Selective Dorsal Rhizotomy

What is selective dorsal rhizotomy surgery?

Selective dorsal rhizotomy (SDR) is a surgical procedure to permanently reduce spasticity (muscle tightness) in children with cerebral palsy.

It involves cutting certain sensory nerve fibers in your child’s lower spinal cord that are causing muscle tightness in their legs. The surgery doesn’t intentionally cause paralysis or affect leg movement itself.

The procedure requires intensive follow-up rehabilitative and physical therapy for the best possible results. Not every child with spastic cerebral palsy is a candidate for SDR.

What does selective dorsal rhizotomy treat?

Healthcare providers sometimes use selective dorsal rhizotomy to treat spasticity in children with cerebral palsy.

Cerebral palsy (CP) is a condition that affects a child's ability to control their skeletal muscles. Damage to or abnormalities in the parts of your brain that manage movement and coordination cause cerebral palsy.

Many people with CP have spasticity, a phenomenon that causes certain muscles to contract all at once when you try to move or even when you’re at rest. This can affect your mobility, cause pain and interfere with daily activities.

Selective dorsal rhizotomy is mainly for children who have spastic diplegic cerebral palsy (meaning it mostly affects their legs) or severe spastic quadriplegic cerebral palsy (meaning it affects all four extremities).

How does selective dorsal rhizotomy work?

A reflex of nerves located in your spinal cord controls your muscle tone (the natural tension in a relaxed muscle). This reflex involves a sensory nerve bringing information from a muscle back to your spinal cord, and a motor nerve going back to the muscle and actually causing it to contract.

Normally, messages from your brain reduce this reflex and control the way that muscles contract. In other words, you have voluntary control over these muscles. But cerebral palsy results in a reduction in control over these spinal nerves. This causes a state of continuous contraction in some muscles.

Selective dorsal rhizotomy can often release some of this muscle tightness (spasticity). Cutting only the sensory nerve rootlets causing spasticity decreases muscle stiffness without affecting other functions. By testing all the dozens of sensory nerve rootlets, the neurosurgeon knows which ones are causing the issue and which ones are working as they should.

With spasticity relieved, underlying muscle groups can start working more normally so your child’s mobility and function improve. This helps prevent extreme muscle scarring, known as contractures. In addition, it can prevent joint and bone deformities that children with cerebral palsy can develop if spasticity continues over a long period of time.

How common is selective dorsal rhizotomy?

Selective dorsal rhizotomy isn’t a common surgery for spasticity and cerebral palsy. There are other more common treatments for these conditions. In addition, there are a limited number of hospitals that perform the surgery, and not every child with CP is a candidate for it.

How can my child and I prepare for selective dorsal rhizotomy?

As selective dorsal rhizotomy (SDR) is only effective for some children with cerebral palsy, your child will have to go through a screening process to see if they’d benefit from the surgery.

They’ll likely see several specialists for evaluations, including:

• Pediatric neurosurgeon: This is a specialist who has experience performing SDR on children. They’ll examine your child’s lower extremities and evaluate their underlying muscles.
• Pediatric orthopaedic surgeon: This specialist will examine your child to determine whether any orthopaedic (bone or joint) surgery is necessary to help fix issues such as bone deformities or contractures (extreme muscle stiffness).
• Physical therapist: This specialist will measure your child’s spasticity and muscle function in their legs.
• Occupational therapist: This specialist will evaluate your child's current and potential abilities to perform everyday activities, such as walking, eating, dressing and playing.

After each team member has individually met with your child, the group will jointly discuss whether SDR might be helpful.

Your child may need further screening before the surgery, including:

• In-depth evaluations by physical and occupational therapists to assess your child's physical abilities completely. They’ll videotape your child moving and performing daily activities. They’ll then form a plan for physical and occupational therapy after the surgery.
• A brain MRI to ensure that no other neurological issues are present.
• A visit with a pediatric neurologist to address any neurological conditions.
• A meeting with the pediatric neurosurgeon to go over the risks of the surgery and what to expect during recovery.
• An appointment with an anesthesiologist to ensure general anesthesia is safe for your child.

What happens during SDR surgery?

