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Selective dorsal rhizotomy (SDR) is a surgical procedure performed on the lower spine to reduce spasticity (involuntary muscle contractions and stiffness) in the legs of children who have one of the spastic forms of cerebral palsy.
Spasticity in children with cerebral palsy interferes with the development of motor skills and can, over time, cause permanent problems as muscles weaken and contractions distort posture.
SDR selectively thins the nerves running from the spinal cord to the legs that are triggering the spasticity. Reducing the spasticity allows for improved motor control of the legs, and ultimately an improvement in how a child stands and walks. With the stiffening nerve signals reduced, control over the legs is improved.
Selective dorsal rhizotomy is most effective in reducing spasticity and improving mobility when performed on children between the ages of 3 and 10. However, it can sometimes reduce symptoms in older children and even in adults.
Primary candidates for SDR are children who have muscle spasticity in their legs that limits their mobility, but have little spasticity in their arms and are generally otherwise well. The procedure, combined with physical therapy, can greatly improve mobility for these children.
Children with severe spasticity in the arms and legs may also be candidates. For these children, the goal of the procedure is to increase independence, enabling them to sit for longer periods or to control movement in a wheelchair, as well as to ease the care required by caregivers.
In some cases, spasticity masks muscle weakness. A child may be able to stand only because of the muscle stiffness, and with the stiffness removed might actually lose mobility. Before recommending surgery to reduce spasticity, thorough screening examinations are done by rehabilitation medicine physicians and physical and occupational therapists to assess muscle strength and other physical abilities.
In preparation for selective dorsal rhizotomy, patients are also evaluated for dystonia (muscle contractions that can result in twisted or abnormal postures). SDR is not effective in reducing dystonia, so if the repetitive muscles spasms and twisting postures of dystonia are a significant part of the child’s muscle control problem, in addition to spastic stiffness, the procedure may not be the best option.
SDR is performed while your child is under general anesthesia. A pediatric neurosurgeon makes a small incision over the middle of the spine to give the surgical team access to the nerve roots that run from the spinal cord to the muscles in the legs.
The motor (ventral) and sensory (dorsal) nerves are separated, and a pad placed between them to remove the motor nerves from the field of operation. Using a surgical microscope, each of the sensory nerve roots is then separated into three to five rootlets and stimulated electronically.
Other members of the surgical team measure the muscle responses in the legs to the stimulation, identifying the specific rootlets that cause the greatest amount of spasticity. The most abnormal rootlets are cut, leaving the other rootlets intact.
In the weeks before the SDR procedure, your child will participate in physical therapy to strengthen and improve range of motion in the trunk and leg muscles. You and your child will learn how to do these exercises at home, and you will be trained on the exercises to be done after the surgery. Arrangements will also be made for any adaptive equipment your child may need after the procedure.
In the days before the procedure, your child will be videotaped to make a record of pre-surgical mobility to compare with progress after the operation.
On the day of the surgery, you child will undergo general anesthesia. At Children’s Hospital of Philadelphia, you can trust our specially trained pediatric anesthesiologists to keep your child comfortable and safe before, during and after their procedure. Read more about our dedicated pediatric anesthesiology team.
The SDR surgery itself takes several hours, as a large number of nerve rootlets must be tested and selectively cut.
For the first 1 1/2 days after undergoing selective dorsal rhizotomy, your child must lie flat. By the second day, most children are able to sit up for short periods and begin physical therapy.
The reduction in spasticity occurs immediately after surgery, and transfer to our inpatient rehabilitation unit is done a few days after surgery.
During inpatient rehabilitation, your child will receive daily physical and occupational therapy. Therapy is designed to improve strength, balance and posture, and to work toward regaining mobility and age-appropriate independence with self-care skills and activities of daily living. Inpatient rehabilitation may also be a time to fit your child with any bracing or to teach them to use any new equipment that might be needed following surgery.
Before your child is released to go home, your medical team will review what you need to know about medication and what activities should be encouraged or avoided. The therapists will also teach you strategies and a home exercise program that you will continue at home after inpatient rehab.
Your child will continue to work with outpatient physical and occupational therapists in the community, which might be closer to where you live. You will have follow-up appointments with Rehabilitation Medicine as well as Neurosurgery to make sure that your child is healing well and to monitor their progress with therapy.
At Children’s Hospital of Philadelphia (CHOP), our Division of Neurosurgery works closely with the multidisciplinary Cerebral Palsy Program to ensure that candidates are screened appropriately for SDR and to provide the full range of supportive therapy before and after surgery in order to optimize outcomes.
Your child will have access to a broad team of specialists with expertise in every element of the care of children with cerebral palsy, and who are committed to staying abreast of the latest technology available and innovative approaches to treatment.