Selective Dorsal Rhizotomy in Cerebral Palsy- Selection and Physiotherapeutic Management: Difference between revisions

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'''Selective Dorsal Rhizotomy (SDR) is a neurosurgical procedure that aims to:'''
'''Selective Dorsal Rhizotomy (SDR) is a neurosurgical procedure that aims to:'''<ref name=":0">Verity, C. (2017). Selective Dorsal Rhizotomy (SDR) | Disability charity Scope UK. [online] Available at: <nowiki>https://www.scope.org.uk/support/therapies/selective-dorsal-rhizotomy</nowiki> [Accessed 20 May 2018].</ref><ref name=":1">Nordmark, E., Josenby, A., Lagergren, J., Andersson, G., Strömblad, L. and Westbom, L. (2008). Long-term outcomes five years after selective dorsal rhizotomy. BMC Pediatrics, 8(1).</ref>
* Reduce spasticity that interferes with motor function in children with spastic Cerebral Palsy.
* Reduce spasticity that interferes with motor function in children with spastic Cerebral Palsy.
* Improve function and mobility
* Improve function and mobility
* Increase independence
* Increase independence
* Increase range of motion and improve positioning
* Increase range of motion and improve positioning
(Verity, 2017 and Nordmark et al., 2008)
'''<u>Funding in the UK:</u>'''
'''<u>Funding in the UK:</u>'''


The SDR procedure is not currently available on the NHS as funding for the surgery has been withdrawn whilst NHS England examines its effectiveness via a process called Commissioning Through Evaluation.  There are 7 funded centres: Alder Hey Children’s NHS Foundation Trust; The Portland Hospital for Women and Children; Great Ormond Street Hospitals NHS Foundation Trust; Leeds Teaching Hospitals NHS Trust; Nottingham University Hospitals NHS Trust; University Hospitals Bristol NHS Foundation Trust; The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS (Scope UK, 2018). They undertake approximately 120 SDR cases a year (NHS England, 2014) with selected children to gather detailed information about clinical outcomes to produce a final report in Autumn 2018. Despite this SDR can be self-funded in the UK through the NHS hospital treatment top-up scheme. (Verity, 2017). In the UK the procedure costs between £30,000- £40,000 (The Portland Hospital, 2015).
The SDR procedure is not currently available on the NHS as funding for the surgery has been withdrawn whilst NHS England examines its effectiveness via a process called Commissioning Through Evaluation.  There are 7 funded centres: Alder Hey Children’s NHS Foundation Trust; The Portland Hospital for Women and Children; Great Ormond Street Hospitals NHS Foundation Trust; Leeds Teaching Hospitals NHS Trust; Nottingham University Hospitals NHS Trust; University Hospitals Bristol NHS Foundation Trust; The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS<ref>Scope UK. (2018). Selective Dorsal Rhizotomy (SDR) | Disability charity Scope UK. [online] Available at: <nowiki>https://www.scope.org.uk/support/therapies/selective-dorsal-rhizotomy</nowiki> [Accessed 22 May 2018]. </ref>. They undertake approximately 120 SDR cases a year<ref>NHS England. (2014). NHS England » NHS England funds the evaluation of specialist surgery for more than 100 children a year with cerebral palsy. [online] England.nhs.uk. Available at: <nowiki>https://www.england.nhs.uk/2014/07/cte-specialist-surgery/</nowiki> [Accessed 20 May 2018].</ref> with selected children to gather detailed information about clinical outcomes to produce a final report in Autumn 2018. Despite this SDR can be self-funded in the UK through the NHS hospital treatment top-up scheme<ref name=":0" />. In the UK the procedure costs between £30,000- £40,000<ref>The Portland Hospital (2015). The Portland Hospital – the first private hospital in the UK to perform the Selective Dorsal Rhizotomy procedure | News | The Portland Hospital. [online] Available at: <nowiki>http://www.theportlandhospital.com/news/the-portland-hospital-the-first-private-hospital-in-the-uk-to-perform-the-selective-dorsal-rhizotomy-procedure/</nowiki> [Accessed 22 May 2018].</ref>.


