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Published on: February 2, 2024
Predictors for the benefit of selective dorsal rhizotomy
Julia F Funk1, Amelie Panthen2, M Sinan Bakir1
1Department of Pediatric Orthopedic Surgery and Neuroorthopedics, Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Germany.
Insights
Selective dorsal rhizotomy (SDR) effectively reduces spasticity and improves gross motor function in children with cerebral palsy. Optimal candidates are typically 4-7 years old with specific GMFM scores, showing sustained benefits without compromising muscle strength.
Area of Science:
- Pediatric Orthopedics
- Neuroscience
- Rehabilitation Medicine
Background:
- Selective dorsal rhizotomy (SDR) is a surgical option for managing spasticity in children with cerebral palsy.
- Patient selection criteria and the long-term functional impact of SDR remain subjects of ongoing research and debate.
- Potential side effects, such as decreased muscle strength, are a consideration in the SDR procedure.
Purpose of the Study:
- To prospectively evaluate the one and two-year outcomes of SDR in children with spastic cerebral palsy.
- To analyze the impact of SDR on gross motor function, spasticity, and muscle strength.
- To identify factors influencing functional benefits and optimal patient selection for SDR.
Main Methods:
- A prospective cohort study involving 54 ambulatory children with cerebral palsy undergoing SDR.
- Assessment of gross motor function using the Gross Motor Function Measure (GMFM-88).
- Evaluation of spasticity with the Modified Ashworth Scale (MAS) and muscle strength with Manual Muscle Testing (MFT).
Main Results:
- Significant reductions in hip adductor and hamstring spasticity were observed and sustained for two years post-SDR.
- Gross Motor Function Measure (GMFM) scores improved significantly at 12 and 24 months after SDR.
- Improvements in muscle strength were noted in knee extension and ankle dorsiflexion, with no compromise in overall muscular strength.
Conclusions:
- SDR is a sustainable treatment for reducing spasticity and enhancing motor skills in children with spastic cerebral palsy.
- Functional improvements correlate with age at surgery and preoperative GMFM scores, suggesting optimal candidates are between 4-7 years old with GMFM scores of 65-85%.
- SDR can lead to clinically relevant functional gains without negatively impacting muscular strength when appropriately indicated.
Abstract:
Selective dorsal rhizotomy (SDR) is a spasticity reducing treatment option for children with spastic cerebral palsy. Selection criteria for this procedure are inconclusive to date. Clinical relevance of the achieved functional improvements and side effects like the negative impact on muscle strength are discussed controversially. In this prospective cohort study one and two year results of 54 children with a mean age of 6.9 (±2.9) years at the time of SDR are analyzed with regard to gross motor function and factors affecting the functional benefit. Only ambulatory children who were able to perform a gross motor function measure test (GMFM-88) were included in this study. Additionally, the modified Ashworth scale (MAS), a manual muscle strength test (MFT), and the body mass index (BMI) were evaluated as possible outcome predictors. MAS of hip adductors and hamstrings decreased significantly (p<0.001) and stayed reduced after two years, while GMFM improved significantly from 79% to 84% 12 months after SDR (p<0.001) and another 2% between 12 and 24 months (p=0.002). Muscle strength did improve significantly concerning knee extension (p=0.008) and ankle dorsiflexion (p=0.006). The improvement of function correlated moderately with age at surgery and preoperative GMFM and weakly with the standard deviation score of the BMI, the dorsiflexor and plantarflexor strength preoperatively as well as with the reduction of spasticity of the hamstrings and the preoperative spasticity of the adductors and hamstrings. Correctly indicated SDR reduces spasticity and increases motor skills sustainably in children with spastic cerebral palsy corresponding to clinically relevant changes of GMFM without compromising muscular strength. Outcome correlates to GMFM and age rather than to MAS and maximal strength testing. The data of this evaluation suggest that children who benefit the most from SDR are between 4 and 7 years old and have a preoperative GMFM between 65% and 85%.
