Parent information about selective dorsal rhizotomy (SDR) for spasticity and cerebral palsy (2014)
Claudia Maizen, Consultant Paediatric Orthopaedic Surgeon
A lot of attention has been drawn to the procedure SDR by the press and many parents ask us whether their children would be suitable for SDR. Some parents raise a lot of money privately or via charities to go to the United States (St Louis, Missouri) for this treatment, but there are also centres in the UK who offer this procedure in the NHS (e.g. Oswestry). It is very important to select the “right patient” for this procedure to achieve good results, and although UK Centres are very specific with their patient selection criteria, other centres, such as in the United States, are less specific in their selection process.
What is SDR?
Introduction
Cerebral palsy is a brain condition that affects movement, posture and coordination. It may be seen at around the time of birth or may not become obvious until early childhood. Some children will have lower limb spasticity, which can cause problems with walking and sitting, as well as discomfort, cramps and spasms.
Selective dorsal rhizotomy is a major surgical procedure that aims to reduce the amount of information carried by the sensory nerves. With the patient under general anaesthetic, a cut is made in the lower back and into the spinal canal to expose the spinal cord and lower nerves. Some of the sensory nerves that carry information from the muscles into the legs are cut. The nerves that make the muscles contract are not cut. After the procedure, the patients will need long-term physiotherapy and may have to learn to walk again and learn different walking skills.
Are there other options?
Other surgical procedures for spasticity include tenotomy (cutting of tendons), neurotomy (cutting of nerves), osteotomy (cutting of bones) and tendon lengthening. Other treatment options include drugs (Baclofen, Botulinum toxin), use of corrective braces, physiotherapy, and electrical stimulation of the muscles or lower spinal cord.
Indications
It is important to understand that SDR does not heal spasticity. It only reduces the spasticity and muscle tone in selected muscle groups of the lower limbs. Certain requirements have to be met in order to achieve good results from this type of surgery.
1. Your child has to be diagnosed with spastic diplegia.
2. He or she should be between 5 and 10 years old and not have any other chronic conditions.
3. The spasticity should be moderate and it is important to have good strength in the extensor muscles around the hip and knee (the muscles which straighten the hip and knee) so when the spasticity is gone, there is still good support from these muscles.
4. The child has to have very good balance and good lumbar spine control.
5. No severe deformity.
6. The child must be able to voluntarily move specific muscles.
7. The child should have very good cognitive abilities and has to be motivated for a very long postoperative rehabilitation process.
The ideal indication is stiffness around the knee during gait and an overactive spastic rectus femoris muscle (the big muscle at the front of the thigh that straightens the knee).
Your child has to undergo very detailed functional assessment and tests including X-rays of the hips and spine, neuroimaging of the brain and spine, and some form of gait analysis as the affected muscles have to be determined by the child's gait.
Possible side effects
The procedure cannot be reversed. The walking ability and bladder function may deteriorate, and there may be later problems such as spinal deformity. During the procedure, the epidural space is obliterated (a hollow space filled with fluid around the spinal cord) and no epidural anaesthetic will be possible for any further surgery. The biggest problems postoperatively are muscle weakness and weight gain. Reduction of spasticity also means reduction of muscle power and therefore weakness. So it is very important to start off with good muscle power preoperatively in order to maintain the ability to walk again after the procedure. An increase in weight probably happens because the spastic muscles burn more calories than normal muscles and when the spasticity is reduced, less calories are burnt. Therefore, it is necessary to pay attention to a healthy and balanced diet postoperatively.
Benefits
The procedure results in better walking ability if the right patient is chosen. It reduces the need for other surgical procedures like soft tissue surgery in the future and has slightly better outcome than multilevel gait improvement surgery in certain children in the long-term. A derotation osteotomy (bony surgery to change the rotation of the legs) might still be needed. Postoperatively, the therapy will be easier but the child will have to continue with stretching exercises and orthoses.
Postoperative treatment
The children and parents must be very motivated for an intensive postoperative rehabilitation programme. You should understand that prolonged physiotherapy and aftercare will be needed and that additional surgery may be necessary. Children that were previously able to walk might have to learn to walk again and to learn different walking skills. In Oswestry, the children spend six weeks in hospital in order to receive this intensive physiotherapy input which might not be possible locally.
Summary
The evidence shows that the procedure SDR is effective but that complications can be serious. SDR is a treatment option for children with spastic diplegia and a specific gait pattern (see indications). The procedure cannot be reversed, reducing the spasticity in certain muscle groups and can improve the walking ability but there are serious risks that can be reduced by a specific selection process to find the “right “patient for this procedure.
