Selective Dorsal Rhizotomy

July 16, 2016

Selective Dorsal Rhizotomy (SDR) surgery is a procedure that treats muscle spasticity caused by abnormal communication among the brain, spinal cord, nerves and muscles.
Spasticity most commonly affects patients who have cerebral palsy. SDR surgery corrects muscle spasticity by cutting the nerve rootlets in the spinal cord that are sending abnormal signals to the muscles.

Selective dorsal rhizotomy has been shown to:

  • Reduce spasticity
  • Improve gait (walking) patterns
  • Help people use energy and oxygen more efficiently
  • Improve range of motion and functional mobility
  • Make it easier to perform self-care activities, such as getting dressed and grooming

Is SDR suitable for everyone?

Children between three and 12 years of age with typical spastic diplegia may be good candidates for SDR. Children older than twelve years may still be good candidates but are more likely to also need orthopedic surgery to correct muscle and bone changes.

Children suitable for SDR need to demonstrate adequate muscle strength in the legs and trunk. They are usually able to stand up and support their body, hold their posture against gravity and make appropriate movements to crawl or walk. These children tend to have delayed physical development and spasticity interferes with their progress.

What Does the Operation Involve?

SDR is carried out while the child is under general anaesthesia and takes around four to five hours. A skin incision is made in the upper lumbar spine. The spinal canal is opened at only one level. An ultrasound probe is used to identify the lower end of the spinal cord. Under the operating microscope, the membrane covering the spinal cord is opened and the lower end of the cord, with the sensory roots entering it, is identified.

Each of the sensory nerve roots is then subdivided into four or five rootlets. Each rootlet is stimulated to identify the ones that contribute most to the spasticity. These rootlets are then divided. The process is repeated for all the other nerve roots, from L1 to S2, on both sides, aiming to divide 50 to 70 per cent of the sensory roots.

At the end of the procedure, the membrane covering the spinal cord is closed again, the back muscles are returned to their original position and the skin is closed with dissoluble stitches.

What is the outlook for children who have had SDR?

Reduction in spasticity is immediately apparent after the procedure, but SDR unmasks any weakness and difficulties with co-ordinating movements common in cerebral palsy. It takes time for the strength in the legs to return. Through the physiotherapy programme, your child will learn to use their body in a new way.

There is now enough evidence to demonstrate that SDR is associated with substantial long-term benefits. These are not only related to reduction in spasticity, but also relate to improved movement and walking as well as improved quality of life for both the children and their families.

One research study has shown that the benefits of SDR one year after surgery were still there 20 years afterwards. A recent large study has shown that children undergoing SDR at a young age continue to improve walking in childhood, without the expected decline in adolescence.

Why is not SDR funded by the NHS?

Until recently NHS England had withdrawn funding for SDR surgery whilst it examined its effectiveness. There will be a trial of 120 children who meet specific criteria for the surgery. Results will be monitored and assessed. The trial will lead to a decision on future NHS funding for the procedure. It’s thought that specialist centres will be designated under the Commissioning Through Evaluation scheme. This scheme will fund centres to undertake SDR with selected children to gather detailed information about clinical outcomes.

However, the costs will still be less than SDR in the USA and follow-up physiotherapy and monitoring of your child is easier.

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