SELECTIVE DORSAL RHIZOTOMY in Ireland

Information for Parents, Children and Families

 

Background

 

Selective Dorsal Rhizotomy (SDR) is an operation used to reduce spasticity (muscle stiffness) in some children with cerebral palsy.

Spasticity has an impact on motor function and quality of life. It can effect gait, cause pain, and contribute to muscle contractures which can lead to deformities. Nerve fibres running from the muscles back to the spinal cord play a major role in maintaining the typical muscle stiffness seen in spasticity. SDR is a surgical procedure performed on these spinal nerve fibres to reduce levels of spasticity in the legs.

 

Spasticity is one of a number of factors that can impact on a child’s motor function. Other factors include weakness, selective motor control, balance, vision, cognition. Therefore the impact of interventions for spasticity can be affected by the presence of other factors such as weakness.

 

There are plans that SDR surgery will occur in Ireland in due course. Meanwhile children who are felt to be suitable for this procedure are referred to Leeds General Infirmary in the UK, and this is funded by the HSE via Treatment Abroad Scheme: www.hse.ie/eng/services/list/1/schemes/treatmentabroad.

 

Who is suitable for consideration for surgery?

 

Children with cerebral palsy can be very different from each other. This is because the condition depends on precisely which parts of the brain are affected. Cerebral palsy is divided into different types, and it is the spastic type which may be treated with SDR.

Every child who has spastic cerebral palsy will have different amounts of spasticity. Children whose problems are mostly due to weak muscles or poor muscle control will not necessarily be helped by SDR.

 

  • Children between 4 and 10 years of age with Spastic Cerebral Palsy affecting predominately their legs (Bilateral/diplegia) may be good candidates for SDR
  • Children should be able to walk and classified as Gross Motor Function Classification System Level II or III
  • Children suitable for SDR need to demonstrate adequate muscle strength in their legs and trunk
  • They should be able to stand up and support their body, hold their posture against gravity and walk
  • Very young children who are still learning to walk are changing very rapidly. For this reason it is important to wait until their walking pattern has settled down before deciding whether SDR is the best option for them
  • Children whose cerebral palsy is due to periventricular leucomalacia (PVL) related to prematurity tend to have a good response to SDR. This is not the case for other causes of cerebral palsy
  • If other areas of the brain involved in balance and coordination are also affected, the child may not be a good candidate for SDR
  • Children with severe cerebral palsy involving the whole body may benefit more from consideration of intrathecal baclofen pumps than SDR surgery
  • For children with severe scoliosis, SDR is not recommended as it may cause the existing spinal curvature to deteriorate
  • Children who have had x-rays that show progressing uncovering of the hip joints may not be suitable for SDR
  • Families and children must be able to commit to extensive post-operative rehabilitation
  • Children must also have the understanding and ability to comply with this rehabilitation

 

Are there alternatives to SDR?

 

Alternatives to SDR to manage children with Spastic Cerebral Palsy include medication, long-term exercise and activity as supported and advised by a physiotherapist, use of botulinum toxin injections into the spastic muscles and orthopaedic procedures. Not every child with cerebral palsy requires intervention and many children are able to lead full and happy lives with exercise and activity alone.

 

Selection Process for SDR

 

Careful patient selection, and a specialist multi-disciplinary approach in assessment and management is essential. Careful selection of suitable surgical candidates by a specialist multi-disciplinary assessment is essential to attain optimal outcomes and goals. There is a multi-disciplinary team of professionals in Ireland (Irish SDR MDT – established in 2012) with expertise in cerebral palsy that meets several times a year to review and approve suitable children for onward referral to the UK. The team includes specialists from Paediatrics, Physiotherapy, Neurosurgery and Gait Analysis. This process is further explained below:

 

In advance of referral to the MDT forum it is requested that the local paediatrician and physiotherapist work-up the case according to a defined protocol. If your local team think your child is suitable for SDR they will arrange for more detailed assessments: specialist physiotherapy assessment and gait analysis. Your child may also require further scans. If following these assessments your child is still considered suitable their case will be put forward for discussion at the SDR MDT forum. This does not involve you/your child attending the forum.

At the SDR MDT forum:

  1. Each individual case is discussed in liaison with the child’s local team
  2. Clinical information specific to each child is reviewed. This includes review of functional ability, muscle tone, joint range, muscle power and gait analysis data
  3. Goals of intervention and possible functional or qualitative benefits of SDR are discussed
  4. Consideration is given to the individual family circumstances, goals and expectations of outcome along with ability to comply with regular physiotherapy home programmes after SDR.
  5. The MRI brain scan is reviewed to ensure there is no evidence of damage to other areas of the brain involved in the control of balance and posture

If your child is felt to be suitable for consideration for surgery, he/she is then referred to Leeds. Over 25 children have been referred to the UK to date. Your child will be called for a consultation with the multi-disciplinary SDR team in Leeds. The team in Leeds makes the final decision regarding whether to proceed with SDR. If you child is found to be a suitable candidate for SDR the ensuing process will be discussed with you, along with information regarding potential complications and the importance of following up with the intense physiotherapy and home exercise programme in the post- operative period.

 

Post-operative physiotherapy:

 

For information on post-operative physiotherapy: www.leedsneurosurgery.com/sdr. There is intensive physiotherapy in the UK for the first three weeks following surgery, which is funded. Following this, upon return to Ireland, an individualised physiotherapy and home exercise programme is implemented. This will have been planned in advance of surgery by the local physiotherapist in conjunction with parents. The lead physiotherapist from the Irish SDT MDT forum will provide guidance and support to families and their local physiotherapists with this rehab.

 
A parent’s perspective:

 

 

For us 4 years post-op, our recommendation to families is to do as much strength building pre-op as possible, and be prepared to work extremely hard post-op. SDR is not a cure – it opens a door which allows muscles to be built which previously were held by spasticity. Often families’ goal is to see their child walk, and of course this is important, but our feeling four years on – seeing our child’s body free from spasticity has changed our child the most. SDR is not for every child, and maybe not for every family, but for those children or adults who meet the criteria and their families that engage in the process it definitely changes lives.”

 
 

If you would like further information regarding this procedure, please discuss this with your paediatrician and physiotherapist.
 
 

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