Selective dorsal rhizotomy in ambulant children with cerebral palsy: an observational cohort study

Abstract

Background Selective dorsal rhizotomy (SDR) is an irreversible surgical procedure involving the division of selected sensory nerve roots, followed by intensive physiotherapy. The aim is to improve function and quality of life in children with cerebral palsy and a Gross Motor Function Classification System (GMFCS) level of II or III (walks with or without assistive devices, respectively). We assessed gross motor function before and after SDR and postoperative quality of life in a study commissioned by NHS England. MethodsWe did a prospective observational study in five hospitals in England who were commissioned to perform SDR on children aged 3-9 years with spastic diplegic cerebral palsy. The primary outcome was score changes in the 66-item Gross Motor Function Measure (GMFM-66) and seven domains of the Cerebral Palsy Quality of Life Questionnaire ([CP-QoL] social wellbeing and acceptance, feelings about functioning, participation and physical health, emotional wellbeing and self-esteem, access to services, family health, and pain and impact of disability) from before to 24 months after SDR. Findings From Sept 4, 2014, to March 21, 2016, 137 children underwent SDR. The mean age was 6•0 years (SD 1•8).The mean GMFM-66 score increased after SDR with an annual change of 3•2 units (95% CI 2•9 to 3•5, n=137). Of the seven CP-QoL domains, five showed significant improvements over time: feelings about functioning mean annual change 3•0 units (95% CI 2•0 to 4•0, n=133), participation and physical health 3•9 units (2•5 to 5•3, n=133), emotional wellbeing and self-esteem 1•3 units (0•2 to 2•3, n=133), family health 2•0 units (0•7 to 3•3, n=132), and pain and impact of disability -2•5 units (-3•9 to -1•2, n=133). 17 adverse events were reported in 15 children, of which none were severe and 15 (88%) resolved.Interpretation SDR improved function and quality of life in the 24 months after surgery in children with cerebral palsy classified as GMFCS levels II and III. On the basis of these findings, an interim national policy decision was made that SDR would be funded for eligible children in England from 2018.

Whether the newly modified rhizotomy protocol is applicable to guide single-level approach SDR to treat spastic quadriplegia and diplegia in pediatric patients with cerebral palsy?

“…These results were comparable to those SDR managed via the traditional way. Not surprisingly, like what earlier studies concluded [1,14,15,[17][18][19], our data showed as well that mild cases improved much better than those severe ones. Cases with their pre-op GMFCS level of II and III had more chance to have their level upgrade than those with IVand V (24/57 vs. 3/24) after the rehabilitation therapy.…”

“…EMG electromyography, SD standard deviation, mA milliampere, ms millisecond Table 3 Changes of muscle tone, muscle strength of the target muscles, and ROM of the joints involved (passive) pre-and postop favorable outcome. Similar results were reported from other centers when SDR was performed in the traditional manner [14][15][16][17]. Further investigation in our study revealed that cases when SDR performed to younger than 6 years old had much Fig.…”

Selective dorsal rhizotomy in children with cerebral palsy

“…Although these adolescents hold the promise of achieving India's economic potential, a growing body of work shows persisting challenges to adolescent health and development, including nutrition deficits, exclusion from livelihood choice, social engagement and health services, and unequal gender norms inside and outside the home. [2][3][4][5][6] Adding to this body of work, a new study by Phuong Nguyen and colleagues 7 presents evidence on the health costs of teenage pregnancy in India, which can be lifelong and intergenerational, that affect the lives of a large number of girls.…”

Improving access to selective dorsal rhizotomy for children with cerebral palsy

“…The UK decision was based on a recently published commissioned multicentre prospective open-label trial of SDR that showed the procedure to be associated with significant increases in gross motor function and quality of life for children with moderate cerebral palsy. 1 In Canada, access to SDR for children with this disorder remains variable and limited, with many provinces not performing this procedure and others capping funding or restricting indications. Many Canadian families have travelled south of the border at their own expense and risk to access SDR, which has attracted considerable media attention.…”

“…Selective dorsal rhizotomy, a surgical procedure to section sensory rootlets in the lumbosacral spine selectively, followed by extensive rehabilitation and physiotherapy, results in improved gait for carefully selected children. 1 Dorsal rhizotomy as a treatment for spasticity has existed for more than 100 years, but the procedure has evolved to be more selective and less invasive. The sensory nerve roots are exposed below the conus medullaris within the cauda equine, separated into rootlets and stimulated; those sensory roots, which generate aberrant motor responses, are cut.…”