Selective Dorsal Rhizotomy

Introduction
Selective Dorsal Rhizotomy is a neurosurgery which involves sectioning (cutting) of some of the sensory nerve fibers that come from the muscles and enter the spinal cord. At the time of the operation, the neurosurgeon divides each of the dorsal roots into 3-5 rootlets and stimulates each rootlet electrically. By examining electromyography (EMG) responses from muscles in the lower extremities, the surgical team identifies the rootlets that cause spasticity. The abnormal rootlets are selectively cut; leaving the normal rootlets intact. This reduces messages from the muscle, resulting in a better balance of activities of nerve cells in the spinal cord, and thus reduces spasticity.  

Selection of a right Candidate for Dorsal Rhizotomy 
Inclusion criteria
Pediatric:

• The child should be at least 2 years of age
• Diagnosis of cerebral palsy spastic diplegia mostly.
• Rarely children with spastic quadriplegia or spastic hemiplegia
• Mode of active mobility such as crawling or walking with or without an assistive device
• On MRI examination there should be no severe damage to the basal ganglia

Adults:

• Diagnosis of spastic diplegia
• Ambulation with or without assistive device
• There should be no fixed deformity or mild fixed deformities
• Patients who show motivation to attend intensive physical therapy and perform home exercise program

A good candidate will have

• Good muscle strength in the legs and trunk
• Evidence of adequate motor control
• History of delayed motor development
• Adequate motivation and ability to cooperate in therapy

• Exclusion criteria
  Children with CP who possess some of the following features are not appropriate candidates SDR, such as
• Children who have suffered meningitis, congenital brain infection, congenital hydrocephalus
• Children who have mixed Cerebral Palsy with predominant rigidity or Dystonic features
• Children with significant Athetosis or ataxia
• Children who have severe scoliosis
• Children who are not going to make functional gains after surgery due to poor cognition or other health issues

Possible Complications 
Paralysis of the legs and bladder, impotence, and sensory loss are the most serious complications. Wound infection and meningitis are also possible, but they are usually controlled with antibiotics. Leakage of the spinal fluid through the wound is another risk. 

Abnormal sensitivity of the skin on the feet and legs is relatively common after SDR, but usually resolves within 6 weeks.

Pre-operative Assessment 
The therapy assessment focuses specifically on the following areas:

• Developmental history
• Spasticity
• Strength
• Motor Control
• Developmental Functions
• Range of Motion
• Balance
• Gait

Possibility of Orthopedic Surgery after SDR 
In case of need all kinds of orthopedic surgery can be done after SDR 

Cost factor and Hospital stay: 
The cost of the procedure is more or less same as any other spinal surgical procedure (Cost varies from 1.5 Lakhs to 2.5 lakhs INR) and the child stays in the hospital for
7-15 days altogether. During the hospital stay the child gets regular specialized therapy. After one week or so the child is discharged from the hospital and a home program is given to the parents to carry out at home

Conclusion- Our experience
In our practice, we have seen a few cases with cerebral palsy operated with SDR / SPR, with appreciable improvements. Fortunately, we have not seen any operated case with negative impact or functional loss.� SDR / SPR can have miraculous results if the candidate is rightly selected.

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