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Published on: February 2, 2024
Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy
Roy W R Dudley1, Michele Parolin, Bruno Gagnon
1Division of Neurosurgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada.
Insights
Selective dorsal rhizotomy (SDR) offers durable improvements in muscle tone, gross motor function, and daily activities for children with spastic cerebral palsy (CP). These benefits extend through adolescence and early adulthood, reducing the need for further interventions.
Area of Science:
- Neurology
- Orthopedics
- Pediatric Rehabilitation
Background:
- Children with spastic cerebral palsy (CP) often experience motor function decline during adolescence.
- Selective dorsal rhizotomy (SDR) is a surgical intervention for spastic CP, but its long-term efficacy remains under investigation.
- Understanding the durability of SDR outcomes is crucial for managing CP progression.
Purpose of the Study:
- To assess the long-term durability of functional outcomes following Selective Dorsal Rhizotomy (SDR) in patients with spastic cerebral palsy (CP).
- To evaluate the sustained effects of SDR on gross motor function, muscle tone, and activities of daily living (ADLs) into early adulthood.
- To identify patient-specific factors influencing heterogeneous responses to SDR.
Main Methods:
- Longitudinal analysis of standardized assessments (Ashworth Scale, GMFM, PEDI) in patients pre- and post-SDR (1-15 years).
- Stratification of patients by Gross Motor Function Classification System (GMFCS) to analyze outcomes based on motor severity.
- Group-based trajectory modeling (GBTM) to identify response patterns and associated pretreatment variables.
- Review of subsequent orthopedic procedures and botulinum toxin (Botox) injections.
Main Results:
- Statistically significant and durable improvements in lower-limb muscle tone, gross motor function (GMFM), and ADLs were observed post-SDR through adolescence and early adulthood.
- Long-lasting benefits were noted across GMFCS Groups I, III, and III.
- GBTM identified four distinct patient response groups, with outcomes associated with spasticity distribution (diplegia favorable) and hip adductor spasticity severity (Ashworth < 3 favorable).
- 59.1% of patients required SDR alone, while 28.4% needed further orthopedic surgery post-SDR.
Conclusions:
- Selective Dorsal Rhizotomy (SDR) provides durable functional benefits for the majority of patients with spastic cerebral palsy (CP) extending into early adulthood.
- Key benefits include sustained improvements in muscle tone, gross motor function, and ADLs, with a reduced need for adjunct interventions.
- Optimal long-term outcomes are associated with GMFCS Groups I-III, spastic diplegia, less severe hip adductor spasticity, and higher preoperative GMFM scores (>60).
Object:
Large-scale natural history studies of gross motor development have shown that children with spastic cerebral palsy (CP) plateau during childhood and actually decline through adolescence. Selective dorsal rhizotomy (SDR) is a well-recognized treatment for spastic CP, but little is known about long-term outcomes of this treatment. The purpose of this study was to assess the durability of functional outcomes in a large number of patients through adolescence and into early adulthood using standardized assessment tools.
Methods:
The authors analyzed long-term follow-up data in children who had been evaluated by a multidisciplinary team preoperatively and at 1, 5, 10, and 15 years after SDR. These evaluations included quantitative, standardized assessments of lower-limb tone (Ashworth Scale), Gross Motor Function Measure (GMFM), and performance of activities of daily living (ADLs) by the Pediatric Evaluation of Disability Inventory in children who had been stratified by motor severity using the Gross Motor Function Classification System (GMFCS). In addition, group-based trajectory modeling (GBTM) was used to identify any heterogeneity of response to SDR among these treated children, and to find which pretreatment variables might be associated with this heterogeneity. Finally, a chart review of adjunct orthopedic procedures required by these children following SDR was performed.
Results:
Of 102 patients who underwent preoperative evaluations, 97, 62, 57, and 14 patients completed postoperative assessments at 1, 5, 10, and 15 years, respectively. After SDR, through adolescence and into early adulthood, statistically significant durable improvements in lower-limb muscle tone, gross motor function, and performance of ADLs were found. When stratified by the GMFCS, long-lasting improvements for GMFCS Groups I, II, and III were found. The GBTM revealed 4 groups of patients who responded differently to SDR. This group assignment was associated with distribution of spasticity (diplegia was associated with better outcomes than triplegia or quadriplegia) and degree of hip adductor spasticity (Ashworth score < 3 was associated with better outcomes than a score of 3), but not with age, sex, degree of ankle plantar flexion spasticity, or degree of hamstring spasticity. In a sample of 88 patients who had complete records of orthopedic procedures and botulinum toxin (Botox) injections, 52 (59.1%) underwent SDR alone, 11 (12.5%) received only Botox injections in addition to SDR, while 25 patients (28.4%) needed further lower-extremity orthopedic surgery after SDR.
Conclusions:
In the majority of patients, the benefits of SDR are durable through adolescence and into early adulthood. These benefits include improved muscle tone, gross motor function, and performance of ADLs, as well as a decreased need for adjunct orthopedic procedures or Botox injections. The children most likely to display these long-term benefits are those in GMFCS Groups I, II, and III, with spastic diplegia, less hip adductor spasticity, and preoperative GMFM scores greater than 60.
