Selective Dorsal Rhizotomy and Postoperative Pain Management

Abstract

Background: Selective dorsal rhizotomy (SDR) is an operation method that decreases the degree of spasticity with long-lasting beneficial effects for children with spastic diplegia. Children undergoing SDR are postoperatively in severe pain, a pain related to both the extensive surgical exposure with multilevel laminectomy and the nerve root manipulation. Various pain management strategies for children undergoing SDR have been published. The postoperative pain treatment is a vital part of the management. The aim of this study was to estimate the number of centers performing SDR, the frequency of SDR surgery and to investigate pain management of the different centers. Methods: A questionnaire comprising 7 questions was sent by mail and/or e-mail to a total of 59 potential centers performing SDR, centers that have published material concerning SDR or centers that have been recommended. Forty-seven (80%) centers responded to the questionnaire; 11 of them do not presently perform SDR surgery, and the remaining 36 centers constitute the material of the present study. Results: 23 of the 36 centers use Peacock’s operation technique and 8 centers use Park’s technique. Continuous intravenous infusion of opioids for postoperative pain treatment is used by 17 (47%) of the centers. Seven (19%) centers use the epidural (ED) approach for treating postoperative pain and 6 (17%) centers use intrathecal (IT) pain treatment. The duration of intravenous ED or IT pain relief ranged from 24 h up to 7 days. To evaluate pain relief, 25 (70%) centers used some form of pain scale. Conclusion: The most common operation techniques in use today are described by Peacock or by Park, with an estimated number of procedures of more than 487/year in 36 centers. The majority of the centers seem to have a satisfactory pain management strategy. These centers administer continuous infusions of opioids, with an intravenous, ED or IT approach, and incorporate the use of a pain assessment tool to evaluate pain relief.

Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature

“…SDR has been performed in children with spastic CP at centres in Africa, North and South America, Asia, Europe, and Australia for more than three decades . Many of these centres have reported both short‐term and long‐term studies, with the focus on SDR outcomes, resulting in 326 publications.…”

“…Peacock and Arens further refined SDR in the 1980s, shifting the site of surgery from the conus medullaris to the cauda equina to facilitate the identification of the dorsal rootlets at their exit foramina. Peacock's technique has been in use for over three decades and is still the most commonly used SDR technique worldwide . However, some authors have questioned the usefulness of the electrophysiological methods used for the specific selection of nerve rootlets to be cut .…”

Gait status 17–26 years after selective dorsal rhizotomy

“…Peacock reintroduced this procedure in Cape Town, South Africa, in the early 1980s [1,2], and after his relocation to Los Angeles, USA, there was rapid worldwide growth in the use of this approach to spasticity management [3]. Despite the broad acceptance of SDR, it has also been considered a controversial procedure, and concerns have been raised about peri-and post-operative complications, muscle weakness, functional deterioration, ongoing need for additional orthopaedic surgeries, and spinal deformities in the long-term [4][5][6][7][8].…”

Nursing Care of the Pediatric Neurosurgery Patient

“…Aside from the incisional pain and soft tissue pain from the laminectomy, there may be dysesthesia of the lower extremities resulting from manipulation of the nerve rootlets (Hesselgard et al 2005 ) . Aside from the incisional pain and soft tissue pain from the laminectomy, there may be dysesthesia of the lower extremities resulting from manipulation of the nerve rootlets (Hesselgard et al 2005 ) .…”