Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children

Abstract

We conclude that SDR is safe and-in combination with physiotherapy-effectively reduces spasticity in GMFCS grade IV and V patients. Our series suggests that spastic quadriplegia is effectively managed with significant improvements in upper limb spasticity that are commensurate with those observed in lower limb muscle groups. These gains are furthermore sustained more than a year postoperatively. In light of these findings, we propose that SDR constitutes an effective treatment option for GMFCS IV and V patients and a rational alternative to intrathecal baclofen.

Selective dorsal rhizotomy in ambulant children with cerebral palsy

“…Isolated incidents of this occurring have been reported for children with more severe impairment. 10 This concern can be minimized by the careful selection of SDR candidates who show minimal signs of dystonia or mixed tone. As suggested previously, the HAT tool can be used to identify dystonia, but at present, there is no objective and quantitative measurement.…”

“…A nonselective dorsal-ventral rhizotomy may be performed in individuals with more severe impairments, functioning at GMFCS levels IV or V, in order to meet palliative care goals such as pain relief and improvement of caregiving. 10 Since this is a different procedure with different indications and expectations, it is outside the scope of this review and will not be addressed here.…”

Complexity of gait in a child with spasticity

“…2,3 However, the indications have been stretched to many different patient populations including those with dystonia and dyskinesia, including non-ambulatory patients. 4 One of the post-SDR complications is weakness with increased pelvic tilt and Trendelenburg gait. But in van Campenhout et al's study, 1 all the patients reportedly met the standard inclusion criteria and the assumption is that they had decreased spasticity.…”

Improving access to selective dorsal rhizotomy for children with cerebral palsy

“…11 The procedure has traditionally been reserved for children with ambulatory cerebral palsy. However, several experts have called for it to be considered for more severely affected, nonambulatory patients, 12 who have traditionally been treated with intrathecal baclofen administration. This procedure involves the surgical implantation of an indwelling pump, which releases • There is evidence from randomized controlled trials and a recent large multicentre cohort study that SDR improves motor function and quality of life in children with cerebral palsy who are ambulatory.…”

“…Recent evidence from case series suggests that SDR may be as effective as intrathecal baclofen treatment in carefully selected children with severe cerebral palsy. 5,12 In nonambulatory cerebral palsy, however, child and caregiver goals must be considered carefully. A reduction in spasticity alone is not the goal of SDR.…”