Long-term outcome after selective dorsal rhizotomy in children with spastic cerebral palsy

Selective dorsal rhizotomy after baclofen intrathecal pump removal: a single-center experience and review of the literature

PURPOSE

Selective dorsal rhizotomy (SDR) and intrathecal baclofen (ITB) pump placement are two surgical options in children affected by spasticity secondary to cerebral palsy 1. The latest literature is an enlarging indication for SDR in case of ITB failure in non-ambulant patients as an alternative to pump reimplantation to reduce spasticity and facilitate patients' care.

METHODS

A retrospective single-center study has screened all children diagnosed with spastic tetraparesis who underwent in the last 10 years SDR and had previously ITB pump implanted. A cohort of six patients was pooled out. Furthermore, pertinent literature has been reviewed.

RESULTS

Indication for pump removal was pump pocket infection, parents' decision, and poor response to ITB. Patients' amount of lifetime with the pump implanted has been 6.9 years. The preoperative and postoperative Ashworth scores were statistically different in both procedures (p = 0.005 and p = 0.,02).

CONCLUSIONS

Only two studies investigated the pediatric population undergoing SDR in the occurrence of ITB pump removal. Authors are offering SDR to all children, regardless of GMFCS groups and previous ITB pump placement. In conclusion, SDR represents a valid tool in neurosurgeon's hands to help ameliorate patients' long-lasting quality of life, reducing the severity of the spasticity and leading to better management by caregivers.

Selective Dorsal Rhizotomy for Spastic Cerebral Palsy: Report of 18 Cases Performed in the North of Vietnam

OBJECTIVE

The purpose of this report is to describe a case series of children undergoing selective dorsal rhizotomy (SDR) for the treatment of spastic cerebral palsy in Vietnam. Also described is an international cooperation model to facilitate the development of a new, multidisciplinary team for the evaluation and treatment of these children.

METHODS

Details of international collaboration are described, including in-person travel and virtual interactions. All cases of children younger than 18 years undergoing SDR for treatment of spastic cerebral palsy at a single center in Hanoi, Vietnam are described, including preoperative evaluation of spasticity and gait as well as results at 6 and 12 months. Results are summarized using descriptive statistics.

RESULTS

Since the beginning of cooperation in training and transferring SDR techniques by experts from the United States, in the period from June 2016 to December 2022, 18 SDR surgeries were performed in Hanoi. Patients' ages ranged from 2 to 14 years; 13 were male and 5 were female. Overall, approximately 60% of nerve rootlets were cut. Modified Ashworth Scale scores at 6 and 12 months after surgery in the hip, knee, and ankle joints showed improvement from preoperative values. There were 2 recorded complications: intracranial hypotension causing subdural hemorrhage and a case of skin infection at the incision site.

CONCLUSIONS

The ongoing international cooperation between Vietnamese and American physicians has helped improve the surgical treatment of spasticity in children with cerebral palsy in Hanoi, providing children with a surgical treatment option with successful outcomes.

Postoperative outcomes and stimulation responses for sectioned nerve roots during selective dorsal rhizotomy in cerebral palsy

BACKGROUND

Cerebral palsy (CP) is the most cause of motor dysfunction in children. Selective dorsal rhizotomy (SDR) plays a major role in long term spasticity control. However, limited data exists on the effect of SDR on postoperative spasticity treatment requirements and supraspinal effects, and the stimulation responses of dorsal nerve roots in those with CP.

METHODS

The current study included the outcome for 35 individuals undergoing SDR for motor functional outcome, spasticity, baclofen dose changes, botulinum toxin injection frequency, and spasticity related orthopedic procedures. We also report on the stimulation responses in 112 individuals who underwent SDR at our institution.

RESULTS

There was a significant difference in gross motor function measures (GMFM)-66 scores at last follow up that remained present when considering only ambulatory children but not with non-ambulatory children. Ashworth scores were significantly decreased for both upper and lower extremities after SDR at all follow up points. There was a significant decrease in Baclofen dose and botulinum toxin injections requirements after SDR, but no significant difference in the need for orthopedic intervention. A total of 5502 dorsal nerve roots were tested showing a decrease in stimulation intensity and increase in grade on the right side and for descending lumbosacral levels.

CONCLUSIONS

SDR improves gross motor scores during short term follow up but has additional benefits in decreasing baclofen dosing and botulinum toxin injections requirements after surgery. They stimulation responses of sectioned dorsal nerve roots adds to the limited available data and our understanding of the pathological changes that occur in CP.

Impact of selective dorsal rhizotomy to cerebral palsy children caregivers' burden

PURPOSE

It is known that cerebral palsy (CP) children's caregivers suffer from burden, depression, and stress, impairing their quality of life (QoL). The more severe the CP, the more burden the caregiver has. Psychosocial support, education, therapies, and financial support are inversely related to the level of stress of the caregiver. Most parents of CP patients submitted to selective dorsal rhizotomy (SDR) report improvement not just on spasticity, but also in the functional role of the children, what can impact on caregiver's QoL. Our objective was to evaluate the burden of CP children's caregivers with and without previous SDR.

METHODS

Spastic CP children caregivers were divided into two groups: those who take care of children without previous SDR (control group) and those that children were previously submitted to SDR (surgical group). The burden index was compared between groups using Burden Interview Questionnaire (BIQ). For statistical analysis, we used SPSS.

RESULTS

The control group had enrolled 31 participants and the surgical group 36. The mean GMFCS level on the control and surgical groups was 3.94 ± 1.26 and 3.74 ± 1.12 (p = 0.61), respectively. The surgical group caregivers presented less burden related to the feeling that they should be doing more to their child (p = 0.003) and if they could do a better job in caring (p = 0.032), compared to controls. The total BIQ index was not significantly different between groups (surgical 32.14 ± 12.34 vs. control 36.77 ± 12.77; p = 0.87). Low economic status had a weak correlation to a higher BIQ index (R2 = 0.24). After age-matching, there was a significative higher BIQ index in the control group (p = 0.008).

CONCLUSION

Caregivers of spastic CP children who were previously submitted to SDR presented less burden related to feeling of the amount of given care than those without previous surgery. The impression that they could do a better job with their kids was higher in the control group. The severity of CP and low economic status were related to more burden in both groups. After pairing groups by age, the control group had a significative higher BIQ index compared to the SDR group.

CLINICAL TRIAL REGISTRATION

Trial registration number: CAAE 73407317.6.0000.0068 (Ethical and Research Committee of University of Sao Paulo, Sao Paulo, Brazil, approved on 08/06/2021). All the subjects were freely given an informed consent to participate in the study that was obtained from all participants. Non-consented ones were excluded from the study.

Postoperative pain and pain management following selective dorsal rhizotomy

BACKGROUND

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure that reduces lower limb spasticity, performed in some children with spastic diplegic cerebral palsy. Effective pain management after SDR is essential for early rehabilitation. This study aimed to describe the anaesthetic and early pain management, pain and adverse events in children following SDR.

METHODS

This was a retrospective cohort study. Participants were all children who underwent SDR at a single Australian tertiary hospital between 2010 and 2020. Electronic medical records of all children identified were reviewed. Data collected included demographic and clinical data (pain scores, key clinical outcomes, adverse events and side effects) and medications used during anaesthesia and postoperative recovery.

RESULTS

22 children (n=8, 36% female) had SDR. The mean (SD) age at surgery was 6 years and 6 months (1 year and 4 months). Common intraoperative medications used were remifentanil (100%), ketamine (95%), paracetamol (91%) and sevoflurane (86%). Postoperatively, all children were prescribed opioid nurse-controlled analgesia (morphine, 36%; fentanyl, 36%; and oxycodone, 18%) and concomitant ketamine infusion. Opioid doses were maximal on the day after surgery. The mean (SD) daily average pain score (Wong-Baker FACES scale) on the day after surgery was 1.4 (0.9), decreasing to 1.0 (0.5) on postoperative day 6 (POD6). Children first attended the physiotherapy gym on median day 7 (POD8, range 7-8). Most children experienced mild side effects or adverse events that were managed conservatively. Common side effects included constipation (n=19), nausea and vomiting (n=18), and pruritus (n=14). No patient required return to theatre, ICU admission or prolonged inpatient stay.