'''<u>Clinically relevant anatomy:</u>'''
'''<u>Clinically relevant anatomy:</u>'''


Two groups of nerve roots leave the spinal cord through the intervertebral foramen: the [https://www.physio-pedia.com/Lumbar_Plexus ventral and dorsal spinal roots] (St. Louis Children’s Hospital, 2018). The ventral nerve roots are efferent motor roots and are responsible for control of muscular contractions, hormone synthesis and gland secretion. The dorsal nerve roots are afferent sensory roots and are responsible for the transmission of sensory stimulation to the CNS (Laser Spine Institute, n.d.). The SDR procedure decreases sensory stimulation to the CNS by dividing the dorsal nerve roots whilst preserving voluntary movement (NHS England, 2013).
Two groups of nerve roots leave the spinal cord through the intervertebral foramen: the [https://www.physio-pedia.com/Lumbar_Plexus ventral and dorsal spinal roots] <ref>St. Louis Children's Hospital (2018). Selective Dorsal Rhizotomy. [image] Available at: <nowiki>http://www.stlouischildrens.org/our-services/center-cerebral-palsy-spasticity/about-selective-dorsal-rhizotomy-sdr</nowiki> [Accessed 21 May 2018].</ref>. The ventral nerve roots are efferent motor roots and are responsible for control of muscular contractions, hormone synthesis and gland secretion. The dorsal nerve roots are afferent sensory roots and are responsible for the transmission of sensory stimulation to the CNS <ref>Laser Spine Institute (n.d.). Guide to a Ventral Nerve Root. [online] Laser Spine Institute. Available at: <nowiki>https://www.laserspineinstitute.com/back_problems/spinal_anatomy/spinal_cord/ventral_root/</nowiki> [Accessed 21 May 2018].</ref>. The SDR procedure decreases sensory stimulation to the CNS by dividing the dorsal nerve roots whilst preserving voluntary movement <ref>NHS England. (2013). Clinical Commissioning Policy Statement : Selective Dorsal Rhizotomy (SDR) [online] Available at: <nowiki>https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/04/e09-ps-a.pdf</nowiki> [Accessed 21 May 2018].</ref>.


'''<u>Procedure:</u>'''
'''<u>Procedure:</u>'''


