Selective Dorsal Rhizotomy

Selective dorsal rhizotomy is a neurosurgical procedure which can permanently reduce spasticity and improve motor functions in children with cerebral palsy. If preformed at an early age it can reduce the number of orthopedic surgeries a child might need in the future.

What is Muscle Stiffness /Spasticity in Children with CP?

In a child with cerebral palsy, damage to the brain has occurred. In newborns with CP the brain damage that occurred is usually in the area that controls the movement of the arms and legs. The stiffness a muscle has is referred to as muscle tone. Normal muscles have enough tone to maintain posture or movement against gravity, while also providing flexibility and speed of movement. The command to increase muscle tone (become stiff) goes to the spinal cord via nerves from the muscle itself. The command to reduce muscle tone (become flexible) comes to the spinal cord from the brain. These two commands must work well together in the spinal cord for the muscles to be able to function smoothly and easily and to maintain strength. The brain of a child with CP is unable to influence the amount of flexibility a muscle should have and as a result the muscles are too stiff (spastic).

What is a Selective Dorsal Rhizotomy?

Since it is not yet possible to operate on the nerves in the brain to correct brain damage in children with CP, doctors are able to operate on the sensory nerve fibers that come from the muscles. During a rhizotomy each nerve root is divided into 3 to 5 nerve rootlets. By cutting some, but not all of these rootlets, it is then possible to reduce the message from the muscle to better balance the messages of flexibility and stiffness. After surgery when the muscle tone becomes more normalized, the child can move more freely and easily and better attain such skills as sitting, crawling and walking.

Who is a Candidate for Selective Dorsal Rhizotomy?

Not all children are good candidates for this surgical procedure and this should be discussed with your child's physician and therapy team. For example, children with hydrocephalus, scoliosis, those who have had meningitis or who are deemed to not make functional gains after surgery would not benefit. For children to be considered for this procedure they must have the following criteria:

• Diagnosis of spastic diplegia, spastic quadriplegia or spastic triplegia
• Be two years of age or older (surgery is recommended between ages 2-5 before major leg deformities have developed)
• No significant damage to the area of brain involved in posture and coordination as shown by MRI
• 3 months since the last Botox injection
• Adequate strength in trunk and legs
• History of delayed motor development
• Commitment to therapy post surgery

Benefits of Selective Dorsal Rhizotomy

• Reduces spasticity
• Movement will be easier after surgery
• Children who were walking with a walker or crutches before surgery will regain these functions after surgery and some will progress to independent walking
• If a child was sitting and also pulling to stand before surgery, but not walking, they will probably be able to walk with a walker within 3 months of surgery
• A child's own cooperation and motivation and intelligence play a key role in how much progress they will make after surgery. There must be a commitment to therapy by the family and a child should reach their full potential after surgery provided they receive physical therapy 4-5 times per week for the first 6 months post-surgery and then 2-4 times per week in the following year or longer.

Definitions:

Contracture: The shortening of a muscle, tendon so that the joint cannot be readily flexed or straightened

Diplegia: Involvement of the hips and legs, trunk and arms to a lesser degree

Quadriplegia: Involvement of all four limbs equally

Spasticity: Stiffness in the arms and leg and trunk muscles

Source: St. Louis Children's Hospital Department of Neurosurgery

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