CONCLUSIONS

Most children achieve good pain management following SDR with opioid and ketamine infusions. Adverse events, while common, are typically mild and managed with medication or therapy. This information can be used as a baseline to improve postoperative care and to support families' understanding of SDR before surgery.

Functional outcome after selective dorsal rhizotomy: a retrospective case control study

PURPOSE

This study examines long-term benefit on functional outcomes and quality of life after selective dorsal rhizotomy (SDR) in children with spastic diplegia in Hong Kong.

METHOD

This is a case control study. Individuals with spastic diplegia who were at 6 to 12 years post-SDR were recruited. Age, gender, cognition, and Gross Motor Function Classification System level-matched individuals with spastic diplegia who had not undergone SDR were recruited as controls. Outcome measures included physical level, functional level, physiological level, and quality of life. All data were compared by independent t-test.

RESULTS

Individuals post-SDR (n = 15) demonstrated a significantly better range of ankle dorsiflexion in knee extension by - 5.7 ± 10.9° than the control group (n = 12). No other significant differences were observed.

CONCLUSION

SDR is a safe, one-off procedure and provides long-term reduction in spasticity with no major complications. With the heterogeneity, we did not demonstrate between-group differences in long-term functional outcomes.

A preliminary study on the spasticity reduction of quadriceps after selective dorsal rhizotomy in pediatric cases of spastic cerebral palsy

OBJECTIVE

This study aimed to evaluate the potential alleviation of quadriceps spasticity in children diagnosed with spastic cerebral palsy (CP) following selective dorsal rhizotomy (SDR).

METHODS

A retrospective study was conducted on children suffering from spastic CP who underwent SDR at the Department of Neurosurgery, Shanghai Children's Hospital, from July 2018 to September 2020. Inclusion criteria comprised children exhibiting quadriceps spasticity exceeding modified Ashworth Scale grade 2. Muscle tone and motor function were assessed before the operation, at short-term follow-up and at the last follow-up after SDR. Additionally, intraoperative neurophysiological monitoring data were reviewed.

RESULTS

The study comprised 20 eligible cases, where, prior to surgery, 35 quadriceps muscles exhibited spasticity exceeding modified Ashworth Scale grade 2. Following short-term and mid-term follow-up, specifically an average duration of 11 ± 2 days and 1511 ± 210 days after SDR, it was observed that muscle tension in adductors, hamstrings, gastrocnemius, and soleus decreased significantly. This reduction was accompanied by a decrease in quadriceps muscle tone in 24 out of 35 muscles (68.6%). Furthermore, the study found that intraoperative electrophysiological parameters can predict postoperative spasticity relief in the quadriceps. The triggered electromyographic (EMG) output of the transected sensory root/rootlets after single-pulse stimulation revealed that the higher the EMG amplitudes in quadriceps, the greater the likelihood of postoperative decrease in quadriceps muscle tension.

CONCLUSIONS

SDR demonstrates the potential to reduce muscle spasticity in lower extremities in children diagnosed with CP, including a notable impact on quadriceps spasticity even they are not targeted in SDR. The utilization of intraoperative neurophysiological monitoring data enhances the predictability of quadriceps spasticity reduction following SDR.

The long-term effects of aggressive spasticity reducing treatment, including selective dorsal rhizotomy, on joint kinematic outcomes of persons with cerebral palsy

BACKGROUND

Selective dorsal rhizotomy (SDR) creates a large and permanent reduction of spasticity for children with cerebral palsy (CP). Previous SDR outcomes studies have generally lacked appropriate control groups, had limited sample sizes, or reported short-term follow-up, limiting evidence for improvement in long-term gait function.

RESEARCH QUESTION

Does aggressive spasticity management for individuals with CP improve long-term gait kinematics (discrete joint kinematics) compared to a control group of individuals with CP with minimal spasticity management?

METHODS

This study was a secondary analysis - focused on joint-level kinematics - of a previous study evaluating the long-term outcomes of SDR. Two groups of participants were recruited based on a retrospectively completed baseline clinical gait study. One group received aggressive spasticity treatment including a selective dorsal rhizotomy (Yes-SDR group), while the other group had minimal spasticity management (No-SDR group). Both groups had orthopedic surgery treatment. Groups were matched on baseline spasticity. All participants prospectively returned for a follow-up gait study in young adulthood (greater than 21 years of age and at least 10 years after baseline). Change scores in discrete kinematic variables from baseline to follow-up were assessed using a linear model that included treatment arm (Yes-SDR, No-SDR), baseline age, and baseline kinematic value. For treatment arm, 5° and 5 Gait Deviation Index points were selected as thresholds to be considered a meaningful difference between treatment groups.

RESULTS

At follow-up, there were no meaningful differences in pelvis, hip, knee, or ankle kinematic variable changes between treatment arms. Max knee flexion - swing showed a moderate treatment effect for Yes-SDR, although it did not reach the defined threshold.

SIGNIFICANCE

Aggressive spasticity treatment does not result in meaningful differences in gait kinematics for persons with cerebral palsy in young adulthood compared to minimal spasticity management with both groups having orthopedic surgery.

[Methods and results of neurosurgical treatment of cerebral palsy]

Treatment of spastic syndrome and muscular dystonia in patients with cerebral palsy is a complex clinical problem. Effectiveness of conservative treatment is not high enough. Modern neurosurgical techniques for spastic syndrome and dystonia are divided into destructive interventions and surgical neuromodulation. Their effectiveness is different and depends on the form of disease, severity of motor disorders and age of patients.

OBJECTIVE

To evaluate the effectiveness of various methods of neurosurgical treatment of spasticity and muscular dystonia in patients with cerebral palsy.

MATERIAL AND METHODS

We To evaluate the effectiveness of various methods of neurosurgical treatment of spasticity and muscular dystonia in patients with cerebral palsy.analyzed literature data in the PubMed database using the keywords «cerebral palsy», «spasticity», «dystonia», «selective dorsal rhizotomy», «selective neurotomy», «intrathecal baclofen therapy», «spinal cord stimulation», «deep brain stimulation».

RESULTS

Effectiveness of neurosurgery was higher for spastic forms of cerebral palsy compared to secondary muscular dystonia. Destructive procedures were the most effective among neurosurgical operations for spastic forms. Effectiveness of chronic intrathecal baclofen therapy decreases in follow-up due to secondary drug resistance. Destructive stereotaxic interventions and deep brain stimulation are used for secondary muscular dystonia. Effectiveness of these procedures is low.

CONCLUSION

Neurosurgical methods can partially reduce severity of motor disorders and expand the possibilities of rehabilitation in patients with cerebral palsy.

Impact of Occupational Therapy on Self-Care After Selective Dorsal Rhizotomy Among Children With Cerebral Palsy

IMPORTANCE

Selective dorsal rhizotomy (SDR) is an established treatment for spastic cerebral palsy (CP). The effects and predictors of occupational therapy's benefit for self-care after SDR in children with CP have not been thoroughly investigated.

OBJECTIVE

To identify changes in self-care after occupational therapy post-SDR and determine whether changes were affected by age, Gross Motor Function Classification System (GMFCS) level, and number of occupational therapy dressing sessions.

DESIGN

In this retrospective cohort study, we collected outcomes pre-SDR, at discharge, and at 1-yr follow-up. Paired t tests and regression analysis were performed.

SETTING

Commission on Accreditation of Rehabilitation Facilities-accredited pediatric inpatient rehabilitation facility.

PARTICIPANTS

Seventy-three children (GMFCS Levels I-III, ages 4-17 yr) diagnosed with spastic CP who underwent SDR from 2014 to 2018.

INTERVENTION

After having SDR, each child received an average of twice daily occupational therapy for an average of 37.3 days.

OUTCOMES AND MEASURES

The Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) and Functional Independence Measure for Children® (WeeFIM) were used to assess self-care performance.

