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Selective dorsal rhizotomy improves ability to walk for children with cerebral palsy.
Cerebral palsy is a motor disorder caused by a nonprogressive injury to the developing brain and commonly limits mobility. For children with cerebral palsy, the loss of mobility comes with multiple health and social issues, including social isolation due to the inability to keep up with peers, loss of independence and a sedentary lifestyle which can result in obesity - further limiting mobility. With a prevalence of three per 1,000, cerebral palsy is the most common disabling movement disorder in children, and is more common among infants born prematurely. This is especially true for diplegic cerebral palsy, which primarily involves the legs and is often seen in the context of periventricular leukomalacia.
Muscle tone is the resting tension on muscles, often high in cerebral palsy. Spasticity is the increase in muscle tone in response to velocity dependent resistance to muscle stretching. This increased tone produces unnatural and imbalanced forces on joints and bones during typical movement (i.e., walking) and creates further orthopedic problems. Sensory feedback from the muscle through the dorsal roots of the spinal cord modulates muscle tone, and targeted treatment of this sensory feedback can improve tone and the ability to walk as a result. Selective dorsal rhizotomy (SDR) is a permanent neurosurgical procedure to reduce spasticity by disrupting the sensory feedback through the spinal cord. Cook Children's is one of only a few hospitals in Texas to offer this procedure.
Candidates for SDR are evaluated in our Complex Motor Disorders Clinic by the multidisciplinary movement disorder team – an experienced pediatric movement disorders neurologist, physical therapist and orthotist. Additional support is provided by a social worker, nutritionist and nurse clinician for patient education. Patients undergo gait analysis in the emPower Center, our state-of-the-art motion analysis lab, to carefully detail the components of muscle strength, tone and orthopedic bone and joint alignment. Individual patient goals and expectations are then detailed. Once the family and evaluation team are in agreement to proceed, patients are evaluated by Richard Roberts, M.D. for evaluation and further explanation of the surgery. A final consultation between neurology and neurosurgery completes the pre-surgical process.
The spinal cord is exposed and dorsal roots are identified. Each dorsal root is meticulously subdivided into individual rootlets. Each rootlet is then stimulated with a small amount of electrical current and muscle activity is measured. The response dictates whether to cut or preserve an individual nerve rootlet. Typically, roots from L1 or L2 through S1 are evaluated. Following the surgery and post-operative recovery, patients come to our inpatient rehabilitation unit (RCU).
Who are the best candidates? The ideal candidate for SDR is an ambulatory or nearly ambulatory patient with diplegic cerebral palsy with good motivation and family support. The best time for SDR is between 4 and 10 years of age. The team will review expectations and establish goals with the family prior to neurosurgical referral.
Expect a four-week hospitalization for the surgery and initial rehabilitation, followed by three to four months of intense outpatient therapy.
Neurology and rehabilitation:
Warren Marks, M.D.
Fernando Acosta Jr., M.D.
Stephanie Acord, M.D.
Richard Roberts, M.D.
Patients can be referred to the Cook Children's movement disorders specialists in our Neurology department at 682-885-2500.