In support of selective dorsal rhizotomy in cerebral palsy: the strength of clinical experience

EDITOR—Tedroff et al. reviewed reported long-term outcome studies of childhood selective dorsal rhizotomy (SDR) for the treatment of spastic cerebral palsy (CP).1 They identified 199 papers in the literature and chose to review 16 with Oxford level 4 evidence. Thirteen of these papers have a sample size of between only 11 and 44 patients. The authors drew predictable conclusions: ‘At 10 years or more follow-up, available studies generate low-level evidence with considerable bias … More long-term follow-up using robust scientific protocols is required before it can be decided whether the use of SDR as routine therapy for children with CP is to be recommended or not’. Thus, the authors call for a long-term controlled outcome study of SDR. In reality, however, there remains a wide gap between CP research and practice, and most current CP interventions have only level 4 evidence. Specifically, there is no long-term controlled study of orthopedic surgery, intrathecal baclofen therapy, botulinum neurotoxin injections, antispasticity medication, orthotics, or physical therapy. In the current context, to call for a long-term controlled study of SDR is, unfortunately, quite unrealistic. Long-term research of CP intervention is practically impossible to conduct because (1) it is prohibitively expensive; (2) it may be unethical to assign patients into a control group; (3) the research design is not feasible because participants in the control group drop out when they receive treatments for spasticity and deformities. In the clinical arena, we can resort to the available evidence and practical experience. Nearly 200 papers in the literature described the beneficial effects of SDR on different domains of CP.2 Many countries around the world adopted SDR, and thousands of patients have undergone surgery. At the St. Louis Children’s Hospital, Missouri, USA, we have performed SDR on over 4100 children and adults in the last 32 years. We found positive functional outcomes in 2 years, and 20 to 28 years after SDR.3, 4 The UK National Institute for Health and Care Excellence in 20135 and the Health Quality Ontario of Canada in 2017 found adequate evidence for the short-term effectiveness of SDR after the initial investigation, including interviews with patients/parents.6 Both agencies decided to fund the SDR. In the USA, all insurance companies have been financing the surgery for over two decades. SDR is the only CP intervention that can eliminate spasticity permanently.4, 7 Without spasticity, children and adults have a better quality of life.2, 8 Also, by eliminating spasticity, SDR might be able to prevent or reverse the course of premature aging, and improve the quality of sitting, standing, balance, walking, ability to exercise, and endurance.9 The outcomes assessed in the present review include ambulatory functions and orthopedic surgery. The authors misinterpreted our long-term study stating that only 42 percent of patients benefited from SDR.4 Without SDR, however, we believe that adults with spastic diplegia would have lost the ability to walk 20 to 28 years after the surgery, implying beneficial effects in 84 percent of our 95 patients. The review considered orthopedic surgery as an SDR outcome measure. However, the rate of the surgery itself is not a dependable outcome measure as it is influenced by multiple variables. An important advance in the last decade is that less invasive orthopedic surgery after SDR can correct deformities, and the extensive multilevel orthopedic surgery can be avoided.10 In the discussion, they speculated on the potential negative effects of SDR on motor development, contributing to ‘a lack of long-term improvement in gross motor function or mobility’. At our center, more than 2900 children at 2 to 6 years of age have undergone SDR in the past 32 years. We have not seen any indication that SDR negatively impacts motor development in childhood. Tedroff et al. also speculated that ‘… the advantages and disadvantages of spasticity and the need to alleviate spasticity may vary with age. Consequently, it appears advisable to reduce spasticity, when necessary, employing reversible treatment options, the nature and degree of which can be adjusted as the child grows’. However, the advantage of spasticity in CP is an opinion not based on evidence, while numerous negative effects have been documented, including soft tissue and bony deformities and impaired gross motor development. The authors also stressed complications, but those collected in Table 1 appear to be CP (rather than SDR)-related. Spine problems, i.e. lumbar hyperlordosis, scoliosis, and spondylolisthesis, are indeed most commonly reported late complications of SDR,11 though the causal relations are unclear. It must be noted that reported spine problems affected patients who underwent SDR through multilevel laminectomies. By contrast, in our over 4100 patients who received SDR through a single level laminectomy between 2 to 50 years of age,12 only two children developed kyphosis at the T12-L1 vertebral level (this required spine fusion). The conclusion that SDR is costly lacks validity if not analyzed against the estimated lifetime health care cost for patients with and without persistent spasticity, and the potential benefit of lifelong strengthening exercise after SDR.

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