RESULTS

The mean WeeFIM dressing (upper and lower body) and mean PEDI-CAT daily activities scores from baseline to discharge and mean WeeFIM lower body dressing at 1-yr follow-up improved significantly. The improvement in lower body dressing correlated with GMFCS level and the number of occupational therapy dressing sessions.

CONCLUSIONS AND RELEVANCE

The improvement in upper and lower extremity dressing and PEDI-CAT daily activities scores suggests that inpatient occupational therapy post-SDR may provide benefits. What This Article Adds: Children diagnosed with CP may undergo surgical interventions to improve their ability to walk. This article demonstrates the benefit of occupational therapy services after SDR to improve upper and lower body dressing skills.

Long-term effects of spasticity treatment, including selective dorsal rhizotomy, for individuals with cerebral palsy

AIM

To understand the long-term effects of comprehensive spasticity treatment, including selective dorsal rhizotomy (SDR), on individuals with spastic cerebral palsy.

METHOD

This was a pre-registered, multicenter, retrospectively matched cohort study. Children were matched on age range and spasticity at baseline. Children at one center underwent spasticity treatment including SDR (Yes-SDR, n=35) and antispastic injections. Children at two other centers had no SDR (No-SDR, n=40 total) and limited antispastic injections. All underwent subsequent orthopedic treatment. Participants returned for comprehensive long-term assessment (age ≥21y, follow-up ≥10y). Assessment included spasticity, contracture, bony alignment, strength, gait, walking energy, function, pain, stiffness, participation, and quality of life.

RESULTS

Spasticity was effectively reduced at long-term assessment in the Yes-SDR group and was unchanged in the No-SDR group. There were no meaningful differences between the groups in any measure except the Gait Deviation Index (Yes-SDR + 11 vs No-SDR + 5) and walking speed (Yes-SDR unchanged, No-SDR declined 25%). The Yes-SDR group underwent more subsequent orthopedic surgery (11.9 vs 9.7 per individual) and antispastic injections to the lower limbs (14.4 vs <3, by design).

INTERPRETATION

Untreated spasticity does not cause meaningful impairments in young adulthood at the level of pathophysiology, function, or quality of life.

Efficacy of Selective Dorsal Rhizotomy and Intrathecal Baclofen Pump in the Management of Spasticity

BACKGROUND

Neurosurgical indications and interventions provided in the management of spasticity have evolved significantly over time. Selective dorsal rhizotomy (SDR) and intrathecal baclofen (ITB) pumps have been used to improve mobility, reduce lower extremity spasticity, and increase quality of life in patients with various diagnoses.

METHODS

Studies describing ITB and SDR outcomes in adult and pediatric patients were identified from Medline and Embase databases. Only publications between January 1990 to January 2021 were included. Combinations of search terms 'Selective Dorsal Rhizotomy', 'Selective Posterior Rhizotomy', 'functional posterior rhizotomy', 'intrathecal baclofen pump', and 'spasticity' were used. Only studies in English language and those that included parameters for lower extremity outcome (i.e., spasticity, ambulation) were included. Only studies describing follow-up 12 months or greater were included. Case reports, reviews without primary data, or inaccessible publications were excluded.

RESULTS

Two hundred and ninety publications between January 1990 to January 2021 were identified. Of these, 62 fit inclusion and exclusion criteria for a total of 1291 adult and 2263 patients. Etiologies in adult and pediatric populations varied substantially with multiple sclerosis, cerebral palsy, and trauma comprising the majority of causes for spasticity in adult patients. In pediatric patients, cerebral palsy was the predominant etiology of spasticity. While outcomes after SDR and ITB varied, both are effective for long-term tone reduction. SDR appeared to have a greater effect on function compared to baseline when comparing relatively similar subgroups. The complication rates for either intervention were significant; ITB had a much greater incidence of wound and hardware adverse events, whereas SDR was associated with a not insignificant incidence of new bladder or sensory deficit.

CONCLUSION

ITB and SDR have demonstrated efficacy and utility for tone reduction in a variety of conditions. The selection of a specific intervention may have a variety of determining features including the etiology of spasticity, age of patient, as well as balancing benefit and complication profiles of each technique. Appropriate patient selection is essential for providing optimal patient outcomes.

Motor and functional outcome of selective dorsal rhizotomy in children with spastic diplegia at 12 and 24 months of follow-up

Background

Selective dorsal rhizotomy (SDR) in ambulatory children affected by cerebral palsy (CP) is a surgical treatment option to lower spasticity and thereby improve gait and ambulation. The aim of the current study is to investigate the outcome of children with respect to spasticity, muscle strength, and overall function after SDR.

Methods

All children who underwent SDR via a single-level laminotomy in the time period from January 2007 to April 2015 at our center were enrolled in this study. Within a standardized evaluation process, the following was assessed routinely pre-operatively and 12 and 24 months following surgery: extent of spasticity at hip adductors and hamstrings as characterized by the Modified Ashworth Scale (MAS), maximal muscle strength as characterized by the Medical Council Research Scale (MRC), overall function regarding ambulation as characterized by the Gross Motors Function Classification System (GFMCS), and overall function as characterized by the Gross Motor Function Measure (GMFM-88).

Results

Matching sets of pre- and post-operative assessments of the chosen outcome parameters were available for 109 of the 150 children who underwent SDR within the observation period. After 24 months, the MAS scores of hip adductors (n = 59) improved in 71% and 76% of children on the right and left side, respectively. In 20% and 19%, it remained unchanged and worsened in 9% and 5% of children on the right and left side, respectively (p < 0.00625). For hamstrings, the rates for the right and left sides were 81% and 79% improvement, 16% and 16% unchanged, and 4% and 5% worsened, respectively (p < 0.00625). Muscle strength of ankle dorsiflexion and knee extension significantly improved after 24 months. Overall function assessed by GMFM-88 improved significantly by 4% after 12 months (n = 77) and by 7% after 24 months (n = 56, p < 0.0001).

Conclusions

The presented data underlines the benefit of SDR in a pediatric patient collective with bilateral spastic CP. The procedure resulted in an effective and permanent reduction of spasticity and improved overall function without causing relevant weakness of the lower extremities.

More than 25 years after selective dorsal rhizotomy: physical status, quality of life, and levels of anxiety and depression in adults with cerebral palsy

OBJECTIVE

The primary purpose of selective dorsal rhizotomy (SDR) is to ameliorate spasticity in the lower extremities of children with cerebral palsy (CP). In correctly selected patients, this neurosurgical procedure has been shown to have a beneficial effect on many aspects of the child's life. However, given the challenges faced by adults with CP, it would be valuable to document the status of this population compared to their peers later in adulthood. Therefore, the aim of this study was to determine the physical status, mental health, and health-related quality of life (HRQoL) of adults with CP who underwent SDR at least 25 years ago, compared to matched typically developing (TD) individuals. The second aim was to investigate relationships between physical status and the other outcome measures.

METHODS

Adults with CP were recruited from a database of children who had undergone SDR performed using the technique introduced by Professor Warwick Peacock at Red Cross War Memorial Children's Hospital in Cape Town, South Africa, between 1981 and 1991. These individuals were matched for age, sex, body mass index, and socioeconomic status to a TD adult cohort from a similar background. The parameters assessed were lower-extremity muscle tone, passive range of motion, muscle strength, selectivity, functional mobility and dynamic balance (Timed Up and Go [TUG] test), HRQoL (SF-36), and anxiety and depression levels.

RESULTS

Twenty-six adults with CP who had a median age of 35.8 years (interquartile range 34.2-41.4 years) (female/male: n = 10/16; Gross Motor Function Classification System level I/II/III: n = 13/10/3), were compared to 26 TD adults. Muscle tone was similar, whereas passive range of motion, muscle strength, selectivity, TUG, and SF-36 physical functioning (concept and summary) scores differed between the cohorts. Other SF-36 parameters, anxiety levels, and depression levels were not different. Strong correlations were found between the muscle strength and TUG scores.

