What is a Selective Dorsal Rhizotomy?
Selective dorsal rhizotomy (SDR) is a surgical procedure that treats moderate and severe spasticity. In a selective dorsal rhizotomy, carefully selected sensory nerve roots in the lower spine are cut to permanently reduce spasticity.
When is this procedure performed?
Selective dorsal rhizotomies are mostly performed in younger pediatric patients whose spasticity results from cerebral palsy or spinal cord injury. It is most effective in patients with few or no contractures (rigid, bent joints). Together with physical therapy, SDR can markedly improve leg and arm function, range of motion, muscle tone, flexibility, positioning, and overall functional ability of an individual with spasticity.
SDR can improve the gait of children who are already mobile. In general, the procedure has the potential to grant the greatest amount of function to patients with good strength, motivation and cognitive function.
In children who are not mobile, SDR is sometimes performed for other reasons: to relieve pain that results from spasticity, to reduce tone and help prevent contractures, or to make activities of daily living and care easier.
How is this procedure performed?
At the Spine Hospital at the Neurological Institute of New York, selective dorsal rhizotomies are performed with a minimally invasive approach. This means that the surgical incision is small–only about an inch and a half long–and a minimum of tissue is disturbed. A minimally invasive SDR is a shorter surgery than is traditionally performed at most other hospitals, and provides a quicker recovery, less postsurgical discomfort, and fewer complications.
The procedure is performed under general anesthesia, which means the patient is unconscious.
The patient is positioned face-down. A small incision is made in the skin over the lower spine. Bone is removed from the back of one vertebra to expose the spinal canal. Inside the spinal canal is a watertight sac called the dural sac. The dural sac surrounds the spinal cord, the nerve roots, and a liquid called the cerebrospinal fluid that is constantly being produced by the body.
The surgeon opens the dural sac directly over the nerve roots causing spasticity. Working carefully, the surgeon separates the nerve roots, and then further separates the roots into rootlets, testing each sensory nerve rootlet with a device that measures electrical signals. As the nerve rootlets are stimulated, physical and occupational therapists in the operating room feel the muscles of the legs and measure the contractions. Normal nerve rootlets are spared, while selected nerve rootlets that cause spasticity are cut.
Then the surgeon closes the dura again. The removed section of bone does not need to be replaced. The skin incision is closed and dressed with a small gauze bandage.
How should my child or I prepare for this procedure?
It is important that you feel completely comfortable with your understanding of the procedure’s goals, risks, expected outcomes and recovery period. The vast majority of children benefit from a 2-4 week stay at an inpatient rehabilitation facility where the child can receive up to three hours a day of therapy. You must be prepared for the intensive physical therapy schedule after surgery.
Many people find it helpful to write down their questions as they think of them and bring the list to their appointments.
Make sure to tell your doctor about any medications or supplements that your child is taking, especially medications that can thin the blood such as aspirin. Your doctor may recommend your child stop taking these medications before his or her procedure. To make it easier, write all medications down before the day of surgery.
Be sure to tell your doctor if your child has an allergy to any medications, food, or latex (some surgical gloves are made of latex).
On the day of surgery, bring items that will be necessary for your child and anyone staying with him or her, such as a toothbrush and toothpaste. You may wish to bring a comforting or familiar object, such as a special blanket. Your child will be given an ID bracelet. It will include his or her name, birthdate, and surgeon’s name.
What can I expect after this procedure?
Without the spasticity, the underlying weakness of the muscles will be revealed. Children who have relied on their spasticity may not be able to do everything they used to do right after the surgery. Intensive physical therapy will help your child build muscle strength and re-train his or her body.
How long will my child stay in the hospital?
The typical hospital stay is 2-3 days. For the first day after surgery, patients will lie flat. Typically children will be ready for discharge to an inpatient rehabilitation facility or home on postoperative day 3.
Will my child need to take any special medications?
Post-surgical discomfort will be controlled with pain medication.
Will my child need rehabilitation or physical therapy?
Yes, dedicated rehabilitation and physical therapy are essential for improvement in function. The therapy team that will have seen your child prior to surgery will see him/her on the second and third days after surgery. (The first postoperative day is for rest.) The therapists and social workers will work with you to arrange inpatient rehabilitation if desired.
Will my child have any long-term limitations due to selective dorsal rhizotomy?
Exactly the opposite. Selective dorsal rhizotomy has been shown to be the most powerful and long-lasting method of reducing spasticity. The benefits of this operation can be expected to last throughout the patient’s life, as studies have demonstrated that even 25 years after a selective dorsal rhizotomy, the spasticity does not return.
Preparing for your appointment
Dr. Richard C. E. Anderson (Pediatric) is an expert in selective dorsal rhizotomy. He can also offer you a second opinion.