Comparison of intrathecal baclofen pump insertion and selective dorsal rhizotomy for nonambulatory children with predominantly spastic cerebral palsy

Abstract

OBJECTIVE In nonambulatory children with predominantly spastic cerebral palsy (CP), the authors compared care needs, symptom burden, and complications after surgical treatment with either intrathecal baclofen (ITB) pump insertion or selective dorsal rhizotomy (SDR). The patients were treated at two Canadian centers with variability in practice pertaining to these surgical options. METHODS The authors performed a retrospective analysis of nonambulatory children with predominantly spastic quadriplegic or diplegic CP who underwent treatment with ITB or SDR. These two strategies were retrospectively assessed by comparing patient data from the two treatment groups for demographic characteristics, outcomes, and complications. A partial least-squares analysis was performed to identify patient phenotypes associated with outcomes. RESULTS Thirty patients who underwent ITB and 30 patients who underwent SDR were included for analysis. Patients in the ITB group were older and had lower baseline functional status, with greater burdens of spasticity, dystonia, pain, deformity, bladder dysfunction, and epilepsy than patients in the SDR group. In addition, children who underwent SDR had lower Gross Motor Function Classification System (GMFCS) levels and were less likely to experience complications than those who underwent ITB. However, children treated with SDR had fewer improvements in pain than children treated with ITB. A single significant latent variable explaining 88% of the variance in the data was identified. CONCLUSIONS Considerable baseline differences exist within this pediatric CP patient population. Factors specific to individual children must be taken into account when determining whether ITB or SDR is the appropriate treatment.

Cervicothoracic Ventral-Dorsal Rhizotomy for Treatment of Brachial Hypertonia in Cerebral Palsy

“…For patients with elements of dystonia an SDR may exacerbate dystonic features [23]. For these patients ITBP is typically used, but it is known to have a higher complication rate than SDR and typical lumbosacral ITBP may have reduced effect in the upper extremities compared with the lower extremities [24][25][26][27]. ITBP demonstrates reduction in upper extremity mAS scores by 0.8 to 1.8 compared with 1.75 to 2.5 in our cohort [26,27].…”

Palliative single-level selective dorsal rhizotomy for children with spastic cerebral palsy Gross Motor Function Classification System level IV and V: a case series and systematic review of the literature

“…Surgical interventions such as selective dorsal rhizotomy (SDR) and intrathecal baclofen (ITB) pumps serve as primary strategies to reduce lower-extremity spasticity, thereby enhancing mobility and improving the quality of life for affected individuals. 4,5 The decision regarding surgical intervention typically depends on the Gross Motor Function Classification System (GMFCS), which categorizes gross motor skills into 5 levels, usually targeting patients with GMFCS levels I-III to maintain or enhance ambulation. [6][7][8] SDR was first described by Peacock in the 1980s and included a multilevel laminectomy, exposing the L2-S2 levels.…”

“…8,10,11 However, traditionally for these patients ITB pumps are implanted with the aim of alleviating spasticity in both the lower and upper extremities and improving dystonia. 5,12 To date, evidence supporting the effectiveness and improvement in quality of life of palliative SDR for GMFCS high-level patients is lacking, although some reports do support its use for children with CP and high GMFCS levels. 5,[13][14][15] The aim of this study was to present our retrospective case series and provide a systematic overview of the literature regarding indication and outcome of palliative SDR for nonambulatory patients with CP and GMFCS levels IV and V, focusing on improvement of spasticity and quality of life of the patients and their caregivers.…”

“…Overall, the literature on palliative SDR is sparse, but promising data have emerged over the last decade. 5,13,[21][22][23][24][25] The traditional indication for single-level SDR consists of maintenance or improvement of ambulation, therefore functional SDR was previously mainly reserved for patients with GMFCS levels I-III. Due to the high psychological and physiological strain for both patients and caregivers, some studies evaluated single-level SDR even for GMFCS level IV and V patients with promising results, finally providing a valuable alternative to ITB pump implantation with the aim of reducing spasticity and therefore reducing pain and facilitating daily care of the patients.…”

Case-based explanation of standard work tools for selective dorsal rhizotomy for cerebral palsy

“…6 Intrathecal baclofen (ITB) and selective dorsal rhizotomy (SDR) represent the primary surgical strategies used to treat spasticity. 7,8 Developed in the 1980s, ITB facilitates increased bioavailability of baclofen relative to oral administration to reduce muscle tone and spasticity. 9,10 However, ITB involves high complication rates from infections, CSF leaks, and catheter-or pump-related factors.…”