Selective Dorsal Rhizotomy for Spasticity Technique

  • Author: Richard CE Anderson, MD; Chief Editor: Kim J Burchiel, MD, FACS  more...
 
Updated: Sep 20, 2015
 

Approach Considerations

Although a traditional selective dorsal rhizotomy (SDR) involves a long skin incision with a 5- or 6-level laminectomy or laminoplasty, it can also be performed with a less-invasive approach through a smaller incision and a single level laminectomy.[25] Advantages of this approach include a smaller incision, fewer levels of bone removal or disruption, and less postoperative pain.[11]

Preoperative antibiotics and steroids are given prior to skin incision.

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Selective Dorsal Rhizotomy

The steps of SDR are illustrated in the images below.

After the conus is clearly identified, a single laAfter the conus is clearly identified, a single laminectomyis done entirely with a Midas Rex craniotome. At least 5 mm of thecaudal conus should be exposed. The laminectomy extends laterallyclose to the facet joint. Courtesy of Tae S Park, MD.
After the dural incision, an operatingmicroscope iAfter the dural incision, an operatingmicroscope is brought into the field. The L-1 and L-2 spinal roots areidentified at the corresponding intervertebral foramina, and the filumterminale in the midline is found. Courtesy of Tae S Park, MD.
The L-2 dorsal root and the dorsal rootsmedial to The L-2 dorsal root and the dorsal rootsmedial to the L-2 root are retracted medially to separate the L2-S2 dorsalroots from the ventral roots. The thin S3-5 spinal roots exiting fromthe conus are identified. A cotton patty is placed over the ventralroots and lower sacral roots. Courtesy of Tae S Park, MD.
A 5 mm Silastic sheet is placed underthe L2-S2 dorA 5 mm Silastic sheet is placed underthe L2-S2 dorsal roots, after which the sugeon again inspects the L-2 dorsal root at the foraminal exit, the lateral surface of the conusbetween the dorsal and ventral roots, and the lower sacral roots near the filum terminale. The Inspection ensures placement of only the the L2-S2 dorsal roots on top of the Silastic sheet. Courtesy of Tae S Park, MD.
The L-2 dorsal root is easily identified. In an atThe L-2 dorsal root is easily identified. In an attempt to identify the L3-S2 dorsal roots, all the dorsal roots are spread over the Silastic sheet and grouped into presumed individual dorsal roots. Then the innervation pattern of each dorsal root is examined with electromyographic (EMG) responses to electrical stimulation with a threshold voltage. Courtesy of Tae S Park, MD.
With a Scheer needle, each dorsal root is subdividWith a Scheer needle, each dorsal root is subdivided into three to five rootlet fascicles, which are subjected to EMG testing. Courtesy of Tae S Park, MD.
Stimulation of an L-2 rootlet fascicle elicits an Stimulation of an L-2 rootlet fascicle elicits an unsustained discharge to a train of titanic stimuli. Courtesy of Tae S Park, MD.
The rootlet is thus spared from sectioning and plaThe rootlet is thus spared from sectioning and placed behind the Silastic sheet. Courtesy of Tae S Park, MD.
Stimulation of a rootlet is thus sectioned. CourteStimulation of a rootlet is thus sectioned. Courtesy of Tae S Park, MD.
The rootlets spared from sectioning are under the The rootlets spared from sectioning are under the Silastic sheet, and the roots to be tested are on top of the Silastic sheet. Note the EMG testing and sectioning of the dorsal roots are performed caudal to the conus. Courtesy of Tae S Park, MD.
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Contributor Information and Disclosures
Author

Richard CE Anderson, MD Assistant Professor of Neurosurgery and Pediatric Neurosurgery, Columbia University Medical Center, Columbia University College of Physicians and Surgeons; Director, Pediatric Neurosurgery, St Joseph's Children's Hospital

Richard CE Anderson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, Congress of Neurological Surgeons, American Association of Neurological Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Paul R Gigante, MD Resident Physician in Neurological Surgery, Columbia University College of Physicians and Surgeons

Paul R Gigante, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery

Disclosure: Nothing to disclose.

