Spinal deformities following selective dorsal rhizotomy

Patient- and Caregiver-Reported Outcome Measures after Single-Level Selective Dorsal Rhizotomy in Pediatric and Young Adult Patients with Spastic Cerebral Palsy

INTRODUCTION

The aim of this cohort study was to assess the outcome of single-level selective dorsal rhizotomy (SDR) in children and young adults with spastic cerebral palsy (CP) treated at our institution, focusing on patient-reported outcome measures (PROMs) and quality of life (QoL) of patients and their caregivers.

METHODS

We included consecutive patients undergoing SDR from 2018 to 2020 at our institution. Subjective outcome was measured through PROMs, while functional outcome was measured through baseline characteristics, operative outcome, as well as short- and long-term follow-up. Furthermore, the effect of age at the time of surgery on patient/caregiver satisfaction was analyzed.

RESULTS

Seven patients (3 female, 43%) with a median age at surgery of 11.9 years (IQR 8.7-15.5) were included. All patients had a Gross Motor Function Classification (GMFCS) score of at least IV before surgery. Five surgeries were palliative and two non-palliative. Based on PROMs, SDR showed very good QoL and health-related outcome measures for both palliative and non-palliative patients. Patient/caregiver satisfaction was higher for the early subgroup (age ≤11) than the late subgroup (age >11). Functional outcome showed reduced spasticity in both groups. Blood transfusions were never needed, while no cerebrospinal fluid leak, infection, or permanent morbidity was seen.

CONCLUSION

Based on PROMs, SDR leads to high satisfaction and improved QoL, especially if done at an early age. Further studies with larger cohorts are necessary to underline and confirm our observations.

Safety and Potential Efficacy of Selective Dorsal Rhizotomy in Adults with Spinal Cord Injury-Induced Spasticity: An Open-Label, Non-Randomized, Single-Arm Trial

BACKGROUND

Despite the abundant literature on the use of selective dorsal rhizotomy (SDR) in spastic cerebral palsy, no investigation has evaluated its use in adult patients with chronic spinal cord injury (SCI)-induced spasticity. The present investigation aimed to evaluate the safety and potential efficacy of SDR in chronic SCI-induced spasticity for the first time.

METHODS

In this open-label, single-arm, non-randomized clinical trial, all patients were assigned to the single study intervention arm and underwent SDR. The primary outcome measure was the safety profile of SDR. Secondary outcome measures were Modified Ashworth Scale, Penn Spasm Frequency Scale, visual analog scale for spasticity, Spinal Cord Injury Spasticity Tool, Spinal Cord Independence measure version III, and Short Form 36 Health Survey Questionnaire.

RESULTS

Six patients with cervical SCI and 4 with thoracic SCI were allocated to the single study intervention arm. No adverse event attributable to the SDR was found. Moreover, all secondary outcome measures of the study improved significantly over the study period (P < 0.001). Multiple regression analysis also found a significant association between level of injury and changes in average Modified Ashworth Scale scores (P = 0.041), Spinal Cord Injury Spasticity Tool score (P = 0.013), and Spinal Cord Independence measure version III total (P = 0.002) and mobility domain scores (P = 0.004) at 12-month postoperatively.

CONCLUSIONS

This clinical trial indicated that SDR is a safe and potentially effective procedure in patients with severe and intractable SCI-induced spasticity. However, future clinical trials with larger sample sizes and adequate power are required to validate our findings regarding efficacy.

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.

No support that early selective dorsal rhizotomy increase frequency of scoliosis and spinal pain - a longitudinal population-based register study from four to 25 years of age

Abstract

Spasticity interfering with gross motor development in cerebral palsy (CP) can be reduced with selective dorsal rhizotomy (SDR). Although reported, it is unknown if SDR surgery causes later spine problems. Using CP-registry data from a geographically defined population, the objectives were to compare frequency and time to scoliosis, and spinal pain up to adult age after SDR-surgery or not in all with same medical history, functional abilities, CP-subtype and level of spasticity at 4 years of age. Variables associated with scoliosis at 20 years of age were explored.

Method

In the total population with CP spastic diplegia in Skåne and Blekinge, born 1990–2006, 149 individuals had moderate to severe spasticity and no medical contraindications against SDR at 4 years of age and were included; 36 had undergone SDR at a median age of 4.0 years (range 2.5–6.6 years), and 113 had not.

