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Focal selective dorsal rhizotomy and concurrent deformity correction: a combined approach
Nisha Gadgil1, Aloysia L Schwabe2, Edward Wright2
11Department of Surgery, Division of Neurosurgery, Texas Children's Hospital/Baylor College of Medicine, Houston.
Insights
Selective dorsal rhizotomy (SDR) effectively reduces spasticity in children with cerebral palsy. This focal SDR technique, combined with orthopedic surgery, improves spasticity and gait mechanics.
Area of Science:
- Neurosurgery
- Pediatric Orthopedics
- Rehabilitation Medicine
Background:
- Cerebral palsy (CP) frequently causes spastic diplegia, impacting motor function.
- Selective Dorsal Rhizotomy (SDR) is a recognized treatment for reducing spasticity in CP.
- Targeting specific motor distributions with focal SDR offers a refined approach.
Purpose of the Study:
- To describe the technique of minimally invasive focal SDR.
- To propose selection criteria for focal SDR.
- To evaluate the efficacy of focal SDR in improving spasticity and gait in children with CP.
Main Methods:
- Retrospective study of 10 pediatric patients with cerebral palsy undergoing focal SDR.
- 3D gait analysis (baseline and 1-year postoperative).
- Modified Ashworth Scale (MAS) and Gait Deviation Index (GDI) as primary outcome measures.
Main Results:
- Focal SDR significantly reduced plantar flexor spasticity (MAS: -2.2, p < 0.001).
- L5 focal SDR improved hamstring spasticity (MAS: -1.4, p = 0.004).
- Mean improvement in Gait Deviation Index (GDI) was 11 points (p < 0.001).
Conclusions:
- Minimally invasive focal SDR, especially when combined with orthopedic interventions, effectively improves spasticity and gait mechanics in select pediatric CP patients.
- The technique shows promise for targeted spasticity management.
- Further research is needed to optimize patient selection and long-term outcomes.
Objective:
Selective dorsal rhizotomy (SDR) is a neurosurgical procedure to reduce spasticity in children with cerebral palsy and spastic diplegia. The authors developed a procedure called focal SDR for children with spasticity predominantly in the L5 or S1 motor distribution, which can be combined with orthopedic correction of fixed soft-tissue or bony deformity. The authors describe in detail the technique of minimally invasive focal SDR and propose selection criteria.
Methods:
The authors conducted a retrospective study of patients who underwent focal SDR at their institution and underwent baseline and 1-year postoperative 3D gait analysis. Modified Ashworth scale (MAS) and Gait Deviation Index (GDI) scores were the primary outcome measures.
Results:
Ten patients met the study criteria, all with an underlying diagnosis of cerebral palsy. All underwent focal SDR at the unilateral or bilateral S1 level, and 4 additionally underwent focal SDR at the L5 level unilaterally or bilaterally. All but 1 patient underwent concurrent orthopedic surgery. The improvement in spasticity of the plantar flexors, as measured by the MAS score, was 2.2 (p < 0.001). In the patients who underwent L5 focal SDR, there was an improvement in the hamstring MAS score of 1.4 (p = 0.004). The mean improvement in the GDI score following focal SDR was 11 (range -6 to 29, p < 0.001).
Conclusions:
Focally impairing spasticity in the gastrocsoleus complex and/or hamstrings muscle group in the setting of less functionally impactful proximal tone is extremely common in cerebral palsy. The novel technique of focal SDR, combined with orthopedic intervention, improves spasticity scores and overall gait mechanics. Further investigation is warranted to define the ideal candidacy and outcomes.