The operation takes place under general anaesthetic and lasts approximately 5 hours (NICE, 2006). The procedure involves dividing some of the lumbar sensory nerve roots in order to reduce the sensory input to the sensory–motor reflex arcs which are responsible for increased muscle tone. A laminectomy of one or more vertebrae from L1 to S1 vertebrae  is performed to expose the dural sac (Funk and Haberl, 2016), which is opened to display the spinal conus with or without the cauda equina. The sensory nerve roots are identified intraoperatively using electrical stimulation, those that generate unusual electrical activity are thought to be those which contribute to spasticity. The selected sensory rootlets are divided, preserving some sensory supply and the motor roots responsible for voluntary movements (NICE, 2010). Up to 50% of the sensory nerve at each level is divided. (The Robert Jones and Agnes Hunt Orthopaedic Hospital, 2014). SDR is common in North America however there are significant variations between centers in the way the procedure is carried out (Steinbok, 2007).       
The operation takes place under general anaesthetic and lasts approximately 5 hours<ref>NICE (2006).  Interventional procedure overview of selective dorsal rhizotomy for spasticity in cerebral palsy | NICE. [online]Available at: <nowiki>https://www.nice.org.uk/guidance/ipg373/evidence/overview-pdf-316141021</nowiki> [Accessed 20 May 2018].</ref>. The procedure involves dividing some of the lumbar sensory nerve roots in order to reduce the sensory input to the sensory–motor reflex arcs which are responsible for increased muscle tone. A laminectomy of one or more vertebrae from L1 to S1 vertebrae  is performed to expose the dural sac <ref>Funk, J. and Haberl, H. (2016). Monosegmental laminoplasty for selective dorsal rhizotomy—operative technique and influence on the development of scoliosis in ambulatory children with cerebral palsy. Child's Nervous System, 32(5), pp.819-825.</ref>, which is opened to display the spinal conus with or without the cauda equina. The sensory nerve roots are identified intraoperatively using electrical stimulation, those that generate unusual electrical activity are thought to be those which contribute to spasticity. The selected sensory rootlets are divided, preserving some sensory supply and the motor roots responsible for voluntary movements<ref name=":2">NICE (2010). Selective dorsal rhizotomy for spasticity in cerebral palsy | Guidance and guidelines | NICE. [online] Available at: <nowiki>https://www.nice.org.uk/guidance/ipg373/chapter/2-The-procedure#outline-of-the-procedure</nowiki> [Accessed 17 May 2018].</ref>. Up to 50% of the sensory nerve at each level is divided<ref name=":3">The Robert Jones and Agnes Hunt Orthopaedic Hospital. (2014). RJAH Hospital Film. [online] Available at: <nowiki>https://www.rjah.nhs.uk/Our-Services/ORLAU/Selective-Dorsal-Rhizotomy.aspx</nowiki> [Accessed 20 May 2018]</ref>. SDR is common in North America however there are significant variations between centers in the way the procedure is carried out<ref name=":4">Steinbok, P. (2007). Selective dorsal rhizotomy for spastic cerebral palsy: a review. Child's Nervous System, 23(9), pp.981-990.</ref>.       


For a descriptive video of the procedure follow this link to Dr. Samuel Brown discussing Selective Dorsal Rhizotomy (Seattle Children’s SDR Channel, 2017).   
For a descriptive video of the procedure follow this link to Dr. Samuel Brown discussing Selective Dorsal Rhizotomy <ref>Seattle Children's SDR channel (2017). Dr. Samuel Browd discusses Selective Dorsal Rhizotomy (SDR). [video] Available at: <nowiki>https://www.youtube.com/watch?v=HFad8MiTK_g</nowiki> [Accessed 21 May 2018].</ref>.   


https://www.youtube.com/watch?v=HFad8MiTK_g
https://www.youtube.com/watch?v=HFad8MiTK_g
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[[File:SDR Procedure .gif|none|frame|'''Diagram of the Selective Dorsal Rhizotomy procedure''' (St. Louis Children’s Hospital, 2018)]]   
[[File:SDR Procedure .gif|none|frame|'''Diagram of the Selective Dorsal Rhizotomy procedure''' (St. Louis Children’s Hospital, 2018)]]   


'''Advantages and Disadvantages of the different surgical approaches for SDR''' (Steinbok, 2007).  
'''Advantages and Disadvantages of the different surgical approaches for SDR''' <ref name=":4" />.  
{| class="wikitable"
{| class="wikitable"
|'''Procedure'''
|'''Procedure'''
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SDR has been shown to be a safe and effective to reduce spasticity of children in all Gross Motor Function Classification System Levels (GMFCS) with the benefits lasting into adolescence and adulthood (Nordmark et al., 2008; Dudley et al., 2013; Alion et al., 2015).  
SDR has been shown to be a safe and effective to reduce spasticity of children in all Gross Motor Function Classification System Levels (GMFCS) with the benefits lasting into adolescence and adulthood<ref name=":1" /><ref>Dudley, R., Parolin, M., Gagnon, B., Saluja, R., Yap, R., Montpetit, K., Ruck, J., Poulin, C., Cantin, M., Benaroch, T. and Farmer, J. (2013). Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy. Journal of Neurosurgery: Pediatrics, 12(2), pp.142-150.</ref><ref>Ailon, T., Beauchamp, R., Miller, S., Mortenson, P., Kerr, J., Hengel, A. and Steinbok, P. (2015). Long-term outcome after selective dorsal rhizotomy in children with spastic cerebral palsy. Child's Nervous System, 31(3), pp.415-423.</ref>.  


