Selective Dorsal Rhizotomy

Selective Dorsal Rhizotomy  - procedure no longer available at The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (RJAH) - update July 2014.

 

Under the current NHS England rules associated with the Commissioning through Evaluation programme, RJAH is unfortunately unable to offer Selective Dorsal Rhizotomy (SDR) surgery as an NHS service at the Oswestry orthopaedic hospital.   However, as the centre that brought SDR to the UK, our team have extensive experience, dating back to 1995, in the in-depth assessment of potential SDR patients, performance of the SDR procedure itself and the intensive post-operative rehabilitation of patients who have undergone SDR surgery.   We will continue to undertake long term follow up of children who have had their surgery performed at RJAH after meeting our centre’s very exacting selection criteria and we plan to publish our results in order to broaden the evidence base.    

In addition, we continue to offer a comprehensive gait analysis and functional assessment service on the NHS which can provide a comprehensive management plan for the care of adults and children with cerebral palsy and other neurological conditions that affect mobility.     Referrals for assessment should be made to Mr A P Roberts, Consultant Paediatric Orthopaedic Surgeons, Orthotic Research & Locomotor Assessment Unit, RJAH Hospital NHS Foundation Trust, Oswestry, Shropshire, SY10 7AG.


Below is some information that we have historically published about SDR which you might find informative.
 

What is Selective Dorsal Rhizotomy?

Selective Dorsal Rhizotomy (SDR) is a surgical procedure performed on the spinal nerves to reduce levels of spasticity in the legs, followed by an intensive period of in-patient physiotherapy.  The objective of SDR is to allow the patient to become more mobile, more independent and to reduce the need for orthopaedic surgery at a later age.

SDR was performed here at The Robert Jones and Agnes Hunt Hospital in Oswestry from 1995  to 2014.   Our selection criteria have been carefully reviewed and refined over that period.   On the basis of our long-term experience with the procedure we are confident that SDR is appropriate and safe for only a very small percentage of children with cerebral palsy.

We have listed below some of the questions that we have most commonly been asked by parents and clinicians of prospective patients.  If you have any further questions or need any clarification please do not hesitate to get in touch by calling 01691 404236 or emailing karen.edwards@rjah.nhs.uk.


What expertise does RJAH Hospital have with SDR?

The first doctor to promote SDR was South African surgeon, Warwick Peacock.   He took his expertise to the United States and from there the technique has spread throughout Europe and North America.  Surgeons from Oswestry went over to Los Angeles to learn from Warwick Peacock and brought the SDR technique over to the UK.  The SDR programme in Oswestry began in 1995.

Historically clinicians in the UK have been very wary of SDR and for some years Oswestry remained the only centre providing treatment.  Because of the level of doubt amongst other experts we have had to proceed with caution.  We put a great deal of effort into deciding which children were suitable and we follow up our patients for many years in order to learn more about how they progress.  In the first decade we treated 20 patients, of the 70 who were referred to us for consideration.

Our team published a paper in 2007 detailing the results from the first 19 cases and we are currently reviewing the longer term outcomes for that group of patients together with results for a further cohort of more recent cases.

Selective Dorsal Rhizotomy has undergone extensive review by the National Institute for Health and Clinical Excellence (NICE) as part of both a stand-alone evaluation, the latest version of which was published in December 2010: http://guidance.nice.org.uk/IPG373/Guidance/pdf/English

and a wider review of the treatment of spasticity in children published in July 2012: http://publications.nice.org.uk/spasticity-in-children-and-young-people-with-non-progressive-brain-disorders-cg145

Members of the RJAH team made a significant contribution to both evaluations.    The NICE guidance strongly advises that SDR should be undertaken by a multidisciplinary team with specialist training and expertise in the care of spasticity in patients with cerebral palsy, and with access to the full range of treatment options.
 

How good are the results from Oswestry?

There are many different ways of measuring how much a patient has benefited from an SDR.  Our clinical experience is that all patients have reduced spasticity in their legs.  Conversations with the children and families about the changes they have observed have also been very positive.

