gms | German Medical Science

Objective: Traditionally children with cerebral palsy have been treated with physiotherapy, orthesis, botox injection, systemic drug therapy including intrathecal baclofen and orthopedic surgical intervention. Selective dorsal rhizotomy (SDR) is a well-evaluated treatment option, which has been shown to significantly improve GFMF, self care ability and gait patterns in ambulant children with cerebral palsy. Possible negative effects include mainly the unmasking of weakness after the removal of the spasticity and its consequences such as the development of scoliosis or aggravation of hip luxation. The method has been established in a few centers in Germany recently. To prove the effectiveness and safety of a new treatment option, very strict selection criteria in an interdisciplinary setting and standardised outcome assessment are required.

Methods: We treated 6 children, aged 4–12 years, with bilateral spastic cerebral palsy, periventricular leukomalacia in MRI, GMFCS II-III, with normal to slightly impaired cognition. All patients had intensified conservative treatment including botox injection. Patients underwent SDR after 4 level laminotomy (L2 - L5). 5–6 rootlets per dorsal root L2 - S1 were dissected and stimulated. Response was scored according to A) intraoperative multilevel EMG and B) by clinical response in both legs. Rootlets were selected for dissection-depending on the response scores. Patients were discharged to a rehab unit on day 6–8. Patients were assessed pre-operatively and at 3, 6 and 12 months postoperatively with GMFCS, ROM, Ashworth Scale and video gait analysis (Dartfish).

Results: All patients had a significant and sustained reduction of their spasticity in the lower limbs. After the expected initial functional decrease of walking and gait due to increase in weakness, all 6 patients improved their gait within one year compared to baseline, especially regarding gait velocity, walking distance and more physiologic gait pattern. There was no deterioration of hip position or development of spine deformity, neither clinically nor radiologically.

Conclusions: The internationally well-documented success of SDR could be replicated in a very well-selected patient cohort. Patient selection is the key to success of the method and requires extensive experience in the assessment of CP children. The surgical morbidity is low. Functional gains seem to be highest in ambulant cognitively well-mildly impaired children GMFCS II-III, aged 4–10 years without fixed contractures.