Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials

ABBREVIATIONS FMSFunctional Mobility Scale GPS Gait Profile Score SEMLS Single-event multilevel surgery AIM There are conflicting reports about the stability of the Gross Motor Function Classification System (GMFCS) in children with cerebral palsy (CP) after orthopaedic surgery. We studied the stability of the GMFCS in children with bilateral spastic CP after single-event multilevel surgery, using the Gait Profile Score (GPS) as the primary outcome measure.METHOD This was a retrospective cohort study of 107 children (46 females, 61 males) with bilateral spastic CP, classified as GMFCS level II or III, who underwent surgery at a single tertiary institution between 1997 and 2008. The mean age at surgery was 10 years 7 months (SD 2y 8mo). The primary outcome measure was the GPS. Changes in GMFCS level were studied at multiple time points before and after intervention.RESULTS Gait dysfunction was partially corrected, with a mean improvement of 28% in the GPS.The GMFCS remained stable and unchanged in 95% of children and improved by one level in 5% of children. The improvement in GPS was three times the minimal clinically important difference. The mean age at final postoperative GPS assessment was 11 years 10 months (SD 2y 10mo) and at final GMFCS assessment was 15 years 7 months (SD 3y 9mo).INTERPRETATION Stability of the GMFCS was confirmed in the majority of children with bilateral spastic CP after single-event multilevel surgery, despite statistically and clinically significant improvements in gait dysfunction and functional mobility. This information is important in realistic goal-setting and in counselling families.The Gross Motor Function Classification System (GMFCS) is a standardized method to classify gross motor function in children with cerebral palsy (CP) from 1 to 18 years of age. 1,2It is a five-level categorical grading system which classifies differences in gross motor function that are meaningful and significant to children with CP and their families.3 Distinctions between GMFCS levels are based on functional limitations with an emphasis on sitting and walking and the need for assistive devices and wheeled mobility. Children may be quickly and easily classified at any given time, such as during a clinic appointment or gait laboratory assessment, by determining which level best corresponds to the child's current gross motor function. A set of age-appropriate descriptive criteria are used and good correlations have been demonstrated between classifications assigned by parents and by health professionals. 1,2,4 Since the original description by Palisano et al. 1 in 1997, the GMFCS has become widely accepted, widely used, and is considered by many to be an essential tool to communicate about gross motor function in CP. 5,6The GMFCS is a valid and reliable classification tool which is expected to be relatively stable over time, with or without intervention. Palisano et al. 3 reported that 73% of 610 children with CP remained at the same GMFCS level at multiple ratings over time , and McCormick et ...

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“…30 Given that both neurosurgical procedures and orthopaedic surgery do not change the cerebral lesion, this is not surprising.…”

Section: Discussionmentioning

confidence: 99%

“…29 This is in keeping with other interventions such as selective dorsal rhizotomy, which may result in large improvements in gait pattern and efficiency but small improvements in gross motor function. 30 Given that both neurosurgical procedures and orthopaedic surgery do not change the cerebral lesion, this is not surprising.…”

Section: Discussionmentioning

confidence: 99%

Stability of the Gross Motor Function Classification System after single‐event multilevel surgery in children with cerebral palsy

Rutz

Tirosh

Thomason

et al. 2012

Develop Med Child Neuro

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“…Our overall judgment is in line with his conclusion that, without SDR, all the children in this group would have gone on to receive multilevel orthopaedic surgery, though this is a speculative judgment and not possible to prove definitively without a carefully matched control group. Other than the studies summarized in the published meta-analysis by McLaughlin et al (2002) (5) we are not aware of any randomized controlled studies of SDR and none giving long term follow up results including gait analysis data. A number of studies have attempted to create a control group to compare with their SDR patients, either from their data archive (20), from active recruitment (21), from a group of similar patients but with a slightly different presentation (22) or by allowing parental choice (23).…”

Section: Introductionmentioning

confidence: 99%

Changes in gait which occur before and during the adolescent growth spurt in children treated by selective dorsal rhizotomy

et al. 2015

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This paper presents long term follow up results from 17 children (6 girls, 11 boys, GMFCS levels II to IV), treated by means of selective dorsal rhizotomy (SDR). The particular focus is on the effect of the adolescent growth spurt on patients who had previously undergone SDR. The children were all assessed using 3D gait analysis, in combination with clinical examination at three time points -before SDR surgery (PRE), after SDR surgery when preadolescent (POST1) and post-adolescence (POST2). The total follow up period to POST 2 was 8y6m for girls and 9y5m for boys. All children maintained or improved their GMFCS level. Positive changes in ranges of motion and gait were observed at POST1 and these were generally maintained over adolescence to POST2. The mean Gait Profile Score (GPS) had improved by 3.2 points (14.7 to 11.5) at POST1, with a non-significant deterioration of 0.3 over the adolescent growth spurt. These positive results reflect the total package of care for the children, involving careful pre-operative selection by a multidisciplinary team and postoperative management including intensive physiotherapy and maintenance in tuned ankle foot orthoses. 59% of children had some additional orthopaedic surgery, mostly bony procedures. The overall benefits arising from their management need to be considered in the light of the likely deterioration experienced by this patient group. The results of this study support the use of SDR as part of a management strategy for carefully selected children with cerebral palsy with the aim of optimizing gait at skeletal maturity. KEYWORDS: Cerebral palsy; Selective Dorsal Rhizotomy, Gait, Adolescence INTRODUCTIONSelective Dorsal Rhizotomy (SDR) was refined and popularized by the team of Dr Peacock, in South Africa (1), to reduce spasticity in children with cerebral palsy. The procedure has been in use for over 30 years, with a substantial body of literature from centres publishing their local outcomes. The earliest patients treated are now adults, making it possible to assess the long term impact of SDR performed in childhood. Despite substantial clinical experience of SDR there are very few randomized controlled trials, the main three (2,3,4) being summarized in the meta-analysis published by McLaughlin et al in 2002 (5). None of these studies used instrumented 3D gait analysis, and so were not able to report gait changes in detail. The follow up times are also relatively short at between 9 and 24 months. The Oswestry SDR programme began in 1995. All children treated in Oswestry are assessed pre-operatively by means of a full lower limb clinical examination and gait assessment. These measures are then repeated 12 months post-operatively, and the short term outcome data have been presented elsewhere (6). A number of other centres have also reported short term outcome data, including pre and post-operative gait analysis (eg 7,8,9). Common features are seen in data from different centres. Following SDR children typically have greater passive extension at hip and knee ...

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“…4 This procedure is still regarded as a potential treatment especially in children. 5 Another method of treating spasticity by inducing new lesions is the intrathecal use of neurolytic agents like phenol and alcohol. 6 But in the last three decades of the last century non-lesional techniques such as pharmacotherapy and physiotherapy became predominant in the treatment of spasticity.…”

Section: Treatment Of Spasticitymentioning

confidence: 99%

Treatment of spasticity

Rösche

2002

Spinal Cord

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Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials

Cited by 262 publications

References 35 publications

Stability of the Gross Motor Function Classification System after single‐event multilevel surgery in children with cerebral palsy

Stability of the Gross Motor Function Classification System after single‐event multilevel surgery in children with cerebral palsy

Changes in gait which occur before and during the adolescent growth spurt in children treated by selective dorsal rhizotomy

Treatment of spasticity

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