'''<u>Associated risks:</u>'''
'''<u>Associated risks:</u>'''


SDR is a high risk surgery and the procedure is irreversible. Patients may experience deterioration in walking ability, numbness and bladder dysfunction following the operation and later complications including spinal deformity and hip dislocation (NICE, 2010 and The Robert Jones and Agnes Hunt Orthopaedic Hospital, 2014). Scoliosis is generally associated with the traditional multi-level laminectomy technique which exposes about 3 inches of the lower spine (The Robert Jones and Agnes Hunt Orthopaedic Hospital, 2014). Other suggested adverse events include death, worsening motor function and/or paraplegia, infection of the surgical wound, meningitis, cerebrospinal fluid leakage, constipation, weakness, chronic pain, and late arachnoiditis and/or syringomyelia (NICE, 2010).   
SDR is a high risk surgery and the procedure is irreversible. Patients may experience deterioration in walking ability, numbness and bladder dysfunction following the operation and later complications including spinal deformity and hip dislocation<ref name=":2" /><ref name=":3" />. Scoliosis is generally associated with the traditional multi-level laminectomy technique which exposes about 3 inches of the lower spine<ref name=":3" />. Other suggested adverse events include death, worsening motor function and/or paraplegia, infection of the surgical wound, meningitis, cerebrospinal fluid leakage, constipation, weakness, chronic pain, and late arachnoiditis and/or syringomyelia <ref name=":2" />.   


'''<u>[[Cerebral Palsy Introduction|Cerebral Palsy]]</u>'''   
'''<u>[[Cerebral Palsy Introduction|Cerebral Palsy]]</u>'''   


'''<u>[[Spasticity]]</u>'''   
'''<u>[[Spasticity]]</u>'''   
'''<u>Selection criteria for the SDR procedure</u>''' 
'''<u>Outcome measures</u>''' 
'''<u>Medical management following the SDR procedure</u>''' 
'''<u>Physiotherapeutic management following the SDR procedure</u>''' 
'''<u>Clinical bottom line</u>''' 
'''<u>References</u>'''
<references />


Editing in process.  
Editing in process.  


21/05/18
21/05/18

Revision as of 14:19, 26 May 2018

Selective Dorsal Rhizotomy (SDR) is a neurosurgical procedure that aims to:[1][2]

  • Reduce spasticity that interferes with motor function in children with spastic Cerebral Palsy.
  • Improve function and mobility
  • Increase independence
  • Increase range of motion and improve positioning

Funding in the UK:

The SDR procedure is not currently available on the NHS as funding for the surgery has been withdrawn whilst NHS England examines its effectiveness via a process called Commissioning Through Evaluation.  There are 7 funded centres: Alder Hey Children’s NHS Foundation Trust; The Portland Hospital for Women and Children; Great Ormond Street Hospitals NHS Foundation Trust; Leeds Teaching Hospitals NHS Trust; Nottingham University Hospitals NHS Trust; University Hospitals Bristol NHS Foundation Trust; The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS[3]. They undertake approximately 120 SDR cases a year[4] with selected children to gather detailed information about clinical outcomes to produce a final report in Autumn 2018. Despite this SDR can be self-funded in the UK through the NHS hospital treatment top-up scheme[1]. In the UK the procedure costs between £30,000- £40,000[5].

Clinically relevant anatomy:

Two groups of nerve roots leave the spinal cord through the intervertebral foramen: the ventral and dorsal spinal roots [6]. The ventral nerve roots are efferent motor roots and are responsible for control of muscular contractions, hormone synthesis and gland secretion. The dorsal nerve roots are afferent sensory roots and are responsible for the transmission of sensory stimulation to the CNS [7]. The SDR procedure decreases sensory stimulation to the CNS by dividing the dorsal nerve roots whilst preserving voluntary movement [8].