CONCLUSIONS

Normalized lower-extremity muscle tone was sustained 25-35 years after SDR. Whereas the lower scores for physical assessments are in line with findings in other CP populations, remarkably, relatively good mental health and HRQoL scores were reported in this CP group despite their physical limitations. The strong correlation between muscle strength and TUG suggests that strength training after SDR may have value in improving functional mobility and balance.

Surgical Results of Selective Dorsal Rhizotomy for the Treatment of Spastic Cerebral Palsy

Background

Selective dorsal rhizotomy (SDR) is one of the surgical alternatives for treating spasticity, especially in children with spastic diplegia secondary to cerebral palsy (CP). It is becoming increasingly used, and the results of this operation need to be further highlighted.

Aim

The main objective of this article was to present the results of such surgical procedure in a cohort of a specialized center, with a particular focus on a quantitative analysis (goniometry).

Materials and Methods

Retrospective review of the medical records and gait analyses of a cohort of 34 patients diagnosed with CP submitted to elective SDR at our institution, in a period of 6 years, was carried out. All patients underwent a thorough clinical and neurological assessment, gait analysis at a dedicated laboratory, and magnetic resonance imaging of whole neuro-axis.

Statistical Analysis

For continuous quantitative variables (goniometric angles and muscle tone), a t-student test was used. A scatterplot regression analysis was used for the comparison of modified Ashworth scale (mAS) scores and goniometry measurements.

Results and Conclusion

In a mean follow-up of 3.2 years, SDR provides a measurable and consistent improvement in the motor function of spastic patients, as per range of motion and tonus scales, with low complication rates. It also allows for patients to reduce their use of muscle relaxants, even though their global mobility does not change significantly. Therefore, it should be considered for CP patients who suffer with the deleterious effects of spasticity.

Intrathecal baclofen, selective dorsal rhizotomy, and extracorporeal shockwave therapy for the treatment of spasticity in cerebral palsy: a systematic review

Cerebral palsy (CP) is a chronic congenital disorder as the result of abnormal brain development. Children suffering from CP often battle debilitating chronic spasticity, which has been the focus of recent academic literature. In this systematic review, the authors aim to update the current neuromodulation procedures for the treatment of spasticity associated with CP in all age groups. A systematic review following was conducted using PubMed from inception to 2020. After initial title and abstract screening, 489 articles were identified, and 48 studies met the inclusion criteria for this review. In total, a majority of the published articles of treatments for CP were reporting the use of selective dorsal rhizotomy (SDR) (54%), and the remainder were of intrathecal baclofen (ITB) pumps (29%) and extracorporeal shockwave therapy (ESWT) (17%). Each method was found to have improvement of spasticity at a rate that achieved statistical significance. ITB pump therapy is an all-encompassing method of treating spasticity in children from CP, as it allows for a less invasive treatment that can be titrated to individual patient needs; however, its disadvantages include its long-term maintenance requirements. SDR appears to be an effective method for permanent spasticity relief in young patients. ESWT is a more recent and innovative technique for offering relief of spasticity while being minimally invasiveness. Further studies are needed to establish optimal frequencies and sites of application for ESWT.

Energy consumption does not change after selective dorsal rhizotomy in children with spastic cerebral palsy

AIM

To determine whether energy consumption changes after selective dorsal rhizotomy (SDR) among children with cerebral palsy (CP).

METHOD

We retrospectively evaluated net nondimensional energy consumption during walking among 101 children with bilateral spastic CP who underwent SDR (59 males, 42 females; median age [5th centile, 95th centile] 5y 8mo [4y 2mo, 9y 4mo]) compared to a control group of children with CP who did not undergo SDR. The control group was matched by baseline age, spasticity, and energy consumption (56 males, 45 females; median age [5th centile, 95th centile] 5y 8mo [4y 1mo, 9y 6mo]). Outcomes were compared at baseline and follow-up (SDR: mean [SD] 1y 7mo [6mo], control: 1y 8mo [8mo]).

RESULTS

The SDR group had significantly greater decreases in spasticity compared to matched controls (-42% SDR vs -20% control, p<0.001). While both groups had a modest reduction in energy consumption between visits (-12% SDR, -7% control), there was no difference in change in energy consumption (p=0.11) or walking speed (p=0.56) between groups.

INTERPRETATION

The SDR group did not exhibit greater reductions in energy consumption compared to controls. The SDR group had significantly greater spasticity reduction, suggesting that spasticity had minimal impact on energy consumption during walking in CP. These results support prior findings that spasticity and energy consumption decrease with age in CP. Identifying matched control groups is critical for outcomes research involving children with CP to account for developmental changes.

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

This review looks at the advances in the surgical technique, selective dorsal rhizotomy, used for the management of spasticity in children.

Quality of life after selective dorsal rhizotomy: an assessment of family-reported outcomes using the CPQoL questionnaire

BACKGROUND

Selective dorsal rhizotomy (SDR) is widely accepted as an effective procedure for management of lower limb spasticity in children with cerebral palsy. However, effects of the procedure on quality of life are not widely reported and less so using a structured and validated quality of life tool such as Cerebral Palsy Quality of Life Questionnaire (CPQoL). Here, we present complete data for CPQoL outcomes for SDR patients operated in a single institution at 2 years follow-up.

METHODS

Patients were operated over a 5-year period by the same surgeon using the same technique in a single institution. CPQoL questionnaires were completed by patients and families pre-operatively and at 6 months, 1 year and 2 years post-operatively. Data was collected prospectively.

RESULTS

A total of 78 patients (58 male, 20 female), age range 2.6-13.8 years (median 6.33) were included whom underwent SDR between October 2012-November 2017. All had complete follow-up up to 2 years post-procedure (most recent November 2019). Four patients were excluded due to incomplete follow-up data. Statistically significant improvement was seen across five out of seven CPQoL domains and this was sustained to 2 years post-SDR.

CONCLUSIONS

We demonstrate using a validated Quality of Life Tool that SDR has a beneficial effect on the quality of life for patients with cerebral palsy at this length of follow-up.

Pudendal mapping of S1 rootlets in a functional posterior rhizotomy: when an S1 posterior root shows a high pudendal dorsal action potential-a technical note

BACKGROUND

The standard level for lesioning in a functional posterior rhizotomy (FPR) ranges from L2 to S1/S2. Lesioning of the S1 and S2 rootlets strongly correlates with a reduction in ankle spasticity. In the Japanese population, the S2 root often shows the highest dorsal root action potentials (DAPs) in the afferent fibers of the pudendal nerve and is not lesioned to preserve postoperative urinary function. Thus, cutting of the S1 root plays a key role in reducing ankle spasticity in FPR. However, on rare occasions, even an S1 root may show high DAP in the afferent fibers of the pudendal nerve.

PURPOSE

The present, brief, technical note aimed to describe how an S1 root with a relatively high DAP in the afferent fibers of the pudendal nerve may be handed.

METHODS

In the procedure, the S1 root is divided into several rootlets, and each rootlet is tested for the pudendal mapping. A train of electrical stimuli is delivered to each rootlet in the standard FPR. If electromyography (EMG) findings after electrical stimulation are highly abnormal while the pudendal mapping demonstrates no or a relatively low DAPs, the rootlet is cut. In contrast, even if the rootlet shows highly abnormal EMG findings, it is preserved if mapping demonstrates a relatively high DAP.

CONCLUSION

The S1 pudendal mapping is combined with EMG findings to achieve satisfactory reduction in ankle spasticity while preserving urological function.

Long term outcome of Selective Dorsal Rhizotomy for the management of childhood spasticity-functional improvement and complications

BACKGROUND

Selective dorsal rhizotomy (SDR) for the management of lower extremity spasticity is a surgical technique that has existed since the 1900s. While much evidence supports its efficaciousness in reducing tone in the short term, limited information exists detailing the long-term outcome and evolution over time of patients undergoing SDR.

METHODS

All publications with 10 years or more of outcome data on patients undergoing SDR were identified from Medline and Embase databases using the search term "Rhizotmy." Only publications that were in English included patients with cerebral palsy under the age of 21 and discussed SDR for lower extremity spasticity were included. Case reports, reviews without primary data, or publications not accessible online were excluded from the review.

