, Volume 16, Issue 1, pp 3–8 | Cite as

The Evolution of Selective Dorsal Rhizotomy for the Management of Spasticity

  • Johannes M. Nicolaas EnslinEmail author
  • Nelleke Gertrude Langerak
  • Anthony Graham Fieggen


Selective dorsal rhizotomy is a key technique in the surgical management of spasticity in patients with cerebral palsy. The technique evolved from the late 1800s when pioneers like Dana and Abbe performed dorsal rhizotomy in their treatment of refractory pain. These surgeons noted a reduction in muscle tone associated with the operation. When Sherrington then published his Nobel prize-winning work on the corticospinal tract and its role in the neuromuscular system in the 1890s, the course was set for modifying spasticity by aiming surgery at the dorsal roots. This procedure underwent multiple modifications through the next century and today it is, arguably, the most commonly performed operation to treat cerebral palsy children with spasticity. Selective dorsal rhizotomy is a technique that still teaches us a great deal about neurophysiology on a daily basis and it is thanks to the pioneers, described in this article, that we have this tool in our armamentarium.


Selective dorsal rhizotomy History Evolution Techniques Spasticity. 

Supplementary material

13311_2018_690_MOESM1_ESM.pdf (2.4 mb)
ESM 1 (PDF 2456 kb)


