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Selective dorsal rhizotomy as an alternative to intrathecal baclofen pump replacement in GMFCS grades 4 and 5
Harshal Ingale1,2, Ismail Ughratdar3,4, Samiul Muquit3
1Department of Neurosurgery, Queens Medical Centre, Nottingham, UK. drharshalingale@yahoo.com.
Insights
Selective Dorsal Rhizotomy (SDR) offers a cost-effective and less invasive alternative to intrathecal baclofen (ITB) pumps for severe spasticity in children. This procedure demonstrated significant spasticity reduction and improved functional outcomes, suggesting its consideration for ITB-treated patients.
Area of Science:
- Neurology
- Pediatric Surgery
- Rehabilitation Medicine
Background:
- Conventional treatment for cerebral palsy spasticity involves intrathecal baclofen (ITB) pumps for non-ambulant children and selective dorsal rhizotomy (SDR) for ambulant children.
- This study explores SDR as an alternative to ITB pump replacement in children with severe spasticity (GMFCS grades 4-5).
Purpose of the Study:
- To evaluate the efficacy of SDR as a substitute for ITB pump replacement in children with severe spasticity.
- To assess functional outcomes, spasticity reduction, and patient/carer satisfaction following SDR in this specific population.
Main Methods:
- A prospective review of ten pediatric patients with severe spasticity previously treated with ITB pumps.
- Data collection included pre- and post-SDR modified Ashworth scores, urological function assessment, and parent/carer satisfaction surveys.
- Indications for ITB pump replacement included infection or nearing drug depletion.
Main Results:
- Significant reductions in spasticity were observed: mean modified Ashworth scores decreased by 2.4 in lower limbs and 1.70 in upper limbs post-SDR.
- Twenty-seven percent of patients showed improvement in urological function.
- Ninety percent of parents/carers reported improved functional outcomes with SDR compared to ITB.
Conclusions:
- SDR presents a more cost-effective and less intrusive option than ITB pump replacement for selected pediatric patients with severe spasticity.
- SDR demonstrated superior effectiveness in spasticity reduction and eased nursing care compared to ITB.
- Consideration of SDR as an alternative to ITB pump replacement is recommended for patients with complications like infection or end-of-life device concerns.
Background:
Conventionally, selective dorsal rhizotomy (SDR) has been reserved for ambulant children and implantation of intrathecal baclofen (ITB) pump for non-ambulant children with cerebral palsy. Rather than replacing the ITB pump in selected Gross Motor Function Classification System (GMFCS) grades 4 and 5 children, we elected to undertake SDR instead. We discuss the rationale and outcomes.
Objectives:
To assess if children with severe spasticity treated with long-term ITB pump would benefit from SDR as alternative procedure to replacement of ITB pump.
Method:
This study is a prospective review of ten children with severe spasticity. Indications for ITB pump replacement in 3/10 children were previous ITB pump infection and the remaining seven were nearing depletion of drug delivery system. Pre- and post-SDR mean modified Ashworth scores, assessment of urological function and survey of parent/carer satisfaction were undertaken.
Result:
Mean Ashworth score reductions post-SDR in the lower limbs and upper limbs were 2.4 and 1.70, respectively. An improvement in urological function was also noticed in 27% of patients. Overall, 90% of parents/carers felt that functional outcome with SDR was improved compared with that of ITB.
Conclusion:
SDR in comparison to ITB in this subgroup is cheaper, less intrusive by avoiding refills/replacement and found to be more effective than ITB in reducing spasticity and providing ease for nursing care. We therefore suggest that consideration should be given to SDR as an alternative in patients previously implanted with ITB systems complicated by infection or nearing end of battery life.