RESULTS

A total of 2128 publications were initially identified, of which 19 papers describing 1054 patients fit inclusion and exclusion criteria. GMFCS in most patients improved or remained stable over time after surgery, although durability of improvement and final outcome was dependent on initial functional status. Tone was noted to also substantially improve although a small proportion required additional oral or injectable pharmacologic agents and an even smaller proportion required baclofen pumps. Upper extremity function was also noted to improve substantially after SDR. A significant number of patients were independent for activities of daily living and were engaged in secondary education or gainful employment. A significant proportion of patients still required orthopedic surgery to the lower extremities after SDR, although the incidence of spinal deformity was not observed to be substantially elevated over that of natural history.

CONCLUSION

SDR offers substantial improvements to a number of domains beyond pure tone reduction. These changes are durable over time, although patient selection is crucial in identifying those patients that will have the most benefit. Long-term follow-up is in important in this population given the potential need for further interventions that still exist in many patients.

Orthopedic treatment of the lower limbs in spastic paralysis

Spastic paralysis of the limb mainly results from the central lesion, in which spastic cerebral palsy is the common cause. Due to durative muscle spasm in spastic cerebral palsy, it is often accompanied by the formation of secondary musculoskeletal deformities, resulting in limb motor disability. Based on its pathogenesis, surgical treatment is currently applied: selective posterior rhizotomy (SPR) or orthopedic surgery. The primary purpose of early orthopedic surgery was simply to correct limb deformities, which usually led to the recurrence of deformity as a result of the presence of spasticity. With the application of SPR, high muscle tone was successfully relieved, but limb deformity was still present postoperatively. Therefore, this study aimed to elaborate on the management of orthopedic surgery, common deformities of the lower limb, and orthopedic operative methods; discuss the relationship between SPR and orthopedic procedure for limb deformity; and focus on the indications, timing of intervention, and postoperative outcome of different surgical methods.

The progress in the treatment of spastic cerebral palsy with selective dorsal rhizotomy (SDR)

Spasticity is the main disabling clinical manifestation of children with cerebral palsy (CP). Selective dorsal rhizotomy (SDR) has been performed for the treatment of spastic CP in Asia for quite some time from 1990. The purpose of this review is to discuss the historical origin and development of SDR. Our goal here is to identify the current patient selection criteria for SDR and to point out indications and contraindications based on the patients with CP, age from 2 to 18 years-old, over 6000 cases, who received SDR surgery with spasticity of muscle tension more than 3 degrees in our center. We also discuss evidence-based approaches on how to evaluate postoperative patient outcomes of SDR and how complications can be avoided. Finally, we mention progress made in terms of SDR technical advances and how improvements can be made in the future. In conclusion, SDR surgery is a reliable way to improve outcomes of patients with spastic CP and can be done carefully in patients as long as stringent selection criteria are used. However, more research and technological advancements are needed to help address associated complications.

Systematic review of spinal deformities following multi-level selective dorsal rhizotomy

PURPOSE

Cerebral palsy is a common neurological disorder that involves spasticity of the extremities and can lead to lifelong disability. Selective dorsal rhizotomy (SDR) can improve spasticity and quality of life in these patients, but it may be associated with the development of spinal deformity. Risk factors for spinal deformity after SDR have not yet been systematically examined.

METHODS

Medline, Embase, and Web of Science databases were queried for clinical studies reporting incidence of new or worsening spinal deformity, including scoliosis, after SDR. Variables that represent possible risk factors for deformity were correlated with reported incidence of deformity.

RESULTS

Twenty-two articles for a total of 1485 patients met the inclusion criteria for this study. Deformity occurs among all patients with a weighted mean incidence of 28.0%. Scoliosis appears to be the most common deformity occurring with a weighted mean incidence of 31.6%. There is substantial heterogeneity between studies, limiting our analysis. Significant positive correlation was found between percent of patients that developed any type of deformity and the ratio of female to male patients, p = 0.02. Significant positive correlation was also found between percent of patients that develop scoliosis and the ratio of female to male patients, p < 0.01, and between scoliosis and the number of years to follow-up, p < 0.01.

CONCLUSION

Spinal deformity is an important potential complication of SDR with scoliosis being the most common type of deformity. The major risk factor for postoperative deformity is female sex. Deformity was also found to significantly increase with extended follow-up, indicating a slow process that should be carefully monitored.

Long-term effects of selective dorsal rhizotomy in children with cerebral palsy: a systematic review

AIM

To evaluate the long-term effects of selective dorsal rhizotomy (SDR) 10 years or more after the procedure and complications observed any time after SDR in children with cerebral palsy (CP).

METHOD

Embase, PubMed, and the Cochrane Library were searched from their individual dates of inception through 1st June 2018 for full-text original articles in English that described long-term follow-up after SDR in children with CP. The authors independently screened publications to determine whether they met inclusion criteria; thereafter all authors extracted data on patient characteristics, the proportion of the original cohort being followed-up, and the reported outcomes.

RESULTS

Of the 199 studies identified, 16 were included in this evaluation: 14 were case series and two studies reported a retrospectively assigned comparison group. Evidence concerning function was limited by study design differences, clinical variability, loss to follow-up, and heterogeneity across trials.

INTERPRETATION

At 10 years or more follow-up, available studies generate low-level evidence with considerable bias. No functional improvement of SDR over routine therapy is documented. Furthermore, the long-term effects of SDR with respect to spasticity reduction is unclear, with many studies reporting a high amount of add-on spasticity treatment. More long-term follow-up using robust scientific protocols is required before it can be decided whether the use of SDR as routine therapy for children with CP is to be recommended or not.

WHAT THIS PAPER ADDS

Ten years after selective dorsal rhizotomy, available studies supply inconclusive evidence on functional outcomes. The long-term effect on spasticity is uncertain, studies reported a substantial need for add-on treatment. Short- and long-term complications seem frequent but are not reported in a consistent manner.

Intrathecal baclofen versus selective dorsal rhizotomy for children with cerebral palsy who are nonambulant: a systematic review

OBJECTIVE

Cerebral palsy (CP) is the most common childhood physical disability. Historically, children with hypertonia who are nonambulatory (Gross Motor Function Classification System [GMFCS] level IV or V) were considered candidates for intrathecal baclofen (ITB) therapy to facilitate care and mitigate discomfort. Selective dorsal rhizotomy (SDR) was often reserved for ambulant children to improve gait. Recently, case series have suggested SDR as an alternative to ITB in selected children functioning at GMFCS level IV/V. The objective for this study was to systematically review the evidence for ITB and SDR in GMFCS level IV or V children.

METHODS

Medline, Embase, Web of Science, and Cochrane databases were systematically searched. Articles were screened using the following inclusion criteria: 1) peer-reviewed articles reporting outcomes after SDR or ITB; 2) outcomes reported using a quantifiable scale or standardized outcome measure; 3) patients were < 19 years old at the time of operation; 4) patients had a diagnosis of CP; 5) patients were GMFCS level IV/V or results were reported based on GMFCS status and included some GMFCS level IV/V patients; 6) article and/or abstract in English; and 7) primary indication for surgery was hypertonia. Included studies were assessed with the Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) tool.

RESULTS

Twenty-seven studies met inclusion criteria. The most commonly reported outcomes were spasticity (on the Mean Ashworth Scale) and gross motor function (using the Gross Motor Function Measure), although other outcomes including frequency of orthopedic procedures and complications were also reported. There is evidence from case series that suggests that both ITB and SDR can lower spasticity and improve gross motor function in this nonambulatory population. Complication rates are decidedly higher after ITB due in part to the ongoing risk of device-related complications. The heterogeneity among study design, patient selection, outcome selection, and follow-up periods was extremely high, preventing meta-analysis. There are no comparative studies, and meaningful health-related quality of life outcomes such as care and comfort are lacking. This review is limited by the high risk of bias among included studies. Studies of SDR or ITB that did not clearly describe patients as being GMFCS level IV/V or nonambulatory were excluded.