  1. 1.
    C.S.Sherrington. On reciprocal innervation of antagonistic muscles. Third note, Proceedings of the Royal Society of London, 60 (1897) 414–417.CrossRefGoogle Scholar
  2. 2.
    C.S.Sherrington. On the reciprocal innervation of antagonistic muscles. Fifth note, Proceedings of the Royal Society of London, 64 (1899) 179–181.CrossRefGoogle Scholar
  3. 3.
    C.S.Sherrington. On reciprocal innervation of antagonistic muscles.─ Tenth note. Proc. R. Soc. Lond. B, 79 (1907) 337–349.CrossRefGoogle Scholar
  4. 4.
    C.S.Sherrington. Reciprocal innervation of antagonistic muscles. Thirteenth note.―On the antagonism between reflex inhibition and reflex excitation. Proc. R. Soc. Lond. B, 80 (1908) 565–578.CrossRefGoogle Scholar
  5. 5.
    C.S.Sherrington. Reciprocal innervation of antagonistic muscles. Fourteenth note.-On double reciprocal innervation. Proc. R. Soc. Lond. B, 81 (1909) 249–268.CrossRefGoogle Scholar
  6. 6.
    C.S.Sherrington. Flexion-reflex of the limb, crossed extension-reflex, and reflex stepping and standing. The Journal of physiology, 40 (1910) 28–121.CrossRefGoogle Scholar
  7. 7.
    C.S.Sherrington. Nervous rhythm arising from rivalry of antagonistic reflexes: reflex stepping as outcome of double reciprocal innervation. Proc. R. Soc. Lond. B, 86 (1913) 233–261.CrossRefGoogle Scholar
  8. 8.
    W.J.Peacock, L.A.Staudt. Selective posterior rhizotomy: evolution of theory and practice. Pediatric neurosurgery, 17 (1991) 128–134.CrossRefGoogle Scholar
  9. 9.
    T.S.Park, P.E.Gaffney, B.A.Kaufman, M.C.Molleston. Selective lumbosacral dorsal rhizotomy immediately caudal to the conus medullaris for cerebral palsy spasticity. Neurosurgery, 33 (1993) 929–934.Google Scholar
  10. 10.
    V.A.Fasano, G.Barolat-Romana, S.Zeme, A.Sguazzi. Electrophysiological assessment of spinal circuits in spasticity by direct dorsal root stimulation. Neurosurgery, 4 (1979) 146–151.CrossRefGoogle Scholar
  11. 11.
    C.Gros, G.Ouaknine, B.Vlahovitch, P.Frerebeau. La radicotomie sélective postérieure dans le traitement neuro-chirurgical de lhypertonie pyramidale. Neurochirurgie, 13 (1967) 505−+.Google Scholar
  12. 12.
    R.Abbe. Resection of the posterior roots of spinal nerves to relieve pain, pain reflex, athetosis, and spastic paralysis: Dana's operation. Med Rec, 79 (1911) 377–381.Google Scholar
  13. 13.
    W.H.Bennett. A case in which acute spasmodic pain in the left lower extremity was completely relieved by sub-dural division of the posterior roots of certain spinal nerves, all other treatment having proved useless. Death from sudden collapse and cerebral hæmorrhage on the twelfth day after the operation, at the commencement of apparent convalescence, Medico-chirurgical transactions, 72 (1889) 329.CrossRefGoogle Scholar
  14. 14.
    F.Lorenz. Uber chirurgische Behandlung der angeborenen spastischen Gliedstare, Wien Klin Rdsch, 21 (1887) 25–27.Google Scholar
  15. 15.
    T.Matsuo, S.Tada, T.Hajime. Insufficiency of the hip adductor after anterior obturator neurectomy in 42 children with cerebral palsy. Journal of pediatric orthopedics, 6 (1986) 686–692.CrossRefGoogle Scholar
  16. 16.
    C.Gros. Spasticity—clinical classification and surgical treatment, Advances and technical standards in neurosurgery, Springer1979, pp. 55–97.Google Scholar
  17. 17.
    P. Mertens, M. Sindou. Selective peripheral neurotomies for the treatment of spasticity. Neurosurgery for spasticity, Springer1991, pp. 119–132.Google Scholar
  18. 18.
    M.Sindou, B.Abdennebi, P.Sharkey. Microsurgical selective procedures in peripheral nerves and the posterior root-spinal cord junction for spasticity. Stereotactic and Functional Neurosurgery, 48 (1985) 97–104.CrossRefGoogle Scholar
  19. 19.
    C.Sherrington. Decerebrate rigidity, and reflex coordination of movements. The Journal of physiology, 22 (1898) 319–332.CrossRefGoogle Scholar
  20. 20.
    G.Sheean. The pathophysiology of spasticity. European journal of neurology, 9 (2002) 3–9.CrossRefGoogle Scholar
  21. 21.
    P.Foerster. Resection of the posterior spinal nerve-roots in the treatment of gastric crises and spastic paralysis, SAGE Publications, 1911.Google Scholar
