Motor and functional outcome of selective dorsal rhizotomy in children with spastic diplegia at 12 and 24 months of follow-up

Abstract

Background Selective dorsal rhizotomy (SDR) in ambulatory children affected by cerebral palsy (CP) is a surgical treatment option to lower spasticity and thereby improve gait and ambulation. The aim of the current study is to investigate the outcome of children with respect to spasticity, muscle strength, and overall function after SDR. Methods All children who underwent SDR via a single-level laminotomy in the time period from January 2007 to April 2015 at our center were enrolled in this study. Within a standardized evaluation process, the following was assessed routinely pre-operatively and 12 and 24 months following surgery: extent of spasticity at hip adductors and hamstrings as characterized by the Modified Ashworth Scale (MAS), maximal muscle strength as characterized by the Medical Council Research Scale (MRC), overall function regarding ambulation as characterized by the Gross Motors Function Classification System (GFMCS), and overall function as characterized by the Gross Motor Function Measure (GMFM-88). Results Matching sets of pre- and post-operative assessments of the chosen outcome parameters were available for 109 of the 150 children who underwent SDR within the observation period. After 24 months, the MAS scores of hip adductors (n = 59) improved in 71% and 76% of children on the right and left side, respectively. In 20% and 19%, it remained unchanged and worsened in 9% and 5% of children on the right and left side, respectively (p < 0.00625). For hamstrings, the rates for the right and left sides were 81% and 79% improvement, 16% and 16% unchanged, and 4% and 5% worsened, respectively (p < 0.00625). Muscle strength of ankle dorsiflexion and knee extension significantly improved after 24 months. Overall function assessed by GMFM-88 improved significantly by 4% after 12 months (n = 77) and by 7% after 24 months (n = 56, p < 0.0001). Conclusions The presented data underlines the benefit of SDR in a pediatric patient collective with bilateral spastic CP. The procedure resulted in an effective and permanent reduction of spasticity and improved overall function without causing relevant weakness of the lower extremities.

Using the gross motor function measure evolution ratio to compare different dosage of hyperbaric treatment with conventional therapies in children with cerebral palsy – could it end the controversy?

“…There is no doubt that SDR is very efficient in decreasing spasticity in children with CP ( 64) but the true effects on motor function were also difficult to interpret. The results of the present study confirm that this surgery can produce important gains in gross motor function with a mean GMFMER of 6.5 (31,34,38,(46)(47)(48)(49)(50)(51)(52)(53). In this case the GMFMER value demonstrate a particularly beneficial effect of the treatment, because it applies on a long period, twelve months in most studies (64).…”

Selective dorsal rhizotomy in non-ambulant children with cerebral palsy: a multi-center prospective study

“…A recent study has suggested that the benefits of SDR relating to quality of life, and muscle strength, are maintained after SDR [27]. Another study suggested that the benefit of SDR in GMFCS II and III patients increased between 12 and 24 months, with a greater degree of improvement seen [17,19]. Even if SDR is not successful by measured criteria, the vast majority of patients still report improved functioning, even if this was not quantifiable [28].…”

“…Smaller, single-center studies have suggested that these patients may also benefit from SDR [ 14 , 15 ], although this has yet to be confirmed by larger, prospective studies, and the exact magnitude of the benefit obtained relative to ambulatory patients is also unclear. The effect on quality of life, motor, and spasticity outcomes has been indicated to be favorable [ 16 ], with an increase in gross motor function and spasticity, but there is a need for prospective evidence of this association [ 17 ].…”

Management of Spasticity and Cerebral Palsy Update

“…Another treatment used to alleviate spasticity in children with cerebral palsy is rhizotomy. Studies have shown that performing selective dorsal rhizotomy at a young age can reduce the need for orthopedic surgery [48]. Goals of rhizotomy are decreased tone, increased mobility, and the facilitation of care for the patient; however, the reduction in spasticity cannot be predicted and sometimes results in excessive hypotonia [49].…”