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

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>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 &lt; 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.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>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.</jats:p></jats:sec>

Effect of Long-Term Repeated Interval Rehabilitation on the Gross Motor Function Measure in Children with Cerebral Palsy

“…35 Even regarding the use of invasive treatments, such as intrathecal Baclofen's or selective dorsal rhizotomy (SDR), that should actually had been better followed-up, the evidence is very scarce and insufficient. 36 Therefore, we are not able to compare our data to other results. Due to the high socioeconomic importance of this disease for the health system, however, it is highly relevant to review the effectiveness of the therapeutic programs.…”

Surgical results of selective dorsal rhizotomy for the treatment of spastic cerebral palsy

“…On the other hand, intrathecal baclofen is certainly more effective in the control of extrapyramidal symptoms, especially dystonia. [ 13 14 15 ] Interestingly, no differences in the occurrence of orthopedic deformities (notably hip dislocations and scoliosis) have been seen after both procedures (SDR and ITB). [ 16 17 ] Due to local particularities also, it has been the authors’ policy to manage pure spastic diplegia with SDR and use ITB mainly for dystonic patients.…”

Rizotomía dorsal selectiva para manejar la espasticidad en niños con parálisis cerebral

“…Tradicionalmente, los niños con hipertonía que no eran ambulatorios fueron considerados candidatos para la terapia de baclofeno intratecal para mitigar las molestias, mientras que la rizotomía dorsal selectiva (SDR) se reservaba para niños ambulatorios para mejorar la marcha. En la actualidad, el tratamiento quirúrgico de SDR está cobrando importancia debido a que se está comprobando que ofrece a todos los niños afectados buenas oportunidades para mejorar la calidad de vida (1).…”