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Selective Dorsal Rhizotomy

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A neurosurgical approach to spasticity in children with cerebral palsy Results in a decrease of spasticity

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SDR History

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Dr. Peacock is credited with beginning the present day surgical technique in South Africa in the 1960s Dr. Peacock moved to the United States in the 1980s and began training surgeons here The technique was refined throughout the 1980s-2000, resulting in the current methods used today First SDR at SHC-Twin Cities was done in 1991 At that time kids stayed for 8 weeks of inpatient rehab Through 2015 we have done 183 SDR at SHC

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Cerebral Palsy

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Catch-all term Injury to brain early in life- muscles and peripheral nervous system are not damaged Muscle tone often altered Affects child's ability to move and maintain posture and balance

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Muscle Tone

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Amount of tension or resistance to movement in a muscle: speed dependent May be spastic, ataxic, athetoid, or mixed Used to classify type of CP

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Spastic CP

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the only type of CP that uses SDR Stretch reflex is overactive Injured brain is not able to modulate the reflex arc Children with spastic CP *may* be a candidate for SDR

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Potential candidates for SDR

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Children with CP who have spasticity primarily in the legs (spastic diplegia) Spasticity interferes with function or daily cares Children who can cooperate with a vigorous post-op therapy program

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Evaluation Process

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Comprehensive full-day evaluation Interdisciplinary team discusses the child's suitability for SDR: PT, OT, Social work, Nurse coordinator, neurosurgeon

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Evaluation Parts

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Thorough PT and OT evaluations Gait lab analysis Videotape of functional abilities Social Services assessment: do they have the resources necessary to do rehab after surgery? Neurosurgeon examination

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PT Eval

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Interview Tone testing Strength testing Isolated motor control ROM Sensation Balance Gait analysis Functional ability GMFM Behavior

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PT Eval: Interview

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Birth and development history Current therapies Adaptive equipment Previous tone management

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PT Eval: Tone Testing

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One of the most critical aspects of evaluation Spasticity of major muscle groups in LEs graded using Modified Ashworth Scale Note presence of clonus in gastrocs Note presence of active tone (an observed increase in spasticity with activities: SDR doesn't affect this as much) Note presence of athetosis, ataxia, or rigidity (mixed tone)

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PT Eval: Strength Testing

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One of the most critical aspects of evaluation Use manual muscle testing to evaluate strength of major muscle groups in LEs Graded, using standard 5 point rating scale Note if child has one side of body stronger than the other: if there's a strong asymm it might be less favorable outcome

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PT Eval: Isolated Motor Control

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One of the most critical aspects of evaluation Done in conjunction with strength testing Note if child can isolate a particular motion Note if child can only use patterned movements, such as overall extension or flexion

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PT Eval: ROM

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Use standard goniometry to measure PROM for major joint movements of the Les Check for reduced flexibility in hip flexors, adductors, hamstrings, gastroc/soleus

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PT Eval: Sensation

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Generalized testing: gross testing of LE Test for light touch Note whether sensation is intact, impaired, or absent over broad areas of LEs Test proprioception sense of great toe flexion and extension

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PT Eval: Primitive Reflexes

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Note presence/absence of primitive reflexes: ATNR, STNR, TLP/TLS, Moro reflex, Extensor thrust These reflexes should be integrated by 8-12 months in a typically developing child, but may persist in children with CP-- children may use them to drive movement

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PT Eval: Balance

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Righting reactions of trunk and head in sitting Protective reactions of UEs in sitting Function in sitting (taking off shirt or sock) Protective reactions in standing Function in standing (able to stand independently, able to pick up toy from floor)

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PT Eval: Gait Analysis

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Describe gait characteristics Look at gait both with and without orthotics Look at gait with all assistive devices, if child uses several EMG patterns will show if it's spastic CP

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PT Eval: Functional Ability

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Look at child attempting a variety of developmental activities Rolling, various sitting positions, quadruped, crawling, tall and half-kneeling, sit to stand Look at child's transitional ability, how much assist needed to maintain position, and postural control

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PT Eval: GMFM

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Standardized test for children with CP Looks at function in 5 dimensions Lying and Rolling Sitting Crawling and Kneeling Standing Walking, Running, and Jumping Most kids with SDR will do ok in the 2-3 first sections and will have trouble with the last few

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PT Eval: Behavior

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General impression of behavior Cognition - could child understand commands? Cooperation - did child have much difficulty completing evaluation tasks? Motivation - does child seem motivated to move, walk, and participate in play? Most kids are 4-6yo (age appropriate behaviors expected)

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SDR Selection Criteria

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Presence of spasticity that is not significantly asymmetrical and is primarily in LEs No significant athetosis or ataxia noted (mixed tone) Good isolated motor control and strength Gait characteristics congruent with spasticity per gait lab analysis Good cooperation with therapy activities Family commitment to extensive outpatient therapy needed after selective dorsal rhizotomy Appropriate family expectations

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How does SDR work?