Barbara CS Hamilton Columbia University College of Physicians and Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Kim J Burchiel, MD, FACS John Raaf Professor and Chairman, Department of Neurological Surgery, Professor, Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University School of Medicine; Attending Neurosurgeon, Section of Neurosurgery, Portland Veterans Affairs Medical Center; Attending Neurosurgeon, Shriners Hospital for Children

Kim J Burchiel, MD, FACS is a member of the following medical societies: American Academy of Pain Medicine, American Association of Neurological Surgeons, American College of Surgeons, American Pain Society, International Association for the Study of Pain, Oregon Medical Association, Society of Neurological Surgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

References
  1. Arens LJ, Peacock WJ, Peter J. Selective posterior rhizotomy: a long-term follow-up study. Childs Nerv Syst. 1989 Jun. 5(3):148-52. [Medline].

  2. Kim HS, Steinbok P, Wickenheiser D. Predictors of poor outcome after selective dorsal rhizotomy in treatment of spastic cerebral palsy. Childs Nerv Syst. 2006 Jan. 22(1):60-6. [Medline].

  3. Delgado MR, Hirtz D, Aisen M, Ashwal S, Fehlings DL, et al. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2010 Jan 26. 74(4):336-43. [Medline]. [Full Text].

  4. Hoving MA, van Raak EP, Spincemaille GH, Palmans LJ, Becher JG, Vles JS. Efficacy of intrathecal baclofen therapy in children with intractable spastic cerebral palsy: a randomised controlled trial. Eur J Paediatr Neurol. 2009 May. 13(3):240-6. [Medline].

  5. Albright AL. Intrathecal baclofen in cerebral palsy movement disorders. J Child Neurol. 1996 Nov. 11 Suppl 1:S29-35. [Medline].

  6. Foerster. Resection of the Posterior Spinal Nerve-roots in the Treatment of Gastric Crises and Spastic Paralysis. Proc R Soc Med. 1911. 4:226-46. [Medline]. [Full Text].

  7. Foester O. On the indications and results of the excision of posterior spinal nerve roots in men. Surg Gynecol Obstet. May 1913;16:464-474.

  8. Fasano VA, Barolat-Romana G, Ivaldi A, Sguazzi A. [Functional posterior radiculotomy, in the treatment of cerebral spasticity. peroperative electric stimulation of posterior roots and its use in the choice of the roots to be sectioned]. Neurochirurgie. 1976. 22(1):23-34. [Medline].

  9. Sindou M, Quoex C, Baleydier C. Fiber organization at the posterior spinal cord-rootlet junction in man. J Comp Neurol. 1974 Jan 1. 153(1):15-26. [Medline].

  10. Peacock WJ, Eastman RW. The neurosurgical management of spasticity. S Afr Med J. 1981 Nov 28. 60(22):849-50. [Medline].

  11. Steinbok P. Selective dorsal rhizotomy for spastic cerebral palsy: a review. Childs Nerv Syst. 2007 Sep. 23(9):981-90. [Medline].

  12. Gutknecht SM, Schwartz MH, Munger ME. Ambulatory children with cerebral palsy do not exhibit unhealthy weight gain following selective dorsal rhizotomy. Dev Med Child Neurol. 2015 Apr 27. [Medline].

  13. Steinbok P, Schrag C. Complications after selective posterior rhizotomy for spasticity in children with cerebral palsy. Pediatr Neurosurg. 1998 Jun. 28(6):300-13. [Medline].

  14. Abbott R. Complications with selective posterior rhizotomy. Pediatr Neurosurg. 1992. 18(1):43-7. [Medline].

  15. McFall J, Stewart C, Kidgell V, Postans N, Jarvis S, Freeman R, et al. Changes in gait which occur before and during the adolescent growth spurt in children treated by selective dorsal rhizotomy. Gait Posture. 2015 Jun 29. [Medline].

  16. Josenby AL, Wagner P, Jarnlo GB, Westbom L, Nordmark E. Functional performance in self-care and mobility after selective dorsal rhizotomy: a 10-year practice-based follow-up study. Dev Med Child Neurol. 2015 Mar. 57 (3):286-93. [Medline].

  17. McLaughlin JF, Bjornson KF, Astley SJ, Graubert C, Hays RM, Roberts TS, et al. Selective dorsal rhizotomy: efficacy and safety in an investigator-masked randomized clinical trial. Dev Med Child Neurol. 1998 Apr. 40(4):220-32. [Medline].

  18. McLaughlin J, Bjornson K, Temkin N, Steinbok P, Wright V, Reiner A, et al. Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol. 2002 Jan. 44(1):17-25. [Medline].

  19. Kan P, Gooch J, Amini A, Ploeger D, Grams B, Oberg W, et al. Surgical treatment of spasticity in children: comparison of selective dorsal rhizotomy and intrathecal baclofen pump implantation. Childs Nerv Syst. 2008 Feb. 24(2):239-43. [Medline].

