Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Large-scale natural history studies of gross motor development have shown that children with spastic cerebral palsy (CP) plateau during childhood and actually decline through adolescence. Selective dorsal rhizotomy (SDR) is a well-recognized treatment for spastic CP, but little is known about long-term outcomes of this treatment. The purpose of this study was to assess the durability of functional outcomes in a large number of patients through adolescence and into early adulthood using standardized assessment tools.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors analyzed long-term follow-up data in children who had been evaluated by a multidisciplinary team preoperatively and at 1, 5, 10, and 15 years after SDR. These evaluations included quantitative, standardized assessments of lower-limb tone (Ashworth Scale), Gross Motor Function Measure (GMFM), and performance of activities of daily living (ADLs) by the Pediatric Evaluation of Disability Inventory in children who had been stratified by motor severity using the Gross Motor Function Classification System (GMFCS). In addition, group-based trajectory modeling (GBTM) was used to identify any heterogeneity of response to SDR among these treated children, and to find which pretreatment variables might be associated with this heterogeneity. Finally, a chart review of adjunct orthopedic procedures required by these children following SDR was performed.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Of 102 patients who underwent preoperative evaluations, 97, 62, 57, and 14 patients completed postoperative assessments at 1, 5, 10, and 15 years, respectively. After SDR, through adolescence and into early adulthood, statistically significant durable improvements in lower-limb muscle tone, gross motor function, and performance of ADLs were found. When stratified by the GMFCS, long-lasting improvements for GMFCS Groups I, II, and III were found. The GBTM revealed 4 groups of patients who responded differently to SDR. This group assignment was associated with distribution of spasticity (diplegia was associated with better outcomes than triplegia or quadriplegia) and degree of hip adductor spasticity (Ashworth score &lt; 3 was associated with better outcomes than a score of 3), but not with age, sex, degree of ankle plantar flexion spasticity, or degree of hamstring spasticity. In a sample of 88 patients who had complete records of orthopedic procedures and botulinum toxin (Botox) injections, 52 (59.1%) underwent SDR alone, 11 (12.5%) received only Botox injections in addition to SDR, while 25 patients (28.4%) needed further lower-extremity orthopedic surgery after SDR.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>In the majority of patients, the benefits of SDR are durable through adolescence and into early adulthood. These benefits include improved muscle tone, gross motor function, and performance of ADLs, as well as a decreased need for adjunct orthopedic procedures or Botox injections. The children most likely to display these long-term benefits are those in GMFCS Groups I, II, and III, with spastic diplegia, less hip adductor spasticity, and preoperative GMFM scores greater than 60.</jats:p></jats:sec>

Single-level selective dorsal rhizotomy for spastic cerebral palsy

“…Nordmark et al and Josenby et al found that patients also had improvements in their Paediatric Evaluation of Disability Inventory (PEDI) scores, notably in the functional skills and mobility domains (27,31). Dudley et al found that these gains persisted to 15 years post-SDR (29). The multidimensional benefits of SDR were evident from the PEDI score results, where significant gains in self-care and mobility persisted through to early adulthood.…”

“…The multidimensional benefits of SDR were evident from the PEDI score results, where significant gains in self-care and mobility persisted through to early adulthood. Moreover, SDR patients in this study compared with children who did not undergo SDR had a significant reduction in the need for further orthopedic intervention (29). Tedroff et al on the other hand found that, while spasticity was significantly reduced by SDR at 15-20 years post-SDR, contractures were not prevented and long-term functioning was not improved (28).…”

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

“…In a recent study [11] involving a large number of CP children (n=102) with spastic diplegia, the authors assessed the long-term effects of SDR 1, 5, 10 and 15 years after the operation. Of the 102 children, 57 were assessed at 10 years and 14 were assessed at 15 years.…”

Selective dorsal rhizotomy for spasticity not associated with cerebral palsy: reconsideration of surgical inclusion criteria

“…Subsequent large nonrandomized studies have found similar functional improvements that persist at up to 26 years postoperatively. 4,7,18,36 The presumed mechanism by which SDR alleviates spasticity is by modulation of afferent inputs to lower motor neurons to compensate for a loss of upper motor neuron regulation, although the details of this mechanism are poorly understood. 15 The most common imaging finding associated with CP is periventricular leukomalacia, which is associated with necrosis of the periventricular and subcortical white matter.…”