Procedure:

The operation takes place under general anaesthetic and lasts approximately 5 hours[9]. The procedure involves dividing some of the lumbar sensory nerve roots in order to reduce the sensory input to the sensory–motor reflex arcs which are responsible for increased muscle tone. A laminectomy of one or more vertebrae from L1 to S1 vertebrae  is performed to expose the dural sac [10], which is opened to display the spinal conus with or without the cauda equina. The sensory nerve roots are identified intraoperatively using electrical stimulation, those that generate unusual electrical activity are thought to be those which contribute to spasticity. The selected sensory rootlets are divided, preserving some sensory supply and the motor roots responsible for voluntary movements[11]. Up to 50% of the sensory nerve at each level is divided[12]. SDR is common in North America however there are significant variations between centers in the way the procedure is carried out[13].

For a descriptive video of the procedure follow this link to Dr. Samuel Brown discussing Selective Dorsal Rhizotomy [14].

https://www.youtube.com/watch?v=HFad8MiTK_g

Diagram of the Selective Dorsal Rhizotomy procedure (St. Louis Children’s Hospital, 2018)

Advantages and Disadvantages of the different surgical approaches for SDR [13].

Procedure Advantages Disadvantages
Multi-level laminectomy L1-S1 The root level can be easily determined,

dorsal root can be usually be separated readily from the ventral root at each level

the amount of each dorsal root cut can be easily tailored for the individual clinical situation

the spinal cord is not at risk of damage

the procedure is readily and safely accomplished with loupes or no magnification

Long surgical incision

Extensive muscular dissection

the laminae are cut at multiple levels,

the ventral roots may be damaged during separation from the dorsal roots

significant postoperative pain.

Single or Bi-level laminectomy at the level of the conus Small surgical incision

Small amount of muscle dissection

Fewer lamine are cut

Less postoperative pain

Avoidance of the ventral roots

More technically demanding procedure and  magnification with an operating microscope is required for safety

More difficult to determine root levels

More difficult to tailor the operation to the individual clinical situation

Conus at risk

SDR has been shown to be a safe and effective to reduce spasticity of children in all Gross Motor Function Classification System Levels (GMFCS) with the benefits lasting into adolescence and adulthood[2][15][16].

Associated risks:

SDR is a high risk surgery and the procedure is irreversible. Patients may experience deterioration in walking ability, numbness and bladder dysfunction following the operation and later complications including spinal deformity and hip dislocation[11][12]. Scoliosis is generally associated with the traditional multi-level laminectomy technique which exposes about 3 inches of the lower spine[12]. Other suggested adverse events include death, worsening motor function and/or paraplegia, infection of the surgical wound, meningitis, cerebrospinal fluid leakage, constipation, weakness, chronic pain, and late arachnoiditis and/or syringomyelia [11].

