedure that permanently reduces lower limb spasticity in children with spastic diplegic CP. The current technique is performed through a single level laminectomy at the level of the conus and, with the aid of intraoperative electromyography (EMG), allows selective division of the afferent lumbosacral nerve roots. In carefully selected children, reduction in spasticity has positive effects on the growing child. SDR is associated with minimal complications and good long-term outcomes. This article describes the surgical technique and patient selection, including the importance of medical imaging, and discusses the long-term outcomes of SDR. © 2018 Quantitative Imaging in Medicine and Surgery. All rights reserved.
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Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children
Article
Full-text available
  • Apr 2018
  • ACTA NEUROCHIR
Background: Selective dorsal rhizotomy (SDR) has been established as an effective surgical treatment for spastic diplegia. The applicability of SDR to the full spectrum of spastic cerebral palsy and the durability of its therapeutic effects remain under investigation. There are currently limited data in the literature regarding efficacy and outcomes following SDR in Gross Motor Function Classification System (GMFCS) IV and V patients. Intrathecal baclofen has traditionally been the surgical treatment of choice for these patients. When utilised primarily as a treatment for the relief of spasticity, it is proposed that SDR represents a rational and effective treatment option for this patient group. We report our outcomes of SDR performed on children with severe cerebral palsy (GMFCS grade IV and V). The commensurate improvement in upper as well as lower limb spasticity is highlighted. Apparent benefit to urological function following SDR in this patient group is also discussed. Method: A retrospective review of prospectively collected data for 54 paediatric patients with severe cerebral palsy (GMFCS IV-V) who received SDR plus specialised physiotherapy. Mean age was 10.2 years (range, 3.0-19.5). SDR guided by electrophysiological monitoring was performed by a single experienced neurosurgeon. All subjects received equivalent physiotherapy. The primary outcome measure was change to the degree of spasticity following SDR. Spasticity of upper and lower limb muscle groups were quantified and standardised using the Ashworth score. Measures were collected at baseline and at 2-, 8- and 14-month postoperative intervals. In addition, baseline and 6-month postoperative urological function was also evaluated as a secondary outcome measure. Results: The mean lower limb Ashworth score at baseline was 3.2 (range, 0-4). Following SDR, significant reduction in lower limb spasticity scores was observed at 2 months and maintained at 8 and 14 months postoperatively (Wilcoxon rank, p < 0.001). The mean reduction at 2, 8 and 14 months was 3.0, 3.2 and 3.2 points respectively (range, 1-4), confirming a sustained improvement of spasticity over a 1-year period of follow-up. Significant reduction in upper limb spasticity scores following SDR was also observed (mean, 2.9; Wilcoxon rank, p < 0.001). Overall, the improvement to upper and lower limb tone following SDR-generally to post-treatment Ashworth scores of 0-was clinically and statistically significant in GMFCS IV and V patients. Urological assessment identified pre-existing bladder dysfunction in 70% and 90% of GMFCS IV and V patients respectively. Following SDR, improvement in urinary continence was observed in 71% of affected GMFCS IV and 42.8% of GMFCS V patients. No serious postoperative complications were identified. Conclusions: We conclude that SDR is safe and-in combination with physiotherapy-effectively reduces spasticity in GMFCS grade IV and V patients. Our series suggests that spastic quadriplegia is effectively managed with significant improvements in upper limb spasticity that are commensurate with those observed in lower limb muscle groups. These gains are furthermore sustained more than a year postoperatively. In light of these findings, we propose that SDR constitutes an effective treatment option for GMFCS IV and V patients and a rational alternative to intrathecal baclofen.