Additional information can be obtained here:
National Institute for Health and Care Excellence
www.henryfordtrust.co.uk/SDR%20-%20FAQs.htm
www.stlouischildrens.org/tabid/89/itemid/1539/Cerebral-Palsy-Spasticity--Selective-Dorsal-Rhiz.aspx
Claudia Maizen, Consultant Paediatric Orthopaedic Surgeon
A lot of attention has been drawn to the procedure SDR by the press and many parents ask us whether their children would be suitable for SDR. Some parents raise a lot of money privately or via charities to go to the United States (St Louis, Missouri) for this treatment, but there are also centres in the UK who offer this procedure in the NHS (e.g. Oswestry). It is very important to select the “right patient” for this procedure to achieve good results, and although UK Centres are very specific with their patient selection criteria, other centres, such as in the United States, are less specific in their selection process.
What is SDR?
Introduction
Cerebral palsy is a brain condition that affects movement, posture and coordination. It may be seen at around the time of birth or may not become obvious until early childhood. Some children will have lower limb spasticity, which can cause problems with walking and sitting, as well as discomfort, cramps and spasms.
Selective dorsal rhizotomy is a major surgical procedure that aims to reduce the amount of information carried by the sensory nerves. With the patient under general anaesthetic, a cut is made in the lower back and into the spinal canal to expose the spinal cord and lower nerves. Some of the sensory nerves that carry information from the muscles into the legs are cut. The nerves that make the muscles contract are not cut. After the procedure, the patients will need long-term physiotherapy and may have to learn to walk again and learn different walking skills.
Are there other options?
Other surgical procedures for spasticity include tenotomy (cutting of tendons), neurotomy (cutting of nerves), osteotomy (cutting of bones) and tendon lengthening. Other treatment options include drugs (Baclofen, Botulinum toxin), use of corrective braces, physiotherapy, and electrical stimulation of the muscles or lower spinal cord.
Indications
It is important to understand that SDR does not heal spasticity. It only reduces the spasticity and muscle tone in selected muscle groups of the lower limbs. Certain requirements have to be met in order to achieve good results from this type of surgery.
1. Your child has to be diagnosed with spastic diplegia.
2. He or she should be between 5 and 10 years old and not have any other chronic conditions.
3. The spasticity should be moderate and it is important to have good strength in the extensor muscles around the hip and knee (the muscles which straighten the hip and knee) so when the spasticity is gone, there is still good support from these muscles.
4. The child has to have very good balance and good lumbar spine control.
5. No severe deformity.
6. The child must be able to voluntarily move specific muscles.
7. The child should have very good cognitive abilities and has to be motivated for a very long postoperative rehabilitation process.
The ideal indication is stiffness around the knee during gait and an overactive spastic rectus femoris muscle (the big muscle at the front of the thigh that straightens the knee).
Your child has to undergo very detailed functional assessment and tests including X-rays of the hips and spine, neuroimaging of the brain and spine, and some form of gait analysis as the affected muscles have to be determined by the child's gait.
Possible side effects
The procedure cannot be reversed. The walking ability and bladder function may deteriorate, and there may be later problems such as spinal deformity. During the procedure, the epidural space is obliterated (a hollow space filled with fluid around the spinal cord) and no epidural anaesthetic will be possible for any further surgery. The biggest problems postoperatively are muscle weakness and weight gain. Reduction of spasticity also means reduction of muscle power and therefore weakness. So it is very important to start off with good muscle power preoperatively in order to maintain the ability to walk again after the procedure. An increase in weight probably happens because the spastic muscles burn more calories than normal muscles and when the spasticity is reduced, less calories are burnt. Therefore, it is necessary to pay attention to a healthy and balanced diet postoperatively.
Benefits
The procedure results in better walking ability if the right patient is chosen. It reduces the need for other surgical procedures like soft tissue surgery in the future and has slightly better outcome than multilevel gait improvement surgery in certain children in the long-term. A derotation osteotomy (bony surgery to change the rotation of the legs) might still be needed. Postoperatively, the therapy will be easier but the child will have to continue with stretching exercises and orthoses.
Postoperative treatment
The children and parents must be very motivated for an intensive postoperative rehabilitation programme. You should understand that prolonged physiotherapy and aftercare will be needed and that additional surgery may be necessary. Children that were previously able to walk might have to learn to walk again and to learn different walking skills. In Oswestry, the children spend six weeks in hospital in order to receive this intensive physiotherapy input which might not be possible locally.
Summary
The evidence shows that the procedure SDR is effective but that complications can be serious. SDR is a treatment option for children with spastic diplegia and a specific gait pattern (see indications). The procedure cannot be reversed, reducing the spasticity in certain muscle groups and can improve the walking ability but there are serious risks that can be reduced by a specific selection process to find the “right “patient for this procedure.
Additional information can be obtained here:
National Institute for Health and Care Excellence
www.henryfordtrust.co.uk/SDR%20-%20FAQs.htm
www.stlouischildrens.org/tabid/89/itemid/1539/Cerebral-Palsy-Spasticity--Selective-Dorsal-Rhiz.aspx