  22. 22.
    J.Privat, J.Benezech, P.Frerebeau, C.Gros. Sectorial posterior rhizotomy, a new technique of surgical treatment for spasticity. Acta neurochirurgica, 35 (1976) 181–195.CrossRefGoogle Scholar
  23. 23.
    O.Foerster. On the indications and results of the excision of posterior spinal nerve roots in men. Surg Gynecol Obstet, 16 (1913) 463–475.Google Scholar
  24. 24.
    M.D.Smyth, W.J.Peacock. The surgical treatment of spasticity, Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine, 23 (2000) 153–163.CrossRefGoogle Scholar
  25. 25.
    M.Sindou. Microsurgical DREZotomy (MDT) for pain, spasticity, and hyperactive bladder: a 20-year experience. Acta neurochirurgica, 137 (1995) 1–5.CrossRefGoogle Scholar
  26. 26.
    M.Sindou, G.Fischer, A.Goutelle, B.Schott, L.Mansuy. La radicellotomie postérieure sélective dans le traitement des spasticités. Rev Neurol, 130 (1974) 201–216.Google Scholar
  27. 27.
    V.Fasano, G.Broggi, G.Barolat-Romana, A.Sguazzi. Surgical treatment of spasticity in cerebral palsy. Pediatric Neurosurgery, 4 (1978) 289–305.CrossRefGoogle Scholar
  28. 28.
    R.Abbott, S.L.Forem, M.Johann. Selective posterior rhizotomy for the treatment of spasticity: a review, Child's Nervous System, 5 (1989) 337–346.CrossRefGoogle Scholar
  29. 29.
    G.Barolat. Dorsal selective rhizotomy through a limited exposure of the cauda equina at L-1. Journal of neurosurgery, 75 (1991) 804–807.CrossRefGoogle Scholar
  30. 30.
    N.G.Langerak, R.P.Lamberts, A.G.Fieggen, J.C.Peter, W.J.Peacock, C.L.Vaughan. Selective dorsal rhizotomy: long-term experience from Cape Town, Child's Nervous System, 23 (2007) 1003–1006.CrossRefGoogle Scholar
  31. 31.
    N.G.Langerak, R.P.Lamberts, A.G.Fieggen, J.C.Peter, W.J.Peacock, C.L.Vaughan. Functional status of patients with cerebral palsy according to the International Classification of Functioning, Disability and Health model: a 20-year follow-up study after selective dorsal rhizotomy, Archives of physical medicine and rehabilitation, 90 (2009) 994–1003.CrossRefGoogle Scholar
  32. 32.
    N.G.Langerak, R.P.Lamberts, A.G.Fieggen, J.C.Peter, L.van derMerwe, W.J.Peacock, C.L.Vaughan. A prospective gait analysis study in patients with diplegic cerebral palsy 20 years after selective dorsal rhizotomy, DOI (2008).Google Scholar
  33. 33.
    N.G.Langerak, N.Tam, C.L.Vaughan, A.G.Fieggen, M.H.Schwartz. Gait status 17–26 years after selective dorsal rhizotomy, Gait & posture, 35 (2012) 244–249.CrossRefGoogle Scholar
  34. 34.
    P.Steinbok, T.Hicdonmez, B.Sawatzky, R.Beauchamp, D.Wickenheiser. Spinal deformities after selective dorsal rhizotomy for spastic cerebral palsy, Journal of Neurosurgery: Pediatrics, 102 (2005) 363–373.Google Scholar
  35. 35.
    J.D.Golan, J.A.Hall, G.O'Gorman, C.Poulin, T.E.Benaroch, M.-A.Cantin, J.-P.Farmer. Spinal deformities following selective dorsal rhizotomy. Journal of Neurosurgery: Pediatrics, 106 (2007) 441–449.Google Scholar
  36. 36.
    M.Turi, V.Kalen. The risk of spinal deformity after selective dorsal rhizotomy. Journal of Pediatric Orthopaedics, 20 (2000) 104.Google Scholar
  37. 37.
    M.B.Johnson, L.Goldstein, S.S.Thomas, J.Piatt, M.Aiona, M.Sussman. Spinal deformity after selective dorsal rhizotomy in ambulatory patients with cerebral palsy. Journal of Pediatric Orthopaedics, 24 (2004) 529–536.CrossRefGoogle Scholar
  38. 38.
    P.Steinbok. Selective dorsal rhizotomy for spastic cerebral palsy: a review, Child's nervous system, 23 (2007) 981–990.CrossRefGoogle Scholar
  39. 39.
    P.E.vanSchie, M.Schothorst, A.J.Dallmeijer, R.J.Vermeulen, W.J.vanOuwerkerk, R.L.Strijers, J.G.Becher. Short-and long-term effects of selective dorsal rhizotomy on gross motor function in ambulatory children with spastic diplegia. Journal of Neurosurgery: Pediatrics, 7 (2011) 557–562.Google Scholar
  40. 40.
    N.G.Langerak, C.L.Vaughan, E.B.Hoffman, A.A.Figaji, A.G.Fieggen, J.C.Peter. Incidence of spinal abnormalities in patients with spastic diplegia 17 to 26 years after selective dorsal rhizotomy, Child's Nervous System, 25 (2009) 1593–1603.CrossRefGoogle Scholar
  41. 41.