To understand the results of any treatment scientifically, however, you need to take measurements.  We assess children in some detail before SDR and review them regularly afterwards for a number of years.  Because of this we have objective figures to report.  The results for the first 19 children are in our published paper and here we looked at lots of different measurements.  Perhaps the easiest to understand is the Gross Motor Function Classification System (GMFCS) which classifies children’s ability into 1 of 5 levels.  Because there are only 5 levels the differences between levels are large. 15 children improved by at least 1 level after SDR, showing a substantial improvement.  The remaining children may well have improved but the changes were smaller.  No children got worse.
 

What is spasticity?

Spasticity is abnormal extra activity in muscles.  This can be caused by a number of different neurological conditions but perhaps the commonest is cerebral palsy.  Because of the injury to the brain, the signals received by cells in the spinal cord that control muscles are altered and this means that the reflexes become overactive.  This makes activities such as walking difficult because of the stiffness that children have to work against.

Which patients are suitable for SDR?

Children with cerebral palsy can be very different from each other.  This is because the condition depends on precisely which parts of the brain are affected.  Cerebral palsy is divided into different types, and it is the spastic type which may be treated with SDR.  
Even children who have spastic cerebral palsy will have different amounts of spasticity.  Children whose problems are mostly due to weak muscles or poor muscle control will not necessarily be helped by SDR.

Spastic cerebral palsy is divided into different types according to which limbs are affected.  SDR is most suitable for children with diplegia, whose legs are affected.  Children with hemiplegia (with one arm and one leg affected) tend to do very well with more conventional treatments.

In Oswestry we only treat patients who can walk to some degree.  Many need to use walking aids and splints.  Children who cannot take any steps and rely on a powered wheelchair, however, would not be considered for SDR.  Very young children who are still learning to walk are changing very rapidly.  For this reason we prefer to wait until their walking pattern has settled down before deciding whether SDR is the best option for them.


What age groups are treated with SDR?

Our main aim is to reduce spasticity  in growing children.  With less spasticity children’s muscles and bones grow more normally.  This is particularly true as they develop rapidly through adolescence.  After SDR children have the opportunity to learn to control their legs once the spasticity has been reduced in a way adults do not.  One growth has finished, the clinical condition stays unchanged provided the patient retains their fitness and weight. For this reason, the treatment is not offered to adults.

There is more information about how we select patients for SDR in the paper we have published.  We will be very happy to send you a copy if you would like one.


What happens during the SDR operation?

The surgeon opens up the spine and divides some of the nerves that contribute to the abnormal reflexes causing the spasticity.  Afterwards patients should feel that their muscles are more relaxed and that can help with movements such as walking.

How do surgeons decide which nerves to cut?

Because selective dorsal rhizotomy is a permanent procedure that cannot be undone, it is important to plan the operation carefully.  At this hospital we operate on the first lumbar to the first sacral nerves.   Up to 50% of the sensory nerve at each level is routinely divided.   Some clinicians in other centres divide the S2 nerve but we have been cautious about this because these nerves control the bladder, bowels and sexual function.  S2 is included in rhizotomy procedures to help the calf muscle but we have found that the calf muscle responds well to a selective dorsal rhizotomy at S1 level alone.

What are the risks with SDR?

SDR is a surgical operation and carries some theoretical risks.  These include meningitis, incontinence, numbness, deformity of the spine and dislocation of the hips.  Some of these complications have been reported by other centres.  In Oswestry our patients have had no major problems associated with SDR.  One child needed surgery on a painful hip, but this was some years after the SDR.

The medical literature has reports of scoliosis (a curvature of the spine) following SDR.  This is generally associated with the traditional technique which exposes about 3 inches of the lower spine.  We have not experienced scoliosis in any of our patients.

Children with cerebral palsy often develop tight muscles as they grow.  Bones can also develop with an abnormal twist, causing the feet to point inwards.  Children with these problems may need to have surgery to correct them.  Our experience is that children who have had an SDR do not need as much additional surgery.  As a precaution, however, we do insist that children continue to wear splints as they grow.