By: Christiana Cornea, MD & Smruti K. Patel, MD, FAANS, FCNS, FACS, FAAP
Children with cerebral palsy (CP) often experience spasticity, which means their muscles are tighter than usual and can lead to involuntary movements. This tightness may be present at rest or become worse with movement, especially with quick movements.
Spasticity happens because the brain and nerves send unusual signals to the muscles, causing them to tighten or stiffen. This can make it harder for your child to move comfortably, maintain balance and match their movements. Spasticity can also cause muscle cramps, stiffness and pain.
Building a team of specialists to treat spasticity
Caring for a child with spasticity often involves a multidisciplinary team, meaning specialists from different areas work together. Each team member has a different role in understanding your child’s needs and choosing the treatments that may help them move more comfortably.
Pediatric neurosurgeon: Evaluates how your child’s brain, spinal cord and nerves affect muscle tightness and movement. The neurosurgeon determines whether your child may benefit from a procedure such as selective dorsal rhizotomy (SDR), explained below. They will review imaging, such as MRI scans of the brain and spine.
Pediatric orthopedic surgeon: Evaluates your child’s bones, joints, muscles and posture. They recommend treatments for joint stiffness (contractures), changes in bone structure or other problems with the bones or muscles. In some cases, surgery may be recommended.
Physical therapist (PT): Evaluates your child’s movement, strength, flexibility, balance and muscle tightness. Physical therapy is an important part of spasticity treatment before and after surgery.
Occupational therapist (OT): Helps your child build skills needed for everyday activities, such as dressing, eating, playing and using their hands. The goal is to help your child become as independent as possible.
Pediatric neurologist: Evaluates your child’s muscle tone, movement, development and overall nervous system function. The neurologist may recommend imaging or genetic testing when needed and can also help manage related conditions, such as seizures.
Pediatric physical medicine and rehabilitation (PM&R) specialist: Evaluates how spasticity affects your child’s movement, comfort and daily activities. Treatment may include medications or injections, such as Botox or phenol, to help relax tight muscles. PM&R specialists may also recommend braces, wheelchairs, walkers, communication devices and other equipment to support your child’s daily needs.
The specialists involved in your child’s care may vary depending on your child’s needs and the treatment center. The team works together with you and your child to develop a treatment plan focused on comfort, movement, function and independence.
What is selective dorsal rhizotomy?
Selective dorsal rhizotomy (SDR) is a surgery used to reduce spasticity in some children with cerebral paley. During SDR, the surgeon finds and cuts selected sensory nerve fibers that are sending unusual signals to the nervous system and leading to muscle tightness.
What happens during selective dorsal rhizotomy surgery?
Before surgery: A magnetic resonance imaging (MRI) of your child’s spine helps the surgical team find where the spinal cord ends. This area is called the conus medullaris and is usually located around the L1-L2 level of the spine. Its exact location can vary from child to child.
Finding the correct location: In the operating room, an X-ray is used to confirm the correct level of the spine. There are several ways to perform SDR surgery. One common approach uses a single-level laminectomy, in which a small amount of bone at the back of one vertebra (a bone in the spinal column) is removed. This allows the surgeon to safely reach the nerves.
Identifying the spinal cord and nerves: Some centers also use ultrasound during surgery to confirm the location of the conus medullaris. The surgeon then carefully opens the protective covering around the spinal cord, nerves and spinal fluid (called the dura).
Testing the nerves: The surgical team uses electromyography (EMG), a type of nerve and muscle testing, to help identify the different nerve roots. The sensory nerve roots involved in spasticity are carefully separated from the motor nerve roots, which control movement. Nerves involved in bowel and bladder function are also identified and protected. Each sensory nerve root is carefully divided into smaller nerve fibers called rootlets. Each rootlet is then tested using EMG to see how the muscles respond when the nerve is stimulated.
Checking muscle response: At some centers, a physical therapist is also present in the operating room. The physical therapist watches and feels which muscles in your child’s legs respond during nerve stimulation. This provides more information to help confirm that the muscle response matches the EMG findings.
Cutting unusual rootlets: Using the EMG results and the muscle responses, the surgical team identifies the rootlets most leading to unusual muscle activity. Unusual rootlets are cut, while rootlets with normal or less unusual responses are left alone.
Who is a good candidate for selective dorsal rhizotomy?
Several factors are taken into account when deciding whether SDR may be a good option for your child. The care team will look at the type and location of muscle tightness, your child’s ability to move and participate in therapy and whether there are problems with their bones or joints.
SDR most often benefits children with spastic diplegia, (spasticity that mainly affects the legs). Some children with spastic quadriplegia, where all arms and legs are affected, may also benefit.
Children who can walk or have the potential to walk often benefit the most. This is partly because they can participate in the intensive physical therapy needed after surgery.