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Functional Outcomes of Childhood Selective Dorsal Rhizotomy 20 to 28 Years Later
Article
Full-text available
  • May 2017
Background Selective dorsal rhizotomy (SDR) is a surgical method used to treat childhood spastic cerebral palsy (CP). However, the effects of early SDR on functional outcomes and quality of life decades later in adulthood remains to be elucidated. Objectives To evaluate the long-term outcomes in terms of satisfaction and mobility of adult patients who received childhood SDR. Methods Adult patients who received SDR in childhood were surveyed. The survey questionnaire asked about demographic information, quality of life, health outcomes, SDR surgical outcomes, ambulation, manual ability, pain, braces/orthotics, post-SDR treatment, living situation, education level, and work status. Results Our study included 95 patients. The age that patients received SDR was between two and 18 years. The age at the time of survey was between 23 and 37 years (mean ± S.D., 30.2 ± 3.6 years). Post-SDR follow-up ranged from 20 to 28 years (mean ± S.D., 24.3 ± 2.2 years). Seventy-nine percent of patients had spastic diplegia, 20% had spastic quadriplegia, and one percent had spastic triplegia. Ninety-one percent of patients felt that SDR impacted positively the quality of life and two percent felt that the surgery impacted negatively the quality of life after SDR. Compared to pre-operative ambulatory function, 42% reported higher level of ambulation and 42% ambulated in the same level. Eighty-eight percent of patients would recommend the procedure to others and two percent would not. Thirty-eight percent reported pain, mostly in the back and lower limbs, with mean pain level 4.2 ± 2.3 on the Numeric Pain Rating Scale (NPRS). Decreased sensation in patchy areas of the lower limbs that did not affect daily life was reported by eight percent of patients. Scoliosis was diagnosed in 31%. The severity of scoliosis is unknown. Only three percent of them underwent spinal fusion. Fifty-seven percent of patients required some orthopedic surgery after SDR. The soft-tissue tendon lengthening procedures included lengthening on hamstrings, Achilles tendons or adductors. Out of all bone procedures, 24% of patients had hip surgery, five percent had knee surgery, and 10% had derotational osteotomies. No late side effects of SDR surgery were reported in this survey. Conclusions In our 95 adult patients who received SDR in childhood, the surgery had positive effects on the quality of life and ambulation 20-28 years later. There were no late complications of SDR surgery.
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Improved Scaling of the Gross Motor Function Measure for Children With Cerebral Palsy: Evidence of Reliability and Validity
Article
Full-text available
  • Sep 2000
Background and Purpose. This study examined the reliability, validity, and responsiveness to change of measurements obtained with a 66-item version of the Gross Motor Function Measure (GMFM-66) developed using Rasch analysis. Subjects and Methods. The validity of measurements obtained with the GMFM-66 was assessed by examining the hierarchy of items and the GMFM-66 scores for different groups of children from a stratified random community-based sample of 537 children with cerebral palsy (CP). A subset of 228 children who had been reassessed at 12 months was used to test the hypothesis that children who are young (<5 years of age) and have “mild” CP will demonstrate greater change in GMFM-66 scores than children who are older (≥5 years of age) and whose CP is more severe. Data from an additional 19 children with CP who were assessed twice, one week apart, were used to examine test-retest reliability. Results. The overall changes in GMFM-66 scores over 12 months and a time × severity × age interaction supported our hypotheses. Test-retest reliability was high (intraclass correlation coefficient=.99). Conclusion and Discussion. This study demonstrated that the GMFM-66 has good psychometric properties. By providing a hierarchical structure and interval scaling, the GMFM-66 can provide a better understanding of motor development for children with CP than the 88 item GMFM and can improve the scoring and interpretation of data obtained with the GMFM.
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Factors Associated With Long-Term Improvement of Gait After Selective Dorsal Rhizotomy
Article
  • Jun 2018
  • ARCH PHYS MED REHAB
Objective: To identify factors associated with long-term improvement in gait in children after selective dorsal rhizotomy (SDR). Design: Retrospective cohort study SETTING: University medical center PARTICIPANTS: 36 children (age 4-13y) with spastic diplegia (gross motor classification system level I (n=14), II (n=15) and III (n=7) were included retrospectively from the database of our hospital. Children underwent selective dorsal rhizotomy (SDR) between January 1999 and May 2011. Patients were included if they received clinical gait analysis before and five years post-SDR, age >4 years at time of SDR and if brain MRI-scan was available. Intervention: Selective dorsal rhizotomy MAIN OUTCOME MEASURES: Overall gait quality was assessed with Edinburgh visual gait score (EVGS), before and five years after SDR. In addition, knee and ankle angles at initial contact and midstance were evaluated. To identify predictors for gait improvement, several factors were evaluated including: functional mobility level (GMFCS), presence of white matter abnormalities on brain-MRI, and selective motor control during gait (synergy analysis). Results: Overall gait quality improved after SDR, with a large variation between patients. Multiple linear regression analysis revealed that worse score on EVGS and better GMFCS were independently related to gait improvement. Gait improved more in children with GMFCS I & II compared to III. No differences were observed between children with or without white matter abnormalities on brain MRI. Selective motor control during gait was predictive for improvement of knee angle at initial contact and midstance, but not for EVGS. Conclusion: Functional mobility level and baseline gait quality are both important factors to predict gait outcomes after SDR. If candidates are well selected, SDR can be a successful intervention to improve gait both in children with brain MRI abnormalities as well as other causes of spastic diplegia.