CONCLUSIONS

There is a lack of evidence comparing the outcomes of ITB and SDR in the nonambulatory CP population. This could be overcome with standardized prospective studies using more robust methodology and relevant outcome measures.

Effects of Selective Dorsal Rhizotomy on Ankle Joint Function in Patients With Cerebral Palsy

Selective dorsal rhizotomy (SDR) is a neurosurgical technique performed to reduce muscle spasticity and improve motor functions in children with cerebral palsy (CP). In long term, muscle contractures were observed even after SDR. To better understand what is contributing to contracture formation, it is necessary to assess the effects of SDR on joint stiffness. We hypothesized that ankle passive range of motion (ROM) increases and the quasi-stiffness of the ankle joint decreases after SDR in children with CP. This retrospective study included 10 children with diplegic CP (median age 6 years 2 months) who had undergone SDR and for whom gait analysis data were collected 3 months before (Pre-SDR) and 13 months after (Post-SDR) surgery. Additional to clinical measures, ankle quasi-stiffness (the slope of the ankle moment vs. ankle angle plot) was analyzed from gait data. Passive ankle ROM at 0° (p < 0.0001) and 90° knee angles (p < 0.0001) increased after SDR. Dynamic EMG analysis showed improved phasic gastrocnemius activity (p < 0.0001). Equinus gait was improved with the reduction of peak plantar flexion (p < 0.0001), as well as an increase in peak dorsiflexion (p = 0.006) during walking was observed. Ankle joint quasi-stiffness (Pre- and post-SDR median = 0.056 Nm/kg/° and 0.051 Nm/kg/°, and interquartile range: 0.031 Nm/kg/° and 0.019 Nm/kg/°, respectively) decreased significantly (p = 0.0017) after SDR. Moreover, even though the total time of the gait cycle did not change (p = 0.99), the time interval from maximum dorsiflexion to maximum plantar flexion (Pre- and post-SDR median = 0.125 s and 0.156 s, and interquartile range: 0.153 and 0.253 s, respectively) increased significantly (p = 0.0068) after SDR. In conclusion, the decreased ankle quasi-stiffness and the enhanced time interval in the gait cycle due to SDR indicate better motor control and joint stability. Our findings suggest that the long-term contracture formation occurring even after surgical interventions may be related to the stiffening of non-contractile structures.

Frequency distribution in intraoperative stimulation-evoked EMG responses during selective dorsal rhizotomy in children with cerebral palsy-part 1: clinical setting and neurophysiological procedure

INTRODUCTION

Selective dorsal rhizotomy (SDR) consists of microsurgical partial deafferentation of sensory nerve roots (L1-S2). It is primarily used today in decreasing spasticity in young cerebral palsy (CP) patients. Intraoperative monitoring (IOM) is an essential part of the surgical decision-making process, aimed at improving functional results. The role played by SDR-IOM is examined, while realizing that connections between complex EMG responses to nerve-root stimulation and a patient's individual motor ability remain to be clarified.

METHODS

We conducted this retrospective study, analyzing EMG responses in 146 patients evoked by dorsal-root and rootlet stimulation, applying an objective response-classification system, and investigating the prevalence and distribution of the assessed grades. Part1 describes the clinical setting and SDR procedure, reintroduced in Germany by the senior author in 2007.

RESULTS

Stimulation-evoked EMG response patterns revealed significant differences along the segmental levels. More specifically, a comparison of grade 3+4 prevalence showed that higher-graded rootlets were more noticeable at lower nerve root levels (L5, S1), resulting in a typical rostro-caudal anatomical distribution.

CONCLUSIONS

In view of its prophylactic potential, SDR should be carried out at an early stage in all CP patients suffering from severe spasticity. It is particularly effective when used as an integral part of a coordinated, comprehensive spasticity program in which a team of experts pool their information. The IOM findings pertaining to the anatomical grouping of grades could be of potential importance in adjusting the SDR-IOM intervention to suit the specific individual constellation, pending further validation.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03079362.

Whether the newly modified rhizotomy protocol is applicable to guide single-level approach SDR to treat spastic quadriplegia and diplegia in pediatric patients with cerebral palsy?

PURPOSE

Our aim was to test whether the newly modified rhizotomy protocol which could be effectively used to guide single-level approach selective dorsal rhizotomy (SL-SDR) to treat spastic hemiplegic cases by mainly releasing those spastic muscles (target muscles) marked pre-operatively in their lower limbs was still applicable in spastic quadriplegic or diplegic cerebral palsy (CP) cases in pediatric population.

METHODS

In the current study, we retrospectively conducted a cohort review of cases younger than 14 years of age diagnosed with spastic quadriplegic or diplegic CP who undergone our modified protocol-guided SL-SDR in the Department of Neurosurgery, Children's Hospital of Shanghai since July 2016 to November 2017 with at least 12 months post-op intensive rehabilitation program (pre-op GMFCS level-based). Clinical data including demographics, intra-operative EMG responses interpretation, and relevant assessment of included cases were taken from the database. Inclusion and exclusion criteria were set for the selection of patients in the current study. Muscle tone (modified Ashworth scale) and strength of those spastic muscles (muscle strength grading scale), range of motion (ROM) of those joints involved, the level of Gross Motor Function Classification System (GMFCS), and Gross Motor Function Measure 66 items (GMFM-66) score of those cases were our focus.

RESULTS

A total of 86 eligible cases were included in our study (62 boys). Among these patients, 61.6% were quadriplegic. Pre-operatively, almost 2/3 of our cases were with GMFCS levels II and III. Mean age at the time of surgery in these cases was 6.2 (3.5-12) years. Pre-op assessment marked 582 target muscles in these patients. Numbers of nerve rootlets tested during SDR procedure were between 52 and 84 across our cases, with a mean of 66.5 ± 6.7/case. Among those tested (5721 in 86 cases), 47.9% (2740) were identified as lower limb-related sensory rootlets. Our protocol successfully differentiated sensory rootlets which were considered to be associated with spasticity of target muscles across all our 86 cases (ranged from 3 to 21). Based on our protocol, 871 dorsal nerve rootlets were sectioned 50%, and 78 were cut 75%. Muscle tone of those target muscles reduced significantly right after SL-SDR procedure (3 weeks post- vs. pre-op, 1.7 ± 0.5 vs. 2.6 ± 0.7). After an intensive rehabilitation program for 19.9 ± 6.0 months, muscle tone continued to decrease to 1.4 ± 0.5. With the reduction of muscle tone, strength of those target muscles in our cases improved dramatically with statistical significance achieved (3.9 ± 1.0 at the time of last follow-up vs. 3.3 ± 0.8 pre-op), and as well as ROM. Increase in GMFCS level and GMFM-66 score was observed at the time of last follow-up with a mean of 0.4 ± 0.6 and 6.1 ± 3.2, respectively, when compared with that at pre-op. In 81 cases with their pre-op GMFCS levels II to V, 27 (33.3%) presented improvement with regard to GMFCS level upgrade, among which 4 (4.9%) even upgraded over 2 levels. Better results with regard to upgrading in level of GMFCS were observed in cases with pre-op levels II and III when compared with those with levels IV and V (24/57 vs. 3/24). Upgrading percentage in cases younger than 6 years at surgery was significantly greater than in those older (23/56 vs. 4/25). Cases with their pre-op GMFM-66 score ≥ 50 had greater score increase of GMFM-66 when compared with those less (7.1 ± 3.4 vs. 5.1 ± 2.8). In the meanwhile, better score improvement was revealed in cases when SDR performed at younger age (6.9 ± 3.3 in case ≤ 6 years vs. 4.7 ± 2.7 in case > 6 years). No permanent surgery-related complications were recorded in the current study.

CONCLUSION

SL-SDR when guided by our newly modified rhizotomy protocol was still feasible to treat pediatric CP cases with spastic quadriplegia and diplegia. Cases in this condition could benefit from such a procedure when followed by our intensive rehabilitation program with regard to their motor function.

