What is selective dorsal rhizotomy for cerebral palsy in children?

Selective dorsal rhizotomy (SDR) is a type of spine surgery that’s done to reduce muscle tightness and spasms in the legs of children with cerebral palsy (CP). The goal is to relax the muscles in the legs so that a child can move more easily, and to reduce pain. During this surgery, certain spinal nerves that are causing the leg muscles to spasm are cut. Intensive physical therapy is a key part of the recovery process.

Why might my child need SDR?

SDR may be advised if a child with CP has already tried treatments such as medicines, leg braces, and casting, and hasn’t seen improvements in reducing muscle tightness and spasms.

The SDR procedure involves cutting some of the sensory nerves that send sensation from the muscle to the spinal cord. This can’t be reversed. So before deciding on this surgery, it’s important for parents and the child’s healthcare provider to be sure that SDR is right for the child. A child typically goes through an evaluation process with a multidisciplinary team of specialists to see if they are a good candidate for the surgery.

In general, SDR is often advised for children who:

• Have spastic CP that most affects both legs, but not the arms (called spastic diplegia)

• Have less severe weakness

• Are between ages 3 and 10

• Can handle the intensive physical therapy that’s needed after SDR to improve muscle strength

Experts are still studying the long-term benefits in those with more severe CP.

What are the risks of SDR for a child?

All procedures have risks. Possible complications of SDR can include:

• Infection at the incision site

• Spinal fluid leaking at the incision site

• Back pain

• Slipped vertebrae

• Curvature of the spine

• Numbness or bladder and bowel incontinence, if the wrong nerve fibers are cut

There may be other risks depending on your child’s specific medical condition. Be sure to discuss any concerns with your child’s healthcare provider before the surgery.

How do I help my child get ready for SDR?

• Tell your child’s healthcare provider about any medicines your child takes. This includes over-the-counter and prescription medicines, vitamins, and supplements. Your child may need to stop taking some of these before the surgery.

• Follow any directions your child is given for not eating or drinking before the surgery.

• Follow any other directions from the provider.

What happens during SDR for a child?

Talk with your child’s healthcare provider about what to expect during the surgery. This surgery is done by a neurosurgeon. It's a minimally invasive procedure. In general you can expect:

1. A healthcare provider will give your child medicine (anesthesia) before the surgery starts. This is to stop pain and have your child sleep during the surgery. This medicine is often given through an IV (intravenous) line.

2. A healthcare provider will carefully watch your child's vital signs, like heart rate and blood pressure.

3. During the procedure, your child's surgeon will use ultrasound and a special X-ray to view your child’s spine.

4. The surgeon will make a small cut (incision) in your child’s lower back.

5. A part of the bone (lamina) from the spine is removed to expose the spinal cord and spinal nerves.

6. The surgeon separates out the nerves that are sending messages from the muscle to the spinal cord (the dorsal spinal roots).

7. Electrical stimulation is used test these nerves, and see which ones are causing the leg muscles to spasm.

8. The abnormal nerves will be cut (severed).

9. The incision will be closed using stitches or glue.

What happens after SDR for a child?

Talk with your child’s healthcare provider about what will happen after the surgery. Afterward, you can generally expect the following:

• Your child will be moved to a recovery room. Their vital signs will be closely watched. These include heart rate, breathing, blood pressure, and oxygen levels. Then your child will be moved to a regular room.

• Your child will likely have pain after the surgery. This is treated with pain medicine. Talk with your child’s surgeon about any over-the-counter pain medicines you can give your child.

• Your child can eat a normal diet as soon as they are able.

• Some physical therapy will be started in the hospital.

• Your child will likely go home after a few days.

At home after the procedure:

• Most children will have some leg weakness right after SDR. This can last for a few weeks or months. It may make it hard to sit, stand, or walk. After the surgery, your child will need to follow an intensive physical therapy program for about 6 months to 1 year. This is to help stretch and strengthen the muscles.

• Keep all follow-up appointments.

• Follow all the instructions your child’s provider gives you about activity, medicine, diet, and caring for the incision site.

• Call the provider right away if there is a lot of fluid leaking at the incision site, or if your child has a lot of pain, chills, or a fever. Call 911 if your child has severe symptoms such as trouble breathing, chest pain, numbness, weakness, or severe headache.

The healthcare provider may give you other instructions about what your child can expect after the surgery.

Next steps

Before you agree to the test or the procedure for your child make sure you know:

• The name of the test or procedure

• The reason your child is having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• When and where your child is to have the test or procedure

• Who will do the procedure and what that person’s qualifications are

• What would happen if your child did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how you will get the results

• Who to call after the test or procedure if you have questions or your child has problems

• How much you will have to pay for the test or procedure