Selective Dorsal Rhizotomy (SDR)

At present, SDR is the only surgical procedure that can provide permanent reduction of spasticity in CP. In patients with spastic diplegia SDR always reduced spasticity, and recurrences have been rare. Return of spasticity in later years is highly unlikely after its reduction over many years.
In patients with spastic quadriplegia, however, SDR can fail to reduce spasticity. Recurrence of spasticity is relatively common in severely involved nonambulatory patients with spastic quadriplegia. In patients who can walk with an assistive device, the risk for recurrent spasticity is less than in nonambulatory patients, and even if it does recur, it is less severe than before the operation.

Of all the surgical procedures currently performed on patients with cerebral palsy, selective dorsal rhizotomy (SDR) has undergone more thorough scientific scrutiny than any other (including orthopaedic). Accumulated evidence indicates that SDR is an excellent option for selected patients with spastic CP.

Strength: SDR does not cause permanent weakness, however patients will experience transient motor weakness that may last a few weeks to months and it should be remembered that a varying degree of motor weakness is always present in CP. Patients who use a walker and assistance require much longer to resume the level of walking they were capable of before SDR, although after spasticity is reduced it becomes easier for patients to increase strength with therapy and exercise. Adolescents and adults can start treadmill and other types of exercise that were impossible before SDR.

Motor Function: SDR results in improvements in sitting, standing, walking, and balance control in walking. In three randomized studies of changes in gross motor functions after SDR, two of the studies showed improvements and one did not find significant benefits. Typically, improvements in motor function are most noticeable during the first 6 months: after that, improvements are slow but steady. In children, these improvements can continue up to 10 years of age. In adults and adolescents, improvements continue for approximately 2 years after SDR.

Deformities: Patients with CP almost invariably have some deformities in the lower extremities. Common deformities are hip subluxation, hamstring and heel cord contractures, foot deformities, and in-toeing. These deformities can be improved by SDR. Hip subluxation can progress if left untreated. However, some children under 5 years of age who have poorly developed hip joints do show progression of hip subluxation regardless of treatment. SDR reduces the severity of hamstring and heel cord contractures. It is common to see improvements in in-toeing gait and in other abnormal gait patterns after SDR. Also, the lack of spasticity makes it easy to stretch the tight muscles. Early SDR, at 2-4 years of age, can prevent the development of deformities.

Orthopaedic Surgery: Early SDR may reduce the rate of subsequent orthopaedic procedures. It is important to remember that deformities are due not only to spasticity but also to motor impairment and consequent limited muscle stretching in daily activities. Therefore, many patients will still require follow-up with orthopaedic surgeons after SDR.

Upper Extremity Functions: SDR is performed to improve the lower extremity functions, but it can also improve the gross range of motion of the upper extremities. It does not improve fine motor skills. The upper extremity improvements are seen in children with relatively severe quadriplegic CP. If the upper extremity involvement is mild, SDR will not result in noticeable improvements.

Potty Training: Spastic CP can be associated with small bladder capacity and also with difficulties in sitting, which can delay potty training in young children. Children may complete potty training soon after SDR.

Cognitive Improvements: Some children have shown marked changes in cognitive functions after SDR, and studies have found significant increase in the speed of visual recognition.

Speech Improvement: SDR can be followed by significant improvements of speech. This may be attributed to improved sitting posture, reduced distraction by spasticity, and improved cognitive functions. However, it is difficult to predict which patients will show speech improvements.

Source: Children's Hospital, St. Louis Center for Cerebral Palsy Spasticity

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