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

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.

The medium-term effects of selective dorsal rhizotomy on gait compared to a matched cerebral palsy non-SDR group: A follow-up study

BACKGROUND

Selective dorsal rhizotomy (SDR) has been shown to improve gait in the short-term in children with cerebral palsy (CP). Further study is needed to look at the trajectory of outcomes over the longer-term.

RESEARCH QUESTION

What are the medium-term effects of SDR on gait compared to a matched CP non-SDR group?

METHODS

Participants underwent SDR at mean age 6.3 years and completed baseline, 1-year and 5-year follow-up gait analyses. Non-SDR participants were matched at baseline. Differences were assessed within and between groups. Kinematic variables were analysed using Statistical non-Parametric Mapping (SnPM). Other gait and clinical data were analysed using Friedman's one-way repeated measure analysis of variance and a Mann-Whitney U-test.

RESULTS

The initial SDR group consisted of 29 participants, reducing to 22 at 5-year follow-up. Of these, 15 (68 %) had orthopaedic surgeries either concurrent with or in the intervening period since the SDR, mean 3.3 procedures per participant. The initial non- SDR group had 18 participants, reducing to 17 at 5-year follow-up. Of these, 13 (76 %) had orthopaedic surgeries, mean 5.7 procedures. At 1-year follow-up the SDR group had significantly improved knee extension, ankle dorsiflexion, foot progression, Gait Deviation Index, and normalised step length compared to baseline, p < 0.05, and outcomes were maintained at 5-years. At 1-year follow-up the non-SDR group kinematic patterns were unchanged, but at 5-year follow-up this group demonstrated significantly improved knee extension, ankle dorsiflexion and foot progression. There were no significant kinematic differences between the SDR and the non-SDR group at medium-term follow-up.

SIGNIFICANCE

We have documented the trajectory of gait outcomes post-SDR over 3 assessments and found that short-term gait changes endured in the medium-term. However, kinematic changes were similar to a non-SDR group undergoing routine and orthopaedic care. These outcomes are important to guide surgical decision making and to manage treatment goals and expectations.

Goal setting, goal attainment and quality of life of children following selective dorsal rhizotomy

AIM

The aim of this study is to describe the individualized occupational performance issues identified by parents/carers and children prior to selective dorsal rhizotomy (SDR) surgery and analyse change up to 2 years post surgery in goal attainment and quality of life (QoL).

METHOD

The Australian SDR Research Registry (trial registration: ACTRN12618000985280) was used to extract data for individualized goals, goal attainment and QoL based on the Canadian Occupational Performance Measure (COPM) and the Cerebral Palsy Quality of Life Questionnaire for Children (CP QOL-Child parent-proxy) at baseline and 1 and 2 years following SDR. Change in mean scores was analysed using linear mixed models.

RESULTS

Fifty-two children had COPM scores at baseline and 1 and/or 2 years post, of which 28 had two QoL scores. COPM problem areas included leisure (n = 39), productivity (n = 37) and self-care (n = 173). The most common goals were walking (26.1%), participation in physical activities (17.7%) and transitions (14.1%). Mean COPM scores improved significantly between baseline to 1 year and baseline to 2 years (P < 0.001). Mean QoL scores improved between baseline to 1 year for functional QoL domains: participation and physical health (P = 0.003) and pain and impact of disability (P = 0.011).

CONCLUSIONS

Collaborative goal setting is an integral part of family-centred rehabilitation practice. The COPM was an appropriate individualized outcome measure in identifying meaningful goals for our SDR cohort. Results demonstrate improved scores in goal attainment and improvement in functional QoL domains. This paper highlights the need to include outcomes that measure daily life experiences.

The effect of GMFCS level, age, sex, and dystonia on multi-dimensional outcomes after selective dorsal rhizotomy: prospective observational study

PURPOSE

Investigate the effect of age category (1-9 years vs 10-18 years), sex, Gross Motor Function Classification System (GMFCS) level, and presence of dystonia on changes in eight function test parameters 24 months after selective dorsal rhizotomy (SDR).

METHODS

Prospective, single-center study of all children aged 3-18 years with bilateral cerebral palsy with spasticity who underwent SDR at a tertiary pediatric neurosurgery center between 2012 and 2019. A linear mixed effects model was used to assess longitudinal changes.

RESULTS

From 2012 to 2019, 42 children had follow-up available at 24 months. Mean GMFM-66 scores increased after SDR (mean difference 5.1 units: 95% CI 3.05-7.13, p < 0.001). Statistically significant improvements were observed in CPQoL, PEDI Self-care and Mobility, 6MWT, Gillette, and MAS scores. There was no significant difference in the improvements seen for age category, sex, GMFCS level, and presence of dystonia for most of the parameters tested (5/8, 6/8, 5/8, and 6/8 respectively).

CONCLUSION

SDR may improve gross and fine motor function, mobility and self-care, quality of life, and overall outcome based on extensive scoring parameter testing at 24 months. Atypical patient populations may benefit from SDR if appropriately selected. Multi-center, prospective registries investigating the effect of SDR are required.