A long-term follow-up study of spinal abnormalities and pain in adults with cerebral palsy and spastic diplegia more than 25 years after selective dorsal rhizotomy

Abstract

OBJECTIVEThe main purpose of selective dorsal rhizotomy (SDR) is to reduce spasticity in the lower extremities of children diagnosed with cerebral palsy (CP) and spastic diplegia. The potential for developing spinal abnormalities and pain is a concern, especially in the aging CP population. Therefore, the aim of this study was to evaluate spinal abnormalities, level of pain, and disability (due to back or leg pain) in adults with CP, and associations with participant characteristics, more than 25 years after SDR.METHODSThis is a 9-year follow-up study with data collection conducted in 2008 and 2017. Radiographs were assessed for the degree of scoliosis, thoracic kyphosis and lumbar lordosis curvatures, and prevalence of spondylolysis and spondylolisthesis, while level of pain and disability was determined with a self-developed questionnaire and the Oswestry Disability Index (ODI) questionnaire, respectively.RESULTSTwenty-five participants were included (15 males; median age 35.9 years, IQR 34.3–41.5 years), with a follow-up time after SDR ranging from 25 to 35 years. No clinically relevant changes were found for spinal curvatures, spondylolysis and spondylolisthesis, perceived pain frequency, and ODI scores between 2008 and 2017. While the prevalence of spondylolysis was 44%, spondylolisthesis was found in 20% (of whom 15% were grade I and 5% grade II), lumbar hyperlordosis was found in 32%, thoracic hyperkyphosis in 4%, and scoliosis in 20%. The Cobb angle was < 25°, and no patient required surgery for scoliosis. In addition, the low back was reported as the most common site of pain, with 28% of the adults with CP having daily pain. This resulted in 80% of the cohort indicating none or minimal disability due to pain based on the ODI. The only correlation found was between hyperkyphosis and female gender.CONCLUSIONSAt follow-up more than 25 years after SDR, no progression in spinal abnormalities, level of pain, and disability was found when compared with findings 15 years after SDR. The prevalence of scoliosis, thoracic hyperkyphosis, and lumbar hyperlordosis was within the range reported for adults with CP, while spondylolysis and spondylolisthesis occurred more often than would be expected. It is difficult, however, to establish the role of SDR in this finding, given the limited data on the natural history of CP. Despite the encouraging outcome of this long-term follow-up study after SDR, it is important to continue monitoring adults with CP during the aging process.

Palliative single-level selective dorsal rhizotomy for children with spastic cerebral palsy Gross Motor Function Classification System level IV and V: a case series and systematic review of the literature

“…Nonetheless, the MAS score was available for all studies and showed SDR to be a good and valid option for nonambulatory patients. 24,26,31,32 This finding is consistent with previous reports focusing on ambulatory patients (GMFCS levels I-III) undergoing SDR and underlines its effectiveness even in high-level patients. 2,12,24,28,[33][34][35] Another important and evolving tool for the outcome of a treatment is the implementation of PROMs and scores addressing the quality of life not only of the patients, but also of the caregivers.…”

“…13,21,25 When SDR was first developed and applied in 1987 by Peacock, it gained much popularity for spasticity treatment and remained the standard surgical technique for more than 30 years, exposing spinal roots via multilevel access from the conus medullaris down to S2, with slight modifications over time. 8,26,27 Considering the higher periand postoperative risks of multilevel SDR such as spinal deformity, CSF leaks, and severe infections, this procedure was initially reserved for GMFCS level I-III patients with the aim of maintaining or improving ambulation. 27 The single-level interlaminar approach or single-level laminotomy/laminoplasty approaches are less invasive and used more frequently nowadays, causing fewer postoperative spinal deformities or instabilities and fewer CSF fistulas.…”

Modified Selective Dorsal Rhizotomy Exposure Method for Adults With Spastic Paralysis of the Lower Limbs

“…In addition, 28% of adults with CP experience pain daily. 10 Park et al reported a single laminectomy at the conus level. 3 This technical improvement significantly reduced the incidence of spinal deformities.…”