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Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children

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Abstract

Background

Selective dorsal rhizotomy (SDR) has been established as an effective surgical treatment for spastic diplegia. The applicability of SDR to the full spectrum of spastic cerebral palsy and the durability of its therapeutic effects remain under investigation. There are currently limited data in the literature regarding efficacy and outcomes following SDR in Gross Motor Function Classification System (GMFCS) IV and V patients. Intrathecal baclofen has traditionally been the surgical treatment of choice for these patients. When utilised primarily as a treatment for the relief of spasticity, it is proposed that SDR represents a rational and effective treatment option for this patient group. We report our outcomes of SDR performed on children with severe cerebral palsy (GMFCS grade IV and V). The commensurate improvement in upper as well as lower limb spasticity is highlighted. Apparent benefit to urological function following SDR in this patient group is also discussed.

Method

A retrospective review of prospectively collected data for 54 paediatric patients with severe cerebral palsy (GMFCS IV-V) who received SDR plus specialised physiotherapy. Mean age was 10.2 years (range, 3.0–19.5). SDR guided by electrophysiological monitoring was performed by a single experienced neurosurgeon. All subjects received equivalent physiotherapy. The primary outcome measure was change to the degree of spasticity following SDR. Spasticity of upper and lower limb muscle groups were quantified and standardised using the Ashworth score. Measures were collected at baseline and at 2-, 8- and 14-month postoperative intervals. In addition, baseline and 6-month postoperative urological function was also evaluated as a secondary outcome measure.

Results

The mean lower limb Ashworth score at baseline was 3.2 (range, 0–4). Following SDR, significant reduction in lower limb spasticity scores was observed at 2 months and maintained at 8 and 14 months postoperatively (Wilcoxon rank, p < 0.001). The mean reduction at 2, 8 and 14 months was 3.0, 3.2 and 3.2 points respectively (range, 1–4), confirming a sustained improvement of spasticity over a 1-year period of follow-up. Significant reduction in upper limb spasticity scores following SDR was also observed (mean, 2.9; Wilcoxon rank, p < 0.001). Overall, the improvement to upper and lower limb tone following SDR—generally to post-treatment Ashworth scores of 0—was clinically and statistically significant in GMFCS IV and V patients. Urological assessment identified pre-existing bladder dysfunction in 70% and 90% of GMFCS IV and V patients respectively. Following SDR, improvement in urinary continence was observed in 71% of affected GMFCS IV and 42.8% of GMFCS V patients. No serious postoperative complications were identified.

Conclusions

We conclude that SDR is safe and—in combination with physiotherapy—effectively reduces spasticity in GMFCS grade IV and V patients. Our series suggests that spastic quadriplegia is effectively managed with significant improvements in upper limb spasticity that are commensurate with those observed in lower limb muscle groups. These gains are furthermore sustained more than a year postoperatively. In light of these findings, we propose that SDR constitutes an effective treatment option for GMFCS IV and V patients and a rational alternative to intrathecal baclofen.

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Authors and Affiliations

  1. Department of Neurosurgery, Queen’s Medical Centre, Nottingham, NG7 2UH, UK

    Daniel D’Aquino, Ahmad A. Moussa, Amr Ammar, Harshal Ingale & Michael Vloeberghs

  2. Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK

    Ahmad A. Moussa

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  1. Daniel D’Aquino
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  2. Ahmad A. Moussa
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  3. Amr Ammar
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  4. Harshal Ingale
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  5. Michael Vloeberghs
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Correspondence to Daniel D’Aquino.

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Conflict of interest

All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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For this type of study formal consent is not required. Institutional review board approval for notes review was obtained from Nottingham University Hospitals NHS Trust.

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Comments

The authors review their experience of selective dorsal rhizotomy (SDR) in children with severe cerebral palsy (GMFCS IV and V). They demonstrate the effectiveness of the single level procedure, performed at the conus, on reducing lower limb spasticity. They also emphasise improvements in upper limb spasticity and urological function, without any deterioration in limb weakness.

Although follow-up is relatively short, this study underlines the value of SDR in reducing spasticity in these children and suggests that this procedure may be more beneficial while presenting a significantly lower maintenance burden, than intrathecal baclofen.

Kristian Aquilina

London, UK

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D’Aquino, D., Moussa, A.A., Ammar, A. et al. Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children. Acta Neurochir 160, 811–821 (2018). https://doi.org/10.1007/s00701-017-3349-z

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