Frequency of scoliosis and age when scoliosis was identified, and frequency of spinal pain at 10, 15, 20 and 25 years of age were analysed using Kaplan-Meier survival curves and Fisher’s exact test. Multivariable logistic regression was performed to identify variables to explain scoliosis at 20 years of age. Gross Motor Function Classification System (GMFCS) levels at 4 years of age were used for stratification.

Result

Frequency of scoliosis did not significantly differ between groups having had early SDR surgery or not. In GMFCS IV, the SDR group had later onset and lower occurrence of scoliosis (p = 0.004). Frequency of spinal pain did not differ between the groups (p- levels > 0.28). GMFCS level was the background variable that in the logistic regression explained scoliosis at 20 years of age.

Conclusion

Frequency of back pain and scoliosis in adulthood after early SDR are mainly part of the natural development with age, and not a surgery complication.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03782-5.

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.

Postural deformity in children with cerebral palsy: Why it occurs and how is it managed

Despite the fact that children with cerebral palsy may not have any deformities at the time of birth, postural deformities, such as scoliosis, pelvic obliquity, and windswept hip deformity, can appear with increasing age. This may lead to respiratory function deterioration and, in more severe cases, affects survival. To date, postural care is believed to help improve the health and quality of life of children with cerebral palsy. This review provides an overview of the cause and clinical management of postural deformity that is seen in children with cerebral palsy.

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.

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.

The Evolution of Selective Dorsal Rhizotomy for the Management of Spasticity

Selective dorsal rhizotomy is a key technique in the surgical management of spasticity in patients with cerebral palsy. The technique evolved from the late 1800s when pioneers like Dana and Abbe performed dorsal rhizotomy in their treatment of refractory pain. These surgeons noted a reduction in muscle tone associated with the operation. When Sherrington then published his Nobel prize-winning work on the corticospinal tract and its role in the neuromuscular system in the 1890s, the course was set for modifying spasticity by aiming surgery at the dorsal roots. This procedure underwent multiple modifications through the next century and today it is, arguably, the most commonly performed operation to treat cerebral palsy children with spasticity. Selective dorsal rhizotomy is a technique that still teaches us a great deal about neurophysiology on a daily basis and it is thanks to the pioneers, described in this article, that we have this tool in our armamentarium.

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.

Selective dorsal rhizotomy in ambulant children with cerebral palsy

BACKGROUND

Selective dorsal rhizotomy (SDR) is a surgical procedure for treating spasticity in ambulant children with cerebral palsy (CP). However, controversies remain regarding indications, techniques and outcomes.

CURRENT EVIDENCE SUMMARY

Because SDR is an irreversible procedure, careful patient selection, a multi-disciplinary approach in assessment and management and division of the appropriate proportion of dorsal rootlets are felt to be paramount for maximizing safety. Reliable evidence exists that SDR consistently reduces spasticity, in a predictable manner and to a substantial degree. However, functional improvements are small in the short-term with long-term benefits difficult to assess.

FUTURE OUTLOOK

There is a need for high-quality studies utilizing long-term functional outcomes and well-matched control groups. Collaborative, multicentre efforts are required to further define the role of SDR as part of the management paradigm in maximizing physical function in spastic CP.

Multivariate Analysis and Machine Learning in Cerebral Palsy Research

Cerebral palsy (CP), a common pediatric movement disorder, causes the most severe physical disability in children. Early diagnosis in high-risk infants is critical for early intervention and possible early recovery. In recent years, multivariate analytic and machine learning (ML) approaches have been increasingly used in CP research. This paper aims to identify such multivariate studies and provide an overview of this relatively young field. Studies reviewed in this paper have demonstrated that multivariate analytic methods are useful in identification of risk factors, detection of CP, movement assessment for CP prediction, and outcome assessment, and ML approaches have made it possible to automatically identify movement impairments in high-risk infants. In addition, outcome predictors for surgical treatments have been identified by multivariate outcome studies. To make the multivariate and ML approaches useful in clinical settings, further research with large samples is needed to verify and improve these multivariate methods in risk factor identification, CP detection, movement assessment, and outcome evaluation or prediction. As multivariate analysis, ML and data processing technologies advance in the era of Big Data of this century, it is expected that multivariate analysis and ML will play a bigger role in improving the diagnosis and treatment of CP to reduce mortality and morbidity rates, and enhance patient care for children with CP.