  20. Steinbok P, Reiner AM, Beauchamp R, Armstrong RW, Cochrane DD, Kestle J. A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy. Dev Med Child Neurol. 1997 Mar. 39(3):178-84. [Medline].

  21. Greene WB, Dietz FR, Goldberg MJ, Gross RH, Miller F, Sussman MD. Rapid progression of hip subluxation in cerebral palsy after selective posterior rhizotomy. J Pediatr Orthop. 1991 Jul-Aug. 11(4):494-7. [Medline].

  22. Mooney JF 3rd, Millis MB. Spinal deformity after selective dorsal rhizotomy in patients with cerebral palsy. Clin Orthop Relat Res. 1999 Jul. 48-52. [Medline].

  23. Langerak NG, Lamberts RP, Fieggen AG, Peter JC, van der Merwe L, Peacock WJ, et al. A prospective gait analysis study in patients with diplegic cerebral palsy 20 years after selective dorsal rhizotomy. J Neurosurg Pediatr. 2008 Mar. 1(3):180-6. [Medline].

  24. Carroll KL, Moore KR, Stevens PM. Orthopedic procedures after rhizotomy. J Pediatr Orthop. 1998 Jan-Feb. 18(1):69-74. [Medline].

  25. Park TS, Owen JH. Surgical management of spastic diplegia in cerebral palsy. N Engl J Med. 1992 Mar 12. 326(11):745-9. [Medline].

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Schematic drawings representing the excitatory and inhibitory influences on the spinal cord alpha motor neuron, which innervates the muscle fibers. (A) Normal physiology with a balance of inhibitory influence from descending neurons and excitatory influence from the sensory spinal reflex arc. (B) In children with spasticity, injury to the upper motor neuron results in a decrease in the descending inhibitory influence, leaving a hyperactive spinal cord reflex arc. By cutting some of the dorsal rootlets, selective dorsal rhizotomy can help restore balance to the alpha motor neuron by reducing the amount of excitatory influence on the alpha motor neuron. Courtesy of Tae S Park, MD.
After the conus is clearly identified, a single laminectomyis done entirely with a Midas Rex craniotome. At least 5 mm of thecaudal conus should be exposed. The laminectomy extends laterallyclose to the facet joint. Courtesy of Tae S Park, MD.
After the dural incision, an operatingmicroscope is brought into the field. The L-1 and L-2 spinal roots areidentified at the corresponding intervertebral foramina, and the filumterminale in the midline is found. Courtesy of Tae S Park, MD.
The L-2 dorsal root and the dorsal rootsmedial to the L-2 root are retracted medially to separate the L2-S2 dorsalroots from the ventral roots. The thin S3-5 spinal roots exiting fromthe conus are identified. A cotton patty is placed over the ventralroots and lower sacral roots. Courtesy of Tae S Park, MD.
A 5 mm Silastic sheet is placed underthe L2-S2 dorsal roots, after which the sugeon again inspects the L-2 dorsal root at the foraminal exit, the lateral surface of the conusbetween the dorsal and ventral roots, and the lower sacral roots near the filum terminale. The Inspection ensures placement of only the the L2-S2 dorsal roots on top of the Silastic sheet. Courtesy of Tae S Park, MD.
The L-2 dorsal root is easily identified. In an attempt to identify the L3-S2 dorsal roots, all the dorsal roots are spread over the Silastic sheet and grouped into presumed individual dorsal roots. Then the innervation pattern of each dorsal root is examined with electromyographic (EMG) responses to electrical stimulation with a threshold voltage. Courtesy of Tae S Park, MD.
With a Scheer needle, each dorsal root is subdivided into three to five rootlet fascicles, which are subjected to EMG testing. Courtesy of Tae S Park, MD.
Stimulation of an L-2 rootlet fascicle elicits an unsustained discharge to a train of titanic stimuli. Courtesy of Tae S Park, MD.
The rootlet is thus spared from sectioning and placed behind the Silastic sheet. Courtesy of Tae S Park, MD.
Stimulation of a rootlet is thus sectioned. Courtesy of Tae S Park, MD.
The rootlets spared from sectioning are under the Silastic sheet, and the roots to be tested are on top of the Silastic sheet. Note the EMG testing and sectioning of the dorsal roots are performed caudal to the conus. Courtesy of Tae S Park, MD.
 
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