Frequently Asked Questions about Selective Dorsal Rhizotomy

Selective dorsal rhitzomy is considered a safe and effective operation and is only offered at a handful of pediatric hospitals, including Nationwide Children’s. Here are some frequently asked questions about selective dorsal rhizotomy.

What is selective dorsal rhizotomy (SDR)?

Selective dorsal rhizotomy, or SDR, is a surgery on the spine. It is done to help reduce spasticity – a condition that causes stiff, tight muscles that can’t be controlled because of a problem with the signals the brain sends (or doesn’t send) to the nerves. In nearly everyone who undergoes the operation, SDR improves mobility, reduces pain, and relieves lower-limb muscle spasticity.

In SDR, the surgeon opens a small section of the spine, finds the group of nerve fibers causing the tensed muscles, and disconnects (cuts) the nerves causing the most tension. Your child should then be better able to control their muscles. SDR does not cause floppy or limp arms or legs.

Selective dorsal rhizotomy is offered at only a handful of pediatric hospitals. It is considered a safe and effective operation, but few surgeons are experienced in the technique.

Who should consider SDR?

Most people who are good candidates for SDR surgery have spastic cerebral palsy (CP). Children with brain or spinal cord injuries may also be good candidates for the surgery in some cases.

Your child may be a good candidate for SDR if:

  • He or she has some ability to walk — assisted or independently — but is limited by spasticity in the legs.
  • He or she is not mobile and has spasticity affecting all four limbs that makes daily care, such as dressing and diapering, difficult.

Neurosurgery Chief Jeffrey Leonard, MD, at Nationwide Children’s Hospital has significant experience performing SDRs. Dr. Leonard and his team will evaluate your child during an initial consultation to decide if SDR may be the right option for your child’s spasticity. If your child is a good fit for this procedure, you can rest easy knowing that he or she is in the hands of an expert surgeon at one of the nation’s leading hospitals for both neurosurgery and physical rehabilitation.

SDR versus other spasticity treatments

Neurosurgeons at Nationwide Children’s believe SDR is one of the most beneficial treatment options for spastic CP. With SDR, the improvement in spasticity is often permanent, since the cut nerves do not grow back.

Orthopedic surgery

In most cases, SDR is recommended prior to orthopedic surgery for muscles affected by spasticity. This is because SDR can preserve muscle strength, unlike orthopedic surgery, which clips muscle or tendons to reduce spasticity and causes permanently weaker muscles. Children who undergo SDR are also likely to need fewer orthopedic surgeries overall than children who do not get SDR.

Baclofen pump

SDR is a one-time surgery. For children who receive a baclofen pump (which delivers medicine to relieve spasticity from a pump inserted under the skin), regular visits are required to refill the pump. In addition, a new pump must be surgically inserted every 5 years.

How is SDR done?

SDR takes about four hours at Nationwide Children’s. A surgery nurse will come out from time to time to give you updates on your child’s operation. It involves the following steps:

  1. The surgeon makes a 1- to 2-inch cut along the lower backbone.
  2. Two parts of a single vertebra are taken off:
    1. the spinous processes (the bumpy part of the spine that you can feel under the skin)
    2. the lamina (a flat part of the bone that covers the nerve fibers)
  3. An ultrasound and an X-ray show the surgeon which nerve fibers can be cut (sensory nerves) and which need to stay so that the muscle can be moved and controlled (motor nerves). The surgeon separates the sensory from the motor nerves using a small rubber pad.
  4. The sensory nerves are tested in small bundles using electromyography (EMG). EMG shows the electric activity of the muscles so that the surgeon can see which bundles of nerves cause the spasticity.
  5. Based on the EMG results, the surgeon cuts any severely spastic bundles. Healthy sensory nerve bundles and your child’s motor nerve bundles are left intact.
  6. The surgeon closes up the membrane that protects the nerves, puts a pain relief medication on the nerves, sews the tissue and muscle layers back together, and then glues the skin shut.
What to expect at the hospital

Your child will be put to sleep using medicine (anesthesia) before the surgery begins. An IV will be used to give your child the anesthesia and necessary antibiotics.

