1

Selective Dorsal Rhizotomy

Andrew Roberts - Oswestry

9th May 2012

Brain Injury

Increased Tone

Abnormal Posture

Contracture

Bony Deformity

Birth Maturity

Brain Injury

Increased Tone

Abnormal Posture

Contracture

Bony Deformity

Birth MaturityS

DR

Ph

ysio

thera

py

ITB

Orth

opae

dic

s

SDR Only Reduces Spasticity

Quantum of Benefit ∝∝∝∝ Extent & Severity of Spasticity

What’s the Objective?

• ���� Spasticity

• �Discomfort

• �Contracture

• � Surgery

• �QoL

• �Walking

2

Selection Criteria – Cole et al 2007

The Good

• Insufficient intensity of spasticity

• Insufficient extent of spasticity

The Bad

• Insufficient selective motor control

• Insufficient extensor strength

• Insufficient potential for rehabilitation

• Too heavy

• Too late to usefully alter evolving disability

The Ugly

• Dystonia

• Ataxia

• Not CP

– HSP

– Neuro metabolic disorders

Good

Ugly

Bad

17

1

513

441

The Mix

3

ControlImpaired

Too Deformed

Too Weak

1

7

3

4*20

The Bad (n = 50)

13

8Too Old

Uncooperative

*

The Ugly

Don’t Offer SDR to…

• Too good to benefit

• Another impairment that would limit improvement

• Another diagnosis with neurology other

than pure spasticity

• Those not selected were not “failures” –

they just needed something else.

Pathway (1 of 2)

• Referral

• Clinical Assessment– Physiotherapy

– Orthopaedic

– Neurology

• Gait assessment– Kinematics

– EMG

– Energy consumption

Pathway (2 of 2)

• Functional assessment– SATCo

– GMFCS

• Orthopaedic Imaging– L Spine

– Hips

• Neuro Imaging– Brain

– Whole spine

4

Outcome Assessments

• Spasticity

• Weight across centiles

• MRC Strength

• Degrees of contracture

• Walking Speed M/S

• Energy consumption Ml/Kg/M

• Physiological Cost Index Extra Beats/M

• Gillette Gait Index

• Gross motor Function Measure

Weight Change After SDR

100

0

10

20

30

40

50

60

70

80

90

Speed =

0.17

Speed =

0.24

Speed =

0.27

Speed =

0.28

Speed =

0.47

Speed =

0.65

Speed =

0.67

Speed =

0.72

Speed =

0.72

Speed =

0.91

Speed =

0.96

Speed =

0.99

Speed =

1.12

Weight

(Centiles) G

ain

Lo

ss

Scoliosis After SDREpidural Obliteration

Long Term Issues

• Walking

• Sexual function

• Comfort

• Orthopaedic Surgery

5

Post SDR

• Reduced need for orthopaedic interventions

• Serial casting for calf tightness

• De-rotation surgery for long bones

• Subtalar stabilisation

• Botulinum toxin

• Intrathecal baclofen

Costs Over time

Economic Analysis of Selective Dorsal Rhizotomy

in the UK. Edwards K,

Dissertation Keele University 2010

N Sex Mean age at intervention Mean time of follow up

Multi – level

group

39 21 male

18 female

12yr 7m

(range 8yr 7m to 16yr 4m)

1yr 10m

(range 6m to 3yr 11m)

SDR group 15 13 male

2 female

8yr 5m

(range 5yr 3m to 11yr 11m)

1 yr 3 mo

(range 9m to 2yr)

0

100

200

300

400

500

600

700

800

900

Pre Op Post Op

Gill

ett

e G

ait

Ind

ex

(G

GI)

SDR

Multi Level

0

200

400

600

800

1000

1200

1400

1600

1800

0 200 400 600 800 1000 1200 1400 1600 1800

Pre Op GGI

Po

st

Op

GG

I

Multi Level (N = 39)

SDR (N = 20)

Information Needs for Parents

• SDR does not cure CP

• Selecting the correct treatment for a child requires careful assessment and may not

indicate SDR

• Aftercare and hard work continues until

skeletal maturity

• Diplegia of prematurity

• Plenty of spasticity

• Adequate

– Anti gravity strength

– Potential for rehabilitation

– Selective motor control

• Freedom from skeletal deformity

Information Needs

for Carers