The general steps of a selective dorsal rhizotomy surgery include:

• An anesthesiologist will give your child general anesthesia. This numbs their brain so they fall asleep and don’t feel pain during the surgery.
• The neurosurgeon will make a small cut (incision) in the middle of your child's lower back.
• Through this incision, the neurosurgeon will make a small “window” in your child’s spine through muscle, bone and the covering of the spinal cord (dura) to expose the underlying nerve fibers.
• The neurosurgeon then identifies and separates the motor nerves from the sensory nerves. They’ll shield the motor nerves to make sure they’re protected during the rest of the surgery.
• The neurosurgeon will attach electrodes to sensory nerve roots. Using electromyography (EMG), they’ll stimulate the nerves to see which ones are causing spasticity and which ones are working as they should. The team will do several stimulations to carefully select which nerves they’ll cut.
• The neurosurgeon will cut a certain percentage of the abnormal sensory nerves. Which nerves and how many they cut varies from child to child.
• Once they’ve completed the nerve cutting, they’ll close the incision layer by layer.
• The healthcare team will take your child to a recovery room where they’ll closely observe your child’s recovery. This is usually in the intensive care unit (ICU).

How long does selective dorsal rhizotomy surgery take?

The procedure itself takes about four to five hours.

What happens after selective dorsal rhizotomy surgery?

Children generally stay in the hospital approximately five days after surgery. For the first 24 to 48 hours, your child must lie flat. They’ll begin physical therapy within a few days after the surgery.

What are the benefits of selective dorsal rhizotomy?

It’s important to emphasize that the overall success of selective dorsal rhizotomy requires commitment from your child (and their caregivers) to intensive physical therapy after the surgery. The specific goal outcomes for the surgery are also unique to your child’s situation.

For children with spastic diplegic cerebral palsy, SDR can lead to:

• Improved mobility and walking abilities.
• Increased stamina.
• Better balance with fewer falls.
• Improved sitting and standing posture.
• Less pain from spasticity.

For children with spastic quadriplegic cerebral palsy, SDR may increase independence by allowing them to:

• Sit more comfortably for longer periods of time.
• Use a potty seat.
• Power a wheelchair on their own.

Surgery can also help with the daily care of children with spastic quadriplegic cerebral palsy. With less spasticity, it can be easier for caregivers to change their diapers or use an adaptive feeding device, for example.

Children with spastic diplegic CP tend to have better results from SDR than children with spastic quadriplegic CP.

What are the risks of selective dorsal rhizotomy?

Possible short-term complications of selective dorsal rhizotomy include:

• Infection.
• Bleeding.
• Cerebrospinal fluid (CSF) leak.

Permanent complications of SDR are rare, but they can include:

• Increased sensitivity to touch stimulation (hyperesthesia), which may cause pain.
• Loss of bladder control (urinary incontinence).
• Loss of bowel control (bowel incontinence).
• Weakness or loss of previous ability to walk.

Your child’s healthcare team will review all the possible risks before the surgery.

What is the recovery time for selective dorsal rhizotomy?

Your child will likely stay in the hospital for about five days after the surgery. Physical and occupational therapy are crucial after surgery and start soon after it. Your child will likely participate in these therapies most days of the week for three to six months after the surgery.

Before your child leaves the hospital, their healthcare team will review medications and incision care with you. They’ll let you know what level of activity is permitted for your child and when they can return to school.

Your child will need regular follow-up appointments. Their healthcare team will let you know how frequently these should happen.

What are the physical therapy requirements for SDR?

Physical and occupational therapy typically begins within a few days after surgery. Rehabilitation is essential to ensure beneficial results from the operation.

Physical and occupational therapists will work with you and your child to teach healthy movement of their body and legs. The physical therapist will perform exercises with your child to stretch their muscles and ease movement. Exercises will be passive at first, becoming more active on the child's part as recovery proceeds.

Exercises are designed to:

• Increase strength.
• Develop balance and alignment in sitting and standing.
• Prepare their feet for standing.
• Develop more regular transitions, such as transitioning from sitting to standing.

The occupational therapist will work on improving your child’s range of motion and daily activities to help them feel more comfortable and to increase their independence at home and school.

Your child's physical and occupational therapists will discuss follow-up programs with you in detail. Your hometown physical and occupational therapists will review the therapy and exercises before your child leaves the hospital. They’ll continue therapy several times a week for three to six months.

When should I call my child’s healthcare provider?

If you notice any signs of post-surgery complications, such as infection at the incision site or loss of bladder function, call your child’s healthcare provider right away.

A note from Cleveland Clinic

Any kind of surgery can cause you to worry. Know that your child’s healthcare team are experts. They’ll thoroughly prepare you and your child for selective dorsal rhizotomy surgery (SDR), but don’t hesitate to ask questions or express your concerns.

Physical and occupational therapy are crucial after this surgery, and you and your child must be committed to adhering to the therapy plans.