Selective Dorsal Root Rhizotomy for Spastic Cerebral Palsy: A Longitudinal Case-Control Analysis of Functional Outcome

BACKGROUND

The benefit of selective dorsal rhizotomies (SDR) on motor function relative to the cerebral palsy (CP) natural history remains unknown.

OBJECTIVE

To determine the functional benefit of SDR over the longitudinal CP natural history.

METHODS

Retrospective, single-center, case-control study of patients post-SDR after 1990. Inclusion criteria were the following: diagnosis of spastic CP, at least 1 preoperative and 1 postoperative Gross Motor Function Measure (GMFM-88), at least 1 yr of postoperative follow-up. GMFM-88 assessments were performed at 1, 2, 3, 5, 10, and 15 yr postoperatively and converted to GMFM-66. Cases were stratified by preoperative Gross Motor Function Classification System (GMFCS) and matched against their expected natural history using published reference centiles. After age 12, our cohort and matched controls were also fitted to published nonlinear mixed models of GMFM-66 evolution over time.

RESULTS

Analysis included 190 patients. Median follow-up, 5.3 yr (range: 1-16.9), median age at surgery, 4.6 yr, and 81.6% of patients grouped as GMFCS II or III pre-op. SDR patients performed statistically significantly better than their expected natural history (P &lt; .0005). At 21 yr old, a modeled benefit of 8.435 was observed for GMFCS I (P = .0051), 0.05 for GMFCS II (P = .9647), 6.31 for GMFCS III (P &lt; .0001), and 1.191 for GMFCS IV patients (P = .0207).

CONCLUSION

These results support the use of SDR in carefully selected spastic CP children.

Australian children undergoing selective dorsal rhizotomy: protocol for a national registry of multidimensional outcomes

INTRODUCTION

Selective dorsal rhizotomy (SDR) is a neurosurgical intervention intended to permanently reduce spasticity in the lower limbs and improve mobility in selected children with cerebral palsy (CP). Despite SDR having been performed worldwide for the past 30 years, there is moderate quality of evidence that SDR is effective in reducing spasticity with low to very low evidence of its effectiveness in improving gait, function and participation, using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Published studies have described outcomes for groups that differ in selection, surgical technique and postoperative rehabilitation making it difficult for clinicians to use this information to advise families on best management. There is substantial community interest in SDR. A small number of children with CP undergo SDR in Australia each year and some families seek the intervention at international sites. Capturing clinical outcomes and adverse event (AE) data for Australian children undergoing SDR will provide clinicians with information to help guide families considering SDR.

METHODS AND ANALYSIS

The Australian SDR Research Registry is a national registry of multidimensional outcomes for Australian children undergoing SDR in an Australian or overseas centre. Data will be collected for up to 10 years following the surgery, to include surgery and admission details, surgical and long-term AEs, and outcome measures across the body structure and functions, activity and participation domains of the International Classification of Functioning, Disability and Health. Data will be collected at baseline, during inpatient admission and at 1, 2, 5 and 10 years post. The aim of collecting these data is to improve understanding of short-, medium- and long-term outcomes and adverse effects of the intervention.

ETHICS AND DISSEMINATION

This study was approved by the individual Human Research and Ethics committees at the five Australian tertiary hospitals involved. Results will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12618000985280; Pre-results.

Selective dorsal rhizotomy improves muscle forces during walking in children with spastic cerebral palsy

BACKGROUND

Selective dorsal rhizotomy aims to reduce spasticity in children with cerebral palsy. Early investigations indicated postoperative weakness, whereas more recent studies showed that selective dorsal rhizotomy either does not change or improves muscle strength. All previous studies assessed muscle strength in a static position, which did not represent the walking situation. The aim of this study was to analyze the influence of selective dorsal rhizotomy on muscle forces during gait.

METHODS

Motion capture data of 25 children with spastic cerebral palsy and 10 typically developing participants were collected. A musculoskeletal OpenSim model was used to calculate joint kinematics, joint kinetics and muscle forces during gait. Static optimization and an electromyography-informed approach to calculate muscle forces were compared. A Muscle-Force-Profile was introduced and used to compare the muscle forces during walking before and after a selective dorsal rhizotomy.

FINDINGS

Independent of the approach used (electromyography-informed versus static optimization), selective dorsal rhizotomy significantly normalized forces in spastic muscles during walking and did not reduce the contribution of non-spastic muscles.

INTERPRETATION

This study showed that selective dorsal rhizotomy improves dynamic muscle forces in children with cerebral palsy and leads to less gait pathology, as shown in the improvement in joint kinematics and joint kinetics. Individual muscle force analyses using the Muscle-Force-Profile extend standard joint kinematics and joint moment analyses, which might improve clinical-decision making in children with cerebral palsy in the future. The reference data of our participants and MATLAB code for the Muscle-Force-Profile are publicly available on simtk.org/projects/muscleprofile.

Clinically practical formula for preoperatively estimating the cutting rate of the spinal nerve root in a functional posterior rhizotomy

OBJECTIVE

A functional posterior rhizotomy (FPR) ideally involves minimal cutting of the posterior root while providing maximal reduction of disabling spasticity. However, the ideal cutting rate has yet to be determined. It was hypothesized that the cutting rate of the posterior root would negatively correlate with preoperative motor function in children with spasticity.

METHODS

Children who underwent an FPR between March 1996 and March 2017 and whose pre- and postoperative data were followed more than a year were enrolled. The preoperative Gross Motor Function Measure (GMFM) score and the overall cutting rate of the posterior root were plotted on a scatter plot, and a simple linear regression analysis was performed. The rationale for the cutting rate of the posterior root was tested by postoperative chronological changes in the GMFM score up to 5 years after the FPR. The Gross Motor Function Classification System (GMFCS) was used to group the children. The postoperative and preoperative GMFM were compared at each GMFCS level.

RESULTS

One hundred thirty-seven children (aged 2 to 19 years old, mean 5.9 years old) met the selection criteria. The cutting rate of the posterior root ranged from 17 to 83%, (mean 48.3%). A scatter plot was then made using GMFM scores between 10 and 90. The formula for the simple linear regression analysis was y = - 0.5539x + 73.896 (x, GMFM score; y, overall cutting rate (%)). The formula was further approximated based on the scatter plot findings as y = 100 - x. The postoperative GMFM showed an improved average score for all GMFCS levels although statistically significant improvement at postoperative 5 years was confirmed in only the GMFCS level 1 group.

CONCLUSIONS

The findings of this study supported the hypothesis of the negative correlation of the cutting rate of the posterior root with preoperative motor function in children with spasticity. The amount of posterior nerve root/rootlet cutting during FPR negatively correlated with the preoperative GMFM score. The approximated formula is simple, practical for clinical use, and helpful for preoperatively estimating the required overall cutting rate for the posterior root. The suggested cutting rate induced by the approximated formula should be used as a reference value and be modified according to preoperative motor function, severity and distribution of spasticity, the result of intraoperative neurophysiology, and other factors.

Evidence Supporting Selective Dorsal Rhizotomy for Treatment of Spastic Cerebral Palsy

The objective of this review is to analyze the evidence supporting selective dorsal rhizotomy (SDR) for the treatment of spastic cerebral palsy (CP). We reviewed 85 outcome studies from 12 countries between 1990 and 2017. The published results are overwhelmingly supportive of SDR, and 39 studies form a basis for this review. Also included is some of the clinical experience of the senior author.

The results show that SDR plus postoperative physiotherapy (PT) improved gait, functional independence, and self-care in children with spastic diplegia. In adults with a follow-up of 20 to 28 years, the early improvements after childhood SDR were sustained and improved quality of life. Furthermore, majority of the adults who underwent SDR as children would recommend SDR to others. On the clinical side, while SDRs through multilevel laminectomies or laminoplasty were associated with spinal deformities (i.e., scoliosis, hyperlordosis, kyphosis, spondylolisthesis, spondylolysis, and nonhealing of laminoplasty), SDRs through a single level laminectomy prevented SDR-related spinal problems. The outcomes of SDR specific to spastic quadriplegia require further investigation because of the relatively small patient population with quadriplegia. Lastly, we found that SDR can prevent or reverse premature aging in adolescents and adults with spastic diplegia. In conclusion, the evidence supporting the efficacy of SDR is strong, and SDR is a well-established option for spasticity management in spastic CP.

