Comprehensive short‐term outcome assessment of selective dorsal rhizotomy

Abstract

This study retrospectively evaluated the safety and efficacy of selective dorsal rhizotomy (SDR) in participants who underwent a rigorous selection process, uniform surgical procedure, and a standardized postoperative rehabilitation process. Outcome measures assessed were the Ashworth scale for spasticity, the Gillette Gait Index (GGI) for overall gait pathology, oxygen cost for gait efficiency, and the Gillette Functional Assessment Questionnaire (functional walking ability scale; [FAQ]) for functional mobility. Outcomes were evaluated for 136 children (81 males, 55 females; mean age 7y 3mo [SD 2y 1mo], range 3y 5mo-18y 9mo) for an average of 18.3 months (SD 4.4mo) postoperatively. All participants had a diagnosis of cerebral palsy (CP): 10 quadriplegia, 19 triplegia, and 107 diplegia. Preoperative Gross Motor Function Classification System levels were: Level I n=6; Level II n=64; Level III n=59, and Level IV n=7. All outcome measures improved for the group as a whole. Spasticity improved with 66 to 92% of possible gain in Ashworth scores; GGI was 7.5 times more likely to have a good as opposed to a poor outcome; energy efficiency improved in over half of the participants, and the FAQ demonstrated a statistically significant improvement of 0.9 levels (p<0.001). The rate of complications was low, with peri-and postoperative complications resolved by time of discharge.Despite 20 years of use in cerebral palsy (CP), the selective dorsal rhizotomy (SDR) procedure remains controversial. 1 This is in part due to the risk of peri-and postoperative complications, and also to concerns about the longer-term possibility of crouch gait, spinal deformity, foot deformity, hip subluxation, and functional weakness.2-4 Even among those who use SDR, patient selection criteria and surgical technique are not uniform.2,5 SDR is generally used in a subgroup of individuals with CP to reduce spasticity and increase function. The selection criteria for that subgroup vary from place to place and even within an institution.2,3,5 Published guidelines exist for age, diagnosis, tone, ambulatory ability, birth history, motor control, specific medical conditions, orthopaedic status, availability of postoperative therapy, and intellectual development.2 However, despite the controversy, SDR has been shown to reduce spasticity, improve range of motion, function, and self-care abilities, and normalize gait patterns.

Excellent functional outcome following selective dorsal rhizotomy in a child with spasticity secondary to transverse myelitis

“…A retrospective study involving 136 children with CP who underwent SDR showed a marked reduction in spasticity and improved functional mobility. The study confirmed that the procedure was safe with no long-term complications [2]. Similar excellent functional outcomes of SDR have been described by others [3].…”

Gait status 17–26 years after selective dorsal rhizotomy

“…While this is an important piece of work, the outcomes were based on limited 2D gait analyses. Three-dimensional gait analysis was only widely incorporated in CP research in the late 1990s, and therefore SDR follow-up studies that include 3D gait analysis have focused on short-term follow-up periods [10,23,24]. The current study appears to be the first ever published, which documents 3D gait analysis status of patients with spastic diplegia more than 17 years after SDR.…”

“…The current study appears to be the first ever published, which documents 3D gait analysis status of patients with spastic diplegia more than 17 years after SDR. The combination of these outcomes with the 20 year 2D gait followup study [16], and short-term (on average 10-20 months) 3D follow-up studies of other research groups [10,23,24] results in novel invaluable information for guidance in treatment decision making.…”

Gait analysis to guide a selective dorsal rhizotomy program

“…Control and the pattern of motor disorder resulting from the upper motor neurone lesion can often be inferred from the variability of the gait pattern from step to step as shown in the consistency plot [44]. Typically whilst the pattern may not be normal, a child with relatively good control but bad spasticity will have a very consistent gait pattern from step to step.…”

“…In two papers from Gillette Children's Specialty Healthcare the effect of selective dorsal rhizotomy in isolation [44] and as part of an integrated programme [36] is reported. Crucially, a very rigourous and multidisciplinary selection process underpins both papers producing a highly selected group of children.…”