Slow correction of severe spastic hyperlordosis in an adult by means of magnetically expandable rods

BACKGROUND

We describe a case of severe and progressive lumbar hyperlordosis (160°) in a 28-year-old female university student with cerebral palsy. Her main complaints were abdominal wall pain and increasing inability to sit in her custom wheelchair.

METHOD

When deciding on our opinion about the most promising treatment strategy, we contemplated slow continued correction by means of percutaneously expandable magnetic rods (MAGEC) after the index surgery as a key component of a satisfactory correction in this severe and rigid curve. After an initial radical release and partial correction, a release and correction procedure was required for the bilateral hip flexion contracture. A final in situ posterior fusion was performed as a second spinal procedure, once the desired final correction at 66° of lumbar lordosis was achieved.

RESULT

Three years after the completion of surgery, the patient has a stable clinical and radiological result as well as a solid posterior fusion on CT.

CONCLUSION

This is the first case published in which percutaneous magnetic distraction was successfully used in an adult patient.

Selective dorsal rhizotomy: A multidisciplinary approach to treating spastic diplegia

Background:

Spasticity is a motor disorder that interferes with mobility and affects the quality of life. Different approaches have been utilized to address patients with spastic diplegia, among which is selective dorsal rhizotomy (SDR). Although SDR has been shown to be efficacious in treating spastic patients, many neurologists and neurosurgeons are not well aware of the procedure, its indications, and expected outcomes due to the limited number of centers performing this procedure.

Objectives:

The aim of this study is to describe the collaborative multidisciplinary approach between neurosurgeons, neurophysiologists, and physiotherapists in performing SDR. In addition, we delineate three illustrative cases in which SDR was performed in our patients.

Materials and Methods:

A retrospective review and analysis of the clinical records of our three patients who underwent SDR was conducted and reported. Patients’ outcomes were evaluated and compared to preoperative measurements based on clinical examination of power, tone (Ashworth scale), gait, and range of motion, as well as subjective functional assessment, gross motor function classification system, and gross motor function measure with follow-up at 6, 12, and 24 months postoperatively. A detailed description of our neurosurgical technique in performing SDR in collaboration with neurophysiology and physiotherapy monitoring is provided.

Results:

The three patients who underwent SDR using our multidisciplinary approach improved both functionally and objectively after the procedure. No intraoperative or postoperative complications were encountered. All patients were doing well over a long postoperative follow-up period.

Conclusion:

A multidisciplinary approach to treating spastic diplegia with SDR can provide good short-term and long-term outcomes in select patients suffering from spastic diplegia.

Monosegmental laminoplasty for selective dorsal rhizotomy--operative technique and influence on the development of scoliosis in ambulatory children with cerebral palsy

PURPOSE

Selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy (CP) and is performed either through a lumbosacral multilevel laminectomy or a single-level laminectomy at the medullary conus. Spinal interventions generally involve the risk of subsequent instability depending on the extent of structural weakening. Destabilizing spasticity in CP might further increase this risk for both options. Laminoplasty is frequently applied to reduce instability through anatomical restoration, although the unavoidable interruption of interspinous ligaments might be a reason for inconsistent results. We report on a novel technique of laminoplasty, achieving complete restoration of the dorsal column.

METHODS

One hundred sixteen ambulatory children with gross motor function classification scale (GMFCS) level I to III were submitted to SDR through a single-level approach. The lamina was reinserted with a previously unreported technique of laminoplasty. Osseous reintegration of the excised lamina was supposed, if its spinous process was located in place on late follow-up radiographs. Scoliosis was described via Cobb's angle.

RESULTS

At a mean follow-up of 33 months, radiographs were available from 72 children with a mean age at surgery of 7.2 years. Sixty-two out of the 72 reinserted laminae were supposed to be vital and reintegrated. Seven children developed a predominantly mild scoliosis. No association was found between development of scoliosis and GMFCS level or age.

CONCLUSIONS

This novel laminoplasty technique provides the least invasive approach for SDR. The incidence of scoliosis after this single-level approach is comparable to the natural history of ambulatory CP children.

[Long-term outcomes of SDR in various groups of cerebral palsy (CP) patients]

AIM

Long-term outcomes of selective dorsal rhizotomy (SDR) are not sufficiently summarized in the literature. The aim of this study was to systematize and evaluate long-term outcomes of SDR in various groups of cerebral palsy (CP) patients.

