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[Rhizotomy for children with severe spastic cerebral palsy]
Niels Ove Illum1, Lisbeth Torp-Pedersen, Steen Midholm
1Odense Universitetshospital, Børneafdeling H, Børneneurologisk Afsnit, Fysioterapiafdelingen, Odense. niels.illum@ouh.fyns-amt.dk
Insights
Selective dorsal rhizotomy (SDR) significantly reduced spasticity in children with cerebral palsy, with lasting effects observed up to 60 months post-surgery. Functional improvements required dedicated training and time, becoming significant after five years.
Area of Science:
- Neurosurgery
- Pediatric Neurology
- Rehabilitation Medicine
Context:
- Severe spasticity in children with cerebral palsy significantly hinders motor development.
- Established treatments like botulinum toxin and baclofen may limit long-term functional gains.
- Selective dorsal rhizotomy (SDR) preserves motor fibers while cutting sensory afferents to reduce spasticity.
Purpose:
- To evaluate the efficacy and long-term outcomes of selective dorsal rhizotomy (SDR) in reducing spasticity and improving motor function in children with severe spastic cerebral palsy.
- To report the first Danish study on SDR for pediatric cerebral palsy.
Summary:
- Twenty children (ages 4-16) with severe spastic cerebral palsy underwent SDR, with 20-40% of dorsal root filaments (LII-SII) cut.
- Spasticity scores significantly improved from baseline (median 3.1) to 18 months (median 1.0) and 60 months (median 1.0) post-operation (p < 0.001).
- While mobility showed initial non-significant improvement at 18 months, it became significant by 60 months (p < 0.05), with younger age correlating with better functional outcomes (r=0.8).
Impact:
- SDR provides early and sustained spasticity reduction in pediatric cerebral palsy.
- Significant functional improvements are achievable but necessitate consistent post-operative training and extended follow-up (up to 60 months).
- This study establishes SDR as a viable, effective treatment option for improving motor function in children with severe spastic cerebral palsy.
Introduction:
Severe spasticity is a limiting factor for motor development in children with spastic cerebral palsy. Botulinum toxin, intrathecal baclofen and peroral baclofen all reduce spasticity but might also limit improvements in functional development over time. In the selective dorsal or posterior rhizotomy (SDR) approach, afferent sensory nerve fibers are cut while efferent motor fibers are preserved. In this way spasticity is reduced and motor functions can improve. SDR is an established treatment method, and the first Danish study is reported.
Material And Methods:
Twenty Danish children with severe spastic cerebral palsy were evaluated, operated on and trained over a 10-year period from 1992 to 2002. Those on whom operation was performed ranged from 4 to 16 years of age (median 8 years), and training and follow-up took place during the ensuing 60 months. At time of operation, 20-40% of 100-120 dorsal root filaments were cut, corresponding to the II-V lumbar and I-II sacral nerve roots.
Results:
Spasticity in the lower extremities measured before SDR showed an average Asworth score of 2.0-4.2 (median 3.1). Eighteen months after SDR, scores were 0.8-1.8 (median 1.0), and at 60 months 0.8-1.8 (median 1.0). Both post-operative values were significant (t-test, p < 0.001). Mobility improved over a longer period of time: the Illinois St. Louis scale values before SDR were 1-9 (median 6), while at 18 months post-operative they were 1-9 (median 5) and at 60 months post-operative 1-9 (median 4). At 18 months, scores were non-significant (t test, p > 0.05), but at 60 months they were significant (t < 0.05). According to the Montgomery scale, 4 children had worse post-operative scores and 12 children had better scores. When comparing age at operation with outcome, we observed a certain degree of concordance between relatively younger age and better post-operative muscular function (Pearson's r = 0.8).
Conclusion:
SDR resulted in early and lasting reduction in spasticity in all 20 children operated upon. Improved muscular function, however, required training and time. Not until 60 months after operation were functional measures significantly better than the preoperative values.