 After the operation is complete, your child will recover in the post-surgery room for about 2 hours before going to their room in the neuroscience unit. At Nationwide Children’s, patients undergoing SDR should expect to stay in the hospital a total of 3 weeks. The first week is spent primarily in intensive care and the neuroscience unit, and the last 2 weeks will be in the in-patient rehabilitation unit.

Follow up care and physical therapy

An equally important part of a selective dorsal rhizotomy is what happens after surgery. SDRs are most effective when they are followed by more than a year of vigorous physical therapy.

After SDR, you can expect:

  • The skin glue on the cut will peel off on its own as the skin heals. Nurses will care for your child’s surgical wound while they are at the hospital and will give you training on how to care for the wound once you go home.
  • Your child will have a few weeks to a few months of weakness in the lower limbs, as the body adjusts to the lack of spasticity.
  • Your child will need to attend twice-daily sessions of physical rehabilitation for two weeks during their stay at Nationwide Children’s. During these sessions, the therapist will work with your child to improve muscle strength, control, and coordination using exercises, games and assistive technologies.
    • Physical therapy will also focus on improving balance, walking, sitting, standing and other gross motor skills and muscle control.
  • Your child’s therapist will teach you how to do therapy and exercise at home as well, so that you can continue working on muscle control and flexibility between visits. It is crucial that you do these exercises so that your child continues to make progress.
  • Independent walkers and those who used crutches to walk before the operation often return to previous walking abilities within several weeks; however, patients who required assistance before the operation may take much longer (a few months) to get back to their previous walking level. Improvements come with consistent physical therapy during and after that time period.
  • Once your child returns home, outpatient rehabilitation visits continue 4-5 times per week for 6 months.
What are the benefits of SDR?

SDR is the only surgery that can permanently reduce spasticity in CP. It improves spasticity in people with only lower limb spasticity. In many cases, walking ability and balance improves dramatically. Most people also gain better muscle control when sitting and standing. In most cases, spasticity never returns.

Improvements in motor function are most obvious in the 6 months after SDR, but they often continue slowly and steadily for years after the operation. SDR may make new types of exercise and strength training possible, such as use of a treadmill. People with spastic CP may also experience other positive changes, such as improvements in upper body muscle control, speech, potty training, cognitive abilities or mood.

The surgery may also improve certain CP-related lower limb deformities, such as hip subluxation, contractures in the hamstring or heel cord, foot deformities and in-toeing. SDR at an early age may be most beneficial for minimizing the impact of deformities. SDR also offers a way to treat spasticity without affecting muscle strength, unlike orthopedic surgery.

What are the risks of SDR?

As with any surgery, SDR carries the risk of infection, bleeding, swelling, and a reaction to the anesthesia. Pain relief and antibiotics will be given to help avoid discomfort and infection after the surgery.

 Because the operation involves the spinal cord, other possible (but highly unlikely) risks include:

  • spinal fluid leak (this normally goes away on its own, but in some cases it may require another surgery to stop the leak)
  • bladder dysfunction
  • impotence
  • loss of feeling in the legs
  • unusual sensitivity in the skin of the feet or legs (this usually goes away within 2 to 3 weeks)
  • short-term loss of bladder control (for a few weeks only)
  • development of a spinal deformity

 People with severe spasticity in arms and legs may not always notice a reduction in spasticity after SDR. Spasticity is also more likely to return in these cases even if the surgery initially improved it.

 Even in people who do have a significant improvement in spasticity, orthopedic surgery may eventually be needed for relief of some very tight or shortened tendons or muscles that don’t get better with stretching therapy, night splints, and casting.

 

Questions to ask your child's doctor about SDR
  • Is my child a good candidate for SDR? Why or why not?
  • What types of improvements are we likely to see in my child’s motor skills?
  • How likely is it that improvements would be permanent for my child?
  • What are the alternatives to this surgery?
  • What are the pros and cons of waiting until my child is older to do the operation?
  • What will the physical therapy routine be like?
  • Are there any patient families who would be willing to talk about their experience with us?
  • What treatments do you expect my child will need down the line to manage spasticity or lower limb deformities?
Bhoomi has been able to rely less on her wheelchair, and more on her own two feet, because of a surgery performed at Nationwide Children’s Hospital. Bhoomi was born with cerebral palsy and spasticity, a muscle control disorder that involves tight or stiff muscles and the inability to control those muscles.