Long-term Benefits of Selective Dorsal Rhizotomy

Source: Dudley RWR, Parolin M, Gagnon B, et al. Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy. J Neurosurg Pediatrics. 2013; 12(2): 142– 150; doi: 10.3171/2013.4.PEDS12539Investigators from multiple centers assessed the longterm functional benefit of selective dorsal rhizotomy (SDR) surgery in children with spastic cerebral palsy (CP). They included children who underwent preoperative evaluation for SDR at McGill University between 1991 and 2001 and who were evaluated at 1, 5, 10, and 15 years after SDR with quantitative, standardized assessments of lower-limb spasticity (Ashworth Scale scores of hip adduction, ankle dorsiflexion, hamstrings), Gross Motor Function Measure (GMFM), and performance of activities of daily living (ADLs). Patients with severely limited self-mobility were not typically offered SDR according to the protocol at McGill. The primary outcome was participant course over time for spasticity scores, GMFM scores, and performance of ADLs. Postoperative scores for each of these outcomes were compared to preoperative scores at each follow-up time point. Modeling was used to determine whether there was any heterogeneity of response to SDR among subgroups of children. A secondary outcome, assessed by chart review, was the participant’s need for additional orthopedic or medical interventions.Of the 102 patients who underwent preoperative evaluation, 97, 62, 57, and 14 completed postoperative assessments at 1, 5, 10, and 15 years, respectively. The study population was comprised of 65 boys and 40 girls with a mean age of 5 years at the time of surgery. Most children (n=65) had spastic diplegia, 5 had spastic triplegia, and 11 had spastic quadriplegia. Spasticity scores were significantly improved throughout the study period compared with preoperative scores (P < .001). Similarly, GMFM total scores and performance of ADLs significantly improved throughout follow-up relative to preoperative scores. The participants most likely to display long-term benefits (eg, 10 years with maintenance of function) in spasticity, GMFM, and ADLs were those who were categorized preoperatively into lower (less impaired) GMFCS groups, who had spastic diplegia, who had less hip adductor spasticity, and who had higher (better) GMFM scores. After SDR, a total of 36 patients had additional procedures performed over the course of follow-up; 11 had Botox injections and 25 had lower extremity orthopedic surgeries.The investigators conclude that the benefits of SDR persist well into adolescence and early adulthood.Drs Conley and Ritter have disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Selective dorsal rhizotomy has been generally well tolerated by patients, and both surgeons and primary care physicians have seen an improvement in function during the postoperative period. The current study provides valuable assessment of long-term follow-up of a significant number of patients. The authors provide objective data to support the use of SDR in patients with spastic CP. They show not only improvement in function already lost at the time of surgery, but, perhaps more importantly, they demonstrate that SDR can prevent further loss of function in spastic CP patients who have only mild to moderate impact to ADLs and function.It has been established that untreated children with spastic CP reach 90% of their motor function at approximately 5 years of age and then plateau at approximately 7 years old.1 Russel et al demonstrated a number of adverse effects related to growth present during the adolescent growth period.2 The authors of the current study found that SDR patients did not plateau for 5 years after surgery, at a mean age of 10 years old. These data support a role of SDR prior to adolescent growth to protect them from deterioration that is often observed during adolescence.2The lack of a control group in this study is an obvious weakness. However, 2 of 3 previous randomized controlled trials have shown short-term benefit compared to medical management alone. A meta-analysis by McLaughlin et al has also shown that SDR and physiotherapy are more beneficial than physiotherapy alone.3Overall, this is a well-done study of long-term follow-up and comprehensive outcome analysis of SDR for spastic CP. The investigators present data that suggest not only improvement in function with SDR but also important factors predictive of a good outcome.

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