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Spastic CP - Stretch reflex overactive due to damaged brain's poor ability to modulate reflex arc SDR interrupts reflex arc at sensory nerve level This reduces excitatory sensory input from the LEs

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Surgical Team

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Neurosurgeon Neurophysiologist: monitor neural response and muscle response to nerve stimulation during surgery Physical Therapist or Physiatrist: monitor LE response Surgical Nurses Anesthesiologist

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Surgical Preparation

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Child positioned prone Needle EMG electrodes inserted into major muscle groups of LEs (except psoas) and anal sphincter EMG monitored by neurophysiologist Physical Therapist palpates muscles corresponding to spinal level being stimulated Motor response manually and visually monitored by PT: palpation and visual

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PT Muscle Palpation

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Palpate these muscles with the nerve stimulation: L1 (Hip Flexors) L2 (Hip Flexors, Adductors) L3 (Adductors, Quads, Hamstrings) L4 (Adductors, Quads, Hamstrings) L5 (Adductors, Quads, Hamstrings) S1 (Gastrocs) S2 (Toe Flexors)

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Surgical Procedure

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L1-L5 laminoplasty Stimulation of motor root to identify spinal level Stimulation of sensory root to identify threshold Microdissection into sensory nerve rootlets Stimulation of individual rootlets Rootlets showing abnormal response cut L1-S1 spinal levels tested

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Expected Response to Sensory Root Stimulation

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Single motor twitch response in up to 3 muscle groups No motor response (due to low level of stimulation)

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Abnormal Response to Sensory Root Stimulation

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Sustained motor contraction Crescendo-ing motor contraction (EMG) Motor responses in greater than 3 muscles groups Contralateral motor response

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Post-Op Rehab

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4 week rehab program Inpatient through POD #10 Once sitting tolerance reaches 45 minutes, patient is discharged from inpatient Patient/caregiver stays in our attached Parent Accommodation Center Outpatient Therapy for additional 2 ½ weeks 2 hours of PT and 1 hour of OT per day, M-F

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Therapy Goals

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Increase ROM/flexibility Increase strength and graded motor control Develop good postural alignment in sitting Develop active movement transitions using normal motor patterns Develop reciprocal movements in LEs Initiate ambulation, emphasizing normal movement patterns Address equipment needs for discharge Individualized short-term goals written weekly

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Post-op Movement Precautions

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No hip flexion > 90° : prevent lumbar flexion No straight leg raise > 30°: prevent lumbar flexion No passive trunk rotation Use prone dependent lift for transfers until sitting. Once sitting, child can be lifted maintaining 90°at hip/knees Always support lower body during transfers

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First week of Rehab

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Head of bed (HOB) flat for 72 hours POD #2: Don *PRAFOs and KIs*, Care Conference POD #3: Raise *HOB up to 30°*, Bedside Exercise: heelcord & popliteal angle hamstring stretching, heelslides POD #4: *Bedside Exercises*: add supine hip abduction, TKEs, ankle pumps, Begin rolling with assist (log roll), Transfer to prone cart, May be on cart as tolerated, Family education for transfer technique

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Second week of Rehab

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Begin *PT & OT* in department Progress stretching & strengthening POD #7: *HOB >30° if KIs are off*, Add adductor stretching & hamstring curls, Increase endurance in POE POD #8: *Start sitting* in PT using position of 90° at hip/knees, Transfer in/out of sitting via side-lying with assist, Use scooter board for UE strengthening

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Second week of Rehab (cont)

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POD #9: Start bridges, with pelvic support as needed, Start *four-point & crawling* with abdominal support, Start *wheelchair 30 minutes, 3-4 times/day*, Family education for transfer technique, Start high-back commode for toileting POD #10: W/c time increased to 30-45 minutes, 3-4 times/day, Add sidelying hip abduction exercises, Discharge from inpatient to *PAC* at end of day POD #11: W/c time increased to 45-60 minutes, 3-4 times/day, Start *tricycle*

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Third week of Rehab

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Precautions discontinued, except kids must continue to have lower body support when lifted Progress stretching and strengthening Add four-point hip extension with abdominal support Add abdominal curls Add tall kneel activities using bench for support as needed

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Third week (cont)

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POD #15: Begin sit to stand in parallel bars, emphasizing graded control, *Begin ambulation in parallel bars, Begin tailor sitting* POD #16: *Begin ambulation with reverse walker* POD #17: Work on transitioning in/out of tailor sit, Begin side-sit and long sit, Work on sit to tall kneel with graded control, Progress to half-kneel activities POD #18: Progress more exercises to be done in the standing position

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Discharge Determination

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Determine discharge date once child has begun ambulation with assistive device Child may need another 1-2 weeks of rehab depending on goals, progress, and availability of services in the child's community Contact child's local P.T.

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Fourth week of Rehab

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Progress stretching & strengthening SLR and heel raises Begin stairs Increase ambulation independence and endurance Work on barefoot ambulation Child allowed to play on the floor independently

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Week of Discharge

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Complete discharge evaluation Instruct family in home exercise program of *stretching* and strengthening Provide equipment: wheelchair, assistive device, ankle weights

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Follow Up

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Return to SDR clinic 3 months post-op: brief PT follow-up 6 months post-op: full evaluation 1 year post-op: full evaluation, GMFM 2 year post-op: full evaluation, GMFM, gait lab

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SDR Outcomes

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meta-analysis of three RCTs: SDR+PT vs children who had PT only: N=90, 82 children were under age 8 years, 65 children had GMFCS level of II or III, PT programs for all children included stretching, strengthening, and training in functional movements to enhance mobility, Follow-up was at 9 or 12 months, Children who had SDR+PT had a small significant improvement in GMFM scores: additional 4 percentage points over children who had PT only

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