Selective Dorsal Rhizotomy Referral Pathway        

Selective Dorsal Rhizotomy may be considered to preserve or improve function which is limited by spasticity. A small number of children are known to benefit from this. They need to be carefully selected.

An SDR service will be established in Ireland in due course. In the interim suitable children are referred to Leeds in the UK, on the Treatment Abroad Scheme. There is a national multi-disciplinary SDR forum that advises re suitability of individual children. This team is composed of a small group of professionals from CRC & Enable Ireland and meets twice annually in Dublin, liaising with the relevant local team (by teleconference if necessary).

Following liaison with international centres, review of evidence and audit of cases to date, the referral criteria below have been drafted regarding which children may be suitable. These referral criteria may be expanded upon with time.

Please refer to the accompanying flow chart of the referral pathway for guidance.

Children must meet the baseline criteria below before consideration for referral

Referral Criteria

Spastic bilateral (diplegic) cerebral palsy

GMFCS II, III

Age 4-10y

Spasticity should be limiting function

No previous multi-level orthopaedic surgery

Stable hips <33% Migration

MRI – changes of periventricular leukomalacia. Lesions in basal ganglia or cerebellum are contra- indications to SDR

Well-motivated child with good family support,

Prior to referral to the SDR forum both the child’s local paediatrician and physiotherapist should jointly discuss and consider the child a potential candidate for SDR.

To inform the decision to refer for consideration, when preliminary referral criteria have been met, two assessments are then required in the following order:

  1. An SDR- specific physiotherapy assessment (form available on request, SDR team physiotherapist can assist/guide local physiotherapist in completion of same if required)

 

Potential reasons for being deemed unsuitable based on Physiotherapy Assessment include:

  • Absence of Spasticity (Ashworth score of <1+/2 in most muscle groups)
  • Presence of fixed joint contractures (hips and knees)
  • Lack of ability to isolate lower limb movements (isolated hip flexion, and if possible knee extension and dorsiflexion)
  • Poor anti-gravity strength, less than Gr 3 MOS (particularly knee extensors and hip flexors)
  • Poor trunk control (unable to sit arms/feet free on bench)
  • Poor balance (unable to high kneel, kneel walk or stand)
  • Functional Mobility Scale of 1 at 5, 50 or 500m.
  1. Gait Analysis at CRC (child must be at least 4y to enable a meaningful analysis).

Potential reasons for being deemed unsuitable based on Gait analysis include:

  • Evidence of weakness (excessive movement of pelvis, knee hyperextension)
  • Evidence of poor motor control (mass flexion/extension pattern in sagittal plane hip and knee graphs)
  • No evidence of reduced range associated with spasticity
  • Large variability in gait pattern potentially indicating dystonia and/or poor motor control

The referral letter, accompanied by the completed SDR-specific assessment form, must contain information regarding MRI brain, hip status, response to previous botulinum toxin/spasticity management and goals that have been discussed with the parents and child. The assessment should be completed by the child’s Paediatrician and Physiotherapist.

Detailed review and discussion of the case occurs at the SDR forum, in conjunction with the local team. If felt suitable a referral is made to the team in Leeds. If not felt appropriate this reasons are discussed with referring team who in turn feedback to family.

Should there be a lack of certainty re appropriateness of any referral the SDR assessment team is happy to discuss with local clinicians regarding specific cases at any point. Contact point: 01 8542200 – secretary to Dr Jane Leonard.

It is important for referrers to bear in mind the need for significant physiotherapy input following the procedure.

1.Roberts, A., C. Stewart, and R. Freeman, Gait analysis to guide a selective dorsal rhizotomy program.        Gait Posture, 2015. 42(1): p. 16-22.

2. Wang, K.K., et al., Selective dorsal rhizotomy in ambulant children with cerebral palsy. Journal of Children’s Orthopaedics, 2018: p. 1-15.

3.  Cole, G.F., et al., Selective dorsal rhizotomy for children with cerebral palsy: the Oswestry experience. Arch Dis Child, 2007. 92(9): p. 781-5.

Selective Dorsal Rhizotomy Referral Pathway

 

 

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