MATERIAL AND METHODS

47 patients with spastic CP were operated. In all cases, SDR of the L1-S1 roots was performed under EMG control. In all cases, laminoplasty was used as an approach. Outcomes of surgical treatment were estimated by the Ashworth scale and the GMFM 88 scale. The data were subjected to statistical analysis. The follow-up duration ranged from 12 months to 7 years.

RESULTS

A significant reduction in spasticity from 4.34±0.53 points before surgery to 1.61±0.45 points after surgery (p<0.001) was observed in most cases. The dynamics of locomotor functions was maximal in the 3rd GMFM class: changing from 48±4% points before operation to 52±6% points 12 months after operation (p<0.042). The dynamics of locomotor functions amounted to 2% in the 4th GMFM class and 1% in the 5th GMFM class. The best functional outcomes were obtained in children under 10 years of age. A positive correlation only between the percentage of cut roots and a decrease in spasticity (r= 0.85) was found. No correlation between the amount of cut roots and the dynamics of locomotor functions was observed. No spinal cord deformities were observed during the follow-up period.

CONCLUSION

A reduction in spasticity due to SDR depends on the amount of cut roots. The functional result of SDR is affected not only by a decrease in spasticity but also by the functional status and age of the patient at the time of surgery. In all cases, laminoplasty should be performed to prevent spinal cord deformities.

Surgical management of spasticity

Intractable and severe spasticity in childhood has the ability to impact on the quality of life, function and care of the child. Where medical and physical measures have proved insufficient, a surgical approach may be pursued. Irrespective of the underlying pathology, intrathecal baclofen will reduce spasticity in a controllable and reversible fashion, whereas selective dorsal rhizotomy is reserved for the management of bilateral cerebral palsy due to early birth. Owing to the potential for complications of intrathecal baclofen and the permanence of selective dorsal rhizotomy, careful selection and preparation are required to produce satisfactory results.

Management of spinal deformity in cerebral palsy

An understanding of the three-dimensional components of spinal deformity in children with cerebral palsy is necessary to recommend treatments that will positively affect these patients' quality of life. Management of these deformities can be challenging and orthopedic surgeons should be familiar with the different treatments available for this patient population. This article discusses the incidence, causes, natural history, and treatment of patients with scoliosis.

Long-term outcomes five years after selective dorsal rhizotomy

BACKGROUND

Selective dorsal rhizotomy (SDR) is a well accepted neurosurgical procedure performed for the relief of spasticity interfering with motor function in children with spastic cerebral palsy (CP). The goal is to improve function, but long-term outcome studies are rare. The aims of this study were to evaluate long-term functional outcomes, safety and side effects during five postoperative years in all children with diplegia undergoing SDR combined with physiotherapy.

METHODS

This study group consisted of 35 children, consecutively operated, with spastic diplegia, of which 26 were Gross Motor Function Classification System (GMFCS) levels III-V. Mean age was 4.5 years (range 2.5-6.6). They were all assessed by the same multidisciplinary team at pre- and at 6, 12, 18 months, 3 and 5 years postoperatively. Clinical and demographic data, complications and number of rootlets cut were prospectively registered. Deep tendon reflexes and muscle tone were examined, the latter graded with the modified Ashworth scale. Passive range of motion (PROM) was measured with a goniometer. Motor function was classified according to the GMFCS and measured with the Gross Motor Function Measure (GMFM-88) and derived into GMFM-66. Parent's opinions about the children's performance of skills and activities and the amount of caregiver assistance were measured with Pediatric Evaluation Disability Inventory (PEDI).

RESULTS

The mean proportion of rootlets cut in S2-L2 was 40%. Muscle tone was immediately reduced in adductors, hamstrings and dorsiflexors (p < 0.001) with no recurrence of spasticity over the 5 years. For GMFCS-subgroups I-II, III and IV-V significant improvements during the five years were seen in PROM for hip abduction, popliteal angle and ankle dorsiflexion (p = 0.001), capacity of gross motor function (GMFM) (p = 0.001), performance of functional skills and independence in self-care and mobility (PEDI) (p = 0.001).

CONCLUSION

SDR is a safe and effective method for reducing spasticity permanently without major negative side effects. In combination with physiotherapy, in a group of carefully selected and systematically followed young children with spastic diplegia, it provides lasting functional benefits over a period of at least five years postoperatively.