Cerebral Palsy

Spasticity

Selection criteria for the SDR procedure

Outcome measures

Medical management following the SDR procedure

Physiotherapeutic management following the SDR procedure

Clinical bottom line

References

  1. ↑ 1.0 1.1 Verity, C. (2017). Selective Dorsal Rhizotomy (SDR) | Disability charity Scope UK. [online] Available at: https://www.scope.org.uk/support/therapies/selective-dorsal-rhizotomy [Accessed 20 May 2018].
  2. ↑ 2.0 2.1 Nordmark, E., Josenby, A., Lagergren, J., Andersson, G., Strömblad, L. and Westbom, L. (2008). Long-term outcomes five years after selective dorsal rhizotomy. BMC Pediatrics, 8(1).
  3. ↑ Scope UK. (2018). Selective Dorsal Rhizotomy (SDR) | Disability charity Scope UK. [online] Available at: https://www.scope.org.uk/support/therapies/selective-dorsal-rhizotomy [Accessed 22 May 2018].
  4. ↑ NHS England. (2014). NHS England » NHS England funds the evaluation of specialist surgery for more than 100 children a year with cerebral palsy. [online] England.nhs.uk. Available at: https://www.england.nhs.uk/2014/07/cte-specialist-surgery/ [Accessed 20 May 2018].
  5. ↑ The Portland Hospital (2015). The Portland Hospital – the first private hospital in the UK to perform the Selective Dorsal Rhizotomy procedure | News | The Portland Hospital. [online] Available at: http://www.theportlandhospital.com/news/the-portland-hospital-the-first-private-hospital-in-the-uk-to-perform-the-selective-dorsal-rhizotomy-procedure/ [Accessed 22 May 2018].
  6. ↑ St. Louis Children's Hospital (2018). Selective Dorsal Rhizotomy. [image] Available at: http://www.stlouischildrens.org/our-services/center-cerebral-palsy-spasticity/about-selective-dorsal-rhizotomy-sdr [Accessed 21 May 2018].
  7. ↑ Laser Spine Institute (n.d.). Guide to a Ventral Nerve Root. [online] Laser Spine Institute. Available at: https://www.laserspineinstitute.com/back_problems/spinal_anatomy/spinal_cord/ventral_root/ [Accessed 21 May 2018].
  8. ↑ NHS England. (2013). Clinical Commissioning Policy Statement : Selective Dorsal Rhizotomy (SDR) [online] Available at: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/04/e09-ps-a.pdf [Accessed 21 May 2018].
  9. ↑ NICE (2006).  Interventional procedure overview of selective dorsal rhizotomy for spasticity in cerebral palsy | NICE. [online]Available at: https://www.nice.org.uk/guidance/ipg373/evidence/overview-pdf-316141021 [Accessed 20 May 2018].
  10. ↑ Funk, J. and Haberl, H. (2016). Monosegmental laminoplasty for selective dorsal rhizotomy—operative technique and influence on the development of scoliosis in ambulatory children with cerebral palsy. Child's Nervous System, 32(5), pp.819-825.
  11. ↑ 11.0 11.1 11.2 NICE (2010). Selective dorsal rhizotomy for spasticity in cerebral palsy | Guidance and guidelines | NICE. [online] Available at: https://www.nice.org.uk/guidance/ipg373/chapter/2-The-procedure#outline-of-the-procedure [Accessed 17 May 2018].
  12. ↑ 12.0 12.1 12.2 The Robert Jones and Agnes Hunt Orthopaedic Hospital. (2014). RJAH Hospital Film. [online] Available at: https://www.rjah.nhs.uk/Our-Services/ORLAU/Selective-Dorsal-Rhizotomy.aspx [Accessed 20 May 2018]
  13. ↑ 13.0 13.1 Steinbok, P. (2007). Selective dorsal rhizotomy for spastic cerebral palsy: a review. Child's Nervous System, 23(9), pp.981-990.
  14. ↑ Seattle Children's SDR channel (2017). Dr. Samuel Browd discusses Selective Dorsal Rhizotomy (SDR). [video] Available at: https://www.youtube.com/watch?v=HFad8MiTK_g [Accessed 21 May 2018].
  15. ↑ Dudley, R., Parolin, M., Gagnon, B., Saluja, R., Yap, R., Montpetit, K., Ruck, J., Poulin, C., Cantin, M., Benaroch, T. and Farmer, J. (2013). Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy. Journal of Neurosurgery: Pediatrics, 12(2), pp.142-150.
  16. ↑ Ailon, T., Beauchamp, R., Miller, S., Mortenson, P., Kerr, J., Hengel, A. and Steinbok, P. (2015). Long-term outcome after selective dorsal rhizotomy in children with spastic cerebral palsy. Child's Nervous System, 31(3), pp.415-423.

Editing in process.

21/05/18

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