Evolution of gait in adolescents and young adults with spastic diplegia after selective dorsal rhizotomy in childhood: A 10 year follow-up study

BACKGROUND

Short-term benefit on gait of selective dorsal rhizotomy (SDR) surgery, which relieves spasticity of the lower extremities has been demonstrated in children with cerebral palsy (CP). However very little is known of the evolution of gait when patients become adolescents and young adults.

RESEARCH QUESTION

How does the gait pattern evolve in adolescents and young adults who underwent SDR during childhood?

METHODS

A longitudinal study was performed including 19 ambulant patients with spastic diplegia due to CP or other causes (mean age at SDR: 6.6 ± 1.6 years) who were assessed four times: pre-SDR, 2 years post- SDR, 5 years post-SDR and at least 10 years post-SDR. From 2D video recordings, Edinburgh Visual Gait Score and lower limb joint kinematic parameters were calculated.

RESULTS

Our data show that the improvement in the gait pattern obtained short-term after SDR continues during into adolescence and adulthood. Ten years after SDR all patients improved compared to baseline. Considering the lower limb joint kinematics, most notable improvements were found at knee and ankle joints. Compared to the evaluation before SDR, the range of motion of the knee increased: the knee was more extended at initial contact and knee flexion in midswing improved. Excessive ankle plantar flexion was reduced during the entire gait cycle. Only minor changes were found at hip and pelvis. Eight patients underwent additional orthopaedic surgery in the years after SDR, and the present findings should be considered as a combination of SDR, development and additional treatment.

SIGNIFICANCE

We demonstrate lasting improvement of gait quality in ambulant patients with spastic diplegia who underwent SDR during childhood when they become adolescents and young adults.

Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children

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.

Long-term outcomes after selective dorsal rhizotomy: a retrospective matched cohort study

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 (Δ_non-SDR =12.8 vs Δ_SDR =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.

WHAT THIS PAPER ADDS

Selective dorsal rhizotomy (SDR) and non-SDR groups had significant improvement in gait pathology over time. The non-SDR group had significantly better gait compared with the SDR group at follow-up. The groups had similar levels of energy cost, pain, and quality of life. Non-SDR participants underwent significantly more orthopaedic surgery and antispasticity injections than SDR participants. Use of a clinically similar control group highlights that different treatment courses may result in similar outcomes into young adulthood.

Long-term impact of childhood selective dorsal rhizotomy on pain, fatigue, and function: a case-control study

AIM

Selective dorsal rhizotomy (SDR) is a surgical treatment for spasticity in children with cerebral palsy (CP). Studies suggest long-lasting effects of SDR on spasticity; long-term effects on symptoms and function are not clear. This study tested whether adults with CP (average 22y after SDR) report less pain, fatigue, and functional decline than a retrospectively assessed non-surgical comparison group.

METHOD

This was a case-control study. Eighty-eight adults with CP (mean age 27y; SDR=38 male/female/missing=20/16/2; non-surgical [comparison]=50, male/female=19/31) recruited from a tertiary care center and the community completed a battery of self-reported outcome measures. Regression models were used to test whether SDR status predicted pain, fatigue, functional change, and hours of assistance (controlling for Gross Motor Function Classification System level).

RESULTS

SDR status did not significantly predict pain interference (p=0.965), pain intensity (p=0.512), or fatigue (p=0.404). SDR related to lower decline in gross motor functioning (p=0.010) and approximately 6 fewer hours of daily assistance than for those in the comparison group (p=0.001).

INTERPRETATION

Adults with CP who had SDR in childhood reported less gross motor decline and fewer daily assistance needs than non-surgically treated peers, suggesting the functional impact of SDR persists long after surgery.

Effect of selective dorsal rhizotomy on daily care and comfort in non-walking children and adolescents with severe spasticity

BACKGROUND

In non-walking children with severe spasticity, daily care can be difficult and many patients suffer from pain. Selective dorsal rhizotomy (SDR) reduces spasticity in the legs, and therefore has the potential to improve daily care and comfort.

AIM

To examine effects of SDR on daily care and comfort in non-walking children with severe spasticity due to different underlying neurological conditions.

METHODS

Medical history, changes in daily care and comfort and satisfaction with outcome were assessed retrospectively in non-walking children who underwent SDR in our center, with a mean follow-up of 1y 7m (range 11m-4y 3m). All eligible patients (n = 24, years 2009-2014) were included.

RESULTS

Mean age at SDR was 12y 4m (SD 4y 3m, range 2y 8m-19y 3m). Associated orthopaedic problems were frequent. Seven patients underwent scoliosis correction in the same session. Most improvements were reported in dressing (n = 16), washing (n = 12) and comfort (n = 10). Median score for satisfaction was 7 on a scale of 10 (range 1-9). SDR resulted in reduction of spasticity in leg muscles. In nine patients dystonia was recorded post-operatively, mainly in children with congenital malformations and syndromes.

INTERPRETATION

SDR is a single event intervention that can improve daily care and comfort in non-walking children with severe spasticity, and can safely be combined with scoliosis correction. Despite the improvements, satisfaction is variable. Careful attention is necessary for risk factors for dystonia, which may be unmasked after SDR.

Selective dorsal rhizotomy for hereditary spastic paraparesis in children

PURPOSE

The aim of this study was to determine the outcomes for children who underwent selective dorsal rhizotomy (SDR) for the treatment of spasticity related to spinal pathology.

METHODS

We performed a retrospective review of all cases of SDR at our institution over the last 30 years and identified patients in whom spasticity was attributed to spinal rather than cerebral pathology. We gathered demographic information and recorded functional status and spasticity scores pre-operatively and over long-term follow-up.

RESULTS

We identified four patients who underwent SDR for spinal-related spasticity. All four had hereditary spastic paraparesis (HSP). All patients had reduced spasticity in the lower limbs after SDR, which was maintained over long-term follow-up. Two patients had a more severe and progressive subtype of HSP, and both these patients exhibited functional decline despite improvement in tone.

CONCLUSIONS

Our findings suggest SDR is a reasonable option to consider for relief of spinal-related spasticity in uncomplicated hereditary spastic paraparesis. However, SDR for the treatment of complicated HSP seems to carry more risks and have a less predictable outcome. Overall, SDR is probably best reserved for pathologies that are relatively stable in their disease course.

Selective dorsal rhizotomy as an alternative to intrathecal baclofen pump replacement in GMFCS grades 4 and 5 children

BACKGROUND

Conventionally, selective dorsal rhizotomy (SDR) has been reserved for ambulant children and implantation of intrathecal baclofen (ITB) pump for non-ambulant children with cerebral palsy. Rather than replacing the ITB pump in selected Gross Motor Function Classification System (GMFCS) grades 4 and 5 children, we elected to undertake SDR instead. We discuss the rationale and outcomes.

OBJECTIVES

To assess if children with severe spasticity treated with long-term ITB pump would benefit from SDR as alternative procedure to replacement of ITB pump.

METHOD

This study is a prospective review of ten children with severe spasticity. Indications for ITB pump replacement in 3/10 children were previous ITB pump infection and the remaining seven were nearing depletion of drug delivery system. Pre- and post-SDR mean modified Ashworth scores, assessment of urological function and survey of parent/carer satisfaction were undertaken.

RESULT

Mean Ashworth score reductions post-SDR in the lower limbs and upper limbs were 2.4 and 1.70, respectively. An improvement in urological function was also noticed in 27% of patients. Overall, 90% of parents/carers felt that functional outcome with SDR was improved compared with that of ITB.

CONCLUSION

SDR in comparison to ITB in this subgroup is cheaper, less intrusive by avoiding refills/replacement and found to be more effective than ITB in reducing spasticity and providing ease for nursing care. We therefore suggest that consideration should be given to SDR as an alternative in patients previously implanted with ITB systems complicated by infection or nearing end of battery life.