    T.S.Park, J.M.Johnston. Surgical techniques of selective dorsal rhizotomy for spastic cerebral palsy, Neurosurgical focus, 21 (2006) 1–6.Google Scholar
  42. 42.
    M.Sindou, G.Georgoulis. Keyhole interlaminar dorsal rhizotomy for spastic diplegia in cerebral palsy. Acta neurochirurgica, 157 (2015) 1187–1196.CrossRefGoogle Scholar
  43. 43.
    J.C.Huang, V.Deletis, D.B.Vodusek, R.Abbott. Preservation of pudendal afferents in sacral rhizotomies. Neurosurgery, 41 (1997) 411–415.CrossRefGoogle Scholar
  44. 44.
    F.F.Lang, V.Deletis, H.W.Cohen, L.Velasquez, R.Abbott. Inclusion of the S2 dorsal rootlets in functional posterior rhizotomy for spasticity in children with cerebral palsy. Neurosurgery, 34 (1994) 847–853.Google Scholar
  45. 45.
    P.Steinbok, J.R.Kestle. Variation between centers in electrophysiologic techniques used in lumbosacral selective dorsal rhizotomy for spastic cerebral palsy. Pediatric neurosurgery, 25 (1996) 233–239.CrossRefGoogle Scholar
  46. 46.
    P.Steinbok, B.Gustavsson, J.R.Kestle, A.Reiner, D.D.Cochrane. Relationship of intraoperative electrophysiological criteria to outcome after selective functional posterior rhizotomy. Journal of neurosurgery, 83 (1995) 18–26.CrossRefGoogle Scholar
  47. 47.
    D.J.Sacco, C.M.Tylkowski, B.C.Warf. Nonselective partial dorsal rhizotomy: a clinical experience with 1-year follow-up. Pediatric neurosurgery, 32 (2000) 114–118.CrossRefGoogle Scholar
  48. 48.
    M.A.Pollack. Limited benefit of electrophysiological studies during dorsal rhizotomy, Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine, 17 (1994) 553–555.CrossRefGoogle Scholar
  49. 49.
    T.Nishida, B.Storrs. Electrophysiological monitoring in selective posterior rhizotomy for spasticity: principles, techniques and interpretation of responses, Neurosurgery for Spasticity, Springer1991, pp. 159–163.Google Scholar
  50. 50.
    P.Steinbok, A.J.Tidemann, S.Miller, P.Mortenson, T.Bowen-Roberts. Electrophysiologically guided versus non-electrophysiologically guided selective dorsal rhizotomy for spastic cerebral palsy: a comparison of outcomes, Child's Nervous System, 25 (2009) 1091–1096.CrossRefGoogle Scholar
  51. 51.
    T.Fukuhara, I.M.Najm, K.H.Levin, M.G.Luciano, C.L.Brant. Nerve rootlets to be sectioned for spasticity resolution in selective dorsal rhizotomy. Surgical neurology, 54 (2000) 126–133.CrossRefGoogle Scholar
  52. 52.
    T.Fukuhara, D.Nakatsu, Y.Namba, I.Yamadori. Histological evidence of intraoperative monitoring efficacy in selective dorsal rhizotomy, Child's Nervous System, 27 (2011) 1453–1458.CrossRefGoogle Scholar
  53. 53.
    E.L.Logigian, S.G.Soriano, D.N.Herrmann, J.R.Madsen. Gentle dorsal root retraction and dissection can cause areflexia: implications for intraoperative monitoring during “selective” partial dorsal rhizotomy, Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine, 24 (2001) 1352–1358.CrossRefGoogle Scholar
  54. 54.
    S.Grunt, A.G.Fieggen, R.J.Vermeulen, J.G.Becher, N.G.Langerak. Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature, Developmental Medicine & Child Neurology, 56 (2014) 302–312.CrossRefGoogle Scholar
  55. 55.
    B.M.Myklebust, G.L.Gottlieb, R.D.Penn, G.C.Agarwal. Reciprocal excitation of antagonistic muscles as a differentiating feature in spasticity, Annals of Neurology: Official Journal of the American Neurological Association and the Child NeurologySociety, 12 (1982) 367–374.Google Scholar
  56. 56.
    D.Burke. Spasticity as an adaptation to pyramidal tract injury. Advances in neurology, 47 (1988) 401–423.Google Scholar
  57. 57.
    G.Georgoulis, A.Brînzeu, M.Sindou. Dorsal rhizotomy for children with spastic diplegia of cerebral palsy origin: usefulness of intraoperative monitoring. Journal of Neurosurgery: Pediatrics, DOI (2018) 1–13.Google Scholar

Copyright information

© The American Society for Experimental NeuroTherapeutics, Inc. 2018

Authors and Affiliations

  1. 1.Division of Neurosurgery, Grootte Schuur Hospital, OMB H53University of Cape TownCape TownSouth Africa
  2. 2.Red Cross War Memorial Children’s HospitalCape TownSouth Africa
  3. 3.Neuroscience InstituteUniversity of Cape TownCape TownSouth Africa

Personalised recommendations