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Pediatric Scoliosis and Kyphosis: An Overview of Diagnosis, Management, and Surgical Treatment
Article
  • Dec 2017
  • Pediatr Ann
Evaluation of pediatric spinal deformity requires knowledge of special orthopaedic testing and radiographic interpretation. The determination of recommendations for treatment of spinal abnormalities in children can be challenging and at times complex, as treatment options are dependent upon a variety of factors. The etiology of scoliosis or kyphosis, presence or absence of vertebral anomalies, symptoms, magnitude of the curve, physiologic/skeletal age, and evidence of and risk of progression all require consideration and play a role in the shared decision-making process. This article provides an overview of relevant information and includes research outcomes to support the care of pediatric patients with spinal deformities. [Pediatr Ann. 2017;46(12):e472-e480.].
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Long-term outcomes after selective dorsal rhizotomy: a retrospective matched cohort study
Article
  • Aug 2017
  • DEV MED CHILD NEUROL
Aim: To examine long-term outcomes of selective dorsal rhizotomy (SDR) 10 to 17 years after surgery. Method: Participants who underwent SDR had spastic diplegic cerebral palsy (CP), completed baseline gait analysis, and were 16 to 25 years old at follow-up. Non-SDR participants (i.e. controls) were matched on important clinical parameters at baseline but did not undergo SDR. All study participants completed six surveys assessing pain, quality of life, participation, function, and mobility. Treatment history for lower extremity surgery and antispasticity injections was tabulated. A subset of each study group returned for three-dimensional gait analysis, including kinematics, metabolic energy cost, and physical examination. Gait Deviation Index (GDI) was calculated to measure gait quality. Results: The study cohort had 24 participants with SDR and 11 without SDR. Of these, 13 patients with SDR (five males, eight females; median [IQR] age 17y 2mo [16y 8mo-17y 9mo]) and eight without SDR (three males, five females; median [IQR] age 19y 2mo [17y 3mo-21y 11mo]) completed baseline and follow-up gait analysis. Spasticity significantly decreased in those with SDR (p<0.05). Gait Deviation Index improved more in participants without SDR than those with SDR (Δnon-SDR =12.8 vs ΔSDR =9.1; p=0.01). Compared with the SDR group, participants without SDR underwent significantly more subsequent interventions (p<0.05). Interpretation: Patients in both the SDR and non-SDR groups showed improved gait quality more than 10 years after surgery. Participants without SDR had a larger improvement in gait pathology but underwent significantly more intervention. There were no differences between groups in survey measures. These results suggest differing treatment courses provide similar outcomes into early adulthood.
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Limited Selective Posterior Rhizotomy for the Treatment of Spasticity Secondary to Infantile Cerebral Palsy: A Preliminary Report
Article
  • Oct 1990
A limited selective posterior rhizotomy was performed on 30 children suffering from spasticity secondary to infantile cerebral palsy. As opposed to standard techniques that stimulate and divide the dorsal rootlets from L2 to S1, we dissected L4, L5, and S1 dorsal roots through an L5 to S1 laminectomy. Eight to 12 rootlets from each root were electrically stimulated with two unipolar electrodes (pulse width, 50 µsec: 10–50 V). The muscle responses were observed visually and registered by electromyography. Those rootlets associated with an abnormal motor response as evidenced by sustained muscular contraction or by prolonged electromyographic response were divided. Spasticity was scored from 0 to ++++. The muscular groups assessed were those involved in the flexion of the shoulder, elbow and wrist in the upper limbs, and those involved in flexion and adduction of the hip, flexion of the leg, and plantar flexion in the lower limbs. The patients were assessed 1 week before and 6 months after the operation. Reduction of spasticity was observed in all the muscular groups, and all the patients presented functional improvement of motor abilities. These preliminary results indicate that a limited procedure that reduces the extension of the laminectomy and the length of the operation could be effective for treating spasticity secondary to infantile cerebral palsy.
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