SDR may also be considered for children with more limited movement. In these cases, the main goals are improving comfort and positioning or making daily care easier.
SDR is generally not recommended when involuntary muscle contractions and movements (dystonia) is the main movement problem. Children with mixed movement disorders, such as ataxia (problems with balance and coordination) or athetosis (slow, uncontrolled movements), may also be less likely to benefit.
Because every child with cerebral palsy is different, the care team will carefully evaluate your child’s movement, goals and overall needs before recommending SDR.
When is the best time for surgery?
SDR can be performed in children as young as 2 –years-old. However, your child must be able to participate in frequent and intensive physical therapy for many months after surgery.
There is no strict upper age limit for SDR. However, surgery is often best at a younger age, before long-term muscle tightness leads to permanent changes in the bones and joints. These changes may include fixed joint contractures, where a joint can no longer fully straighten or move, or painful problems with the hips.
Recovery after SDR: a team approach
Recovery after SDR takes time and involves several members of your child’s care team. Physical and occupational therapy are especially important for helping your child build strength and learn new ways to move after surgery.
What happens in the hospital?
Immediately after surgery, your child may spend some time in the intensive care unit (ICU) for close monitoring. The exact recovery plan varies by treatment center. Some centers may limit your child’s movement for a short time to allow the surgical area to heal. Once your child can safely move more freely, physical therapy will begin.
During the first days to weeks after surgery, your child may seem weaker than before surgery. This is expected for many children. Spasticity can sometimes help make up for muscle weakness. Once the tightness is reduced, weakness that was already present may become more noticeable. Physical therapy helps your child strengthen these muscles and adjust to moving with less spasticity.
What does rehabilitation involve?
The rehabilitation plan varies by treatment center and your child’s individual needs. Some children complete a short period of intensive inpatient recovery before going home. Other centers begin intensive outpatient therapy within the first few weeks after surgery.
Physical therapy will, at first, focus on helping your child gain strength, improve muscle control and practice safe movement. As your child progresses, therapy may focus on individual goals such as:
Improving walking and balance
Building strength and endurance
Increasing walking speed
Practicing walking on a treadmill, when appropriate
Improving coordination and power
Occupational therapy may also help your child use these new movement skills during everyday activities, such as dressing, bathing, playing and moving around at home or school.
Will my child need braces or other equipment?
Your child’s physical therapist, occupational therapist, PM&R specialist and orthopedic surgeon will determine whether more support is needed during recovery. The team may recommend braces, walking aids or other equipment to support movement, positioning and independence.
What are the possible risks and complications of SDR?
As with any surgery, SDR has possible risks and complications. Serious complications are uncommon, but it is important to understand both the short-term and long-term risks before deciding whether surgery is right for your child. Your surgical team will discuss your child’s individual risks with you.
Short-term risks:
Infection or problems with wound healing
Bleeding
Side effects from anesthesia
Cerebrospinal fluid (CSF) leak, which occurs when the fluid surrounding the brain and spinal cord leaks through the surgical area
Changes in feeling, such as numbness or unusual sensations
New or increased muscle weakness
Temporary changes in bowel or bladder control
The risk of serious complications, such as a CSF leak or permanent brain problems, is low. Complication rates may vary between treatment centers and based on your child’s individual health and needs.
Long-term risks/considerations:
Changes in feeling: Some children may have numbness, tingling or increased sensitivity.
Bowel or bladder changes: Because some sensory nerves are involved in bowel and bladder function, injury to these nerves can lead to problems with bowel or bladder control. These nerves are carefully found and protected during surgery.
Muscle weakness: Once the spasticity is reduced, muscle weakness may become more noticeable. Strength often improves with intensive physical therapy.
Dystonia: In some children, reducing spasticity may reveal another movement problem called dystonia. Dystonia causes involuntary muscle contractions that can lead to twisting movements or unusual postures. It may become more noticeable with excitement, pain, constipation or when your child is working hard to speak or move. If dystonia becomes a concern after SDR, treatments such as medications or Botox injections may help manage symptoms.
Your child’s care team will continue to monitor their movement, strength, comfort and function after surgery. Ongoing follow-up and rehabilitation allow the team to identify concerns early and adjust your child’s treatment plan as needed.
What can you expect after SDR?
SDR can provide important benefits for children who are good candidates for the surgery. However, every child is different, and results will vary. Surgery is only one part of treatment. Intensive physical therapy after SDR is essential to help your child build strength and get the most benefit from surgery.
What are the potential benefits of SDR?
Less spasticity: Muscle tightness is often noticeably reduced soon after surgery. This may make your child more comfortable and improve positioning. This may mean your child no longer needs medications or injections to control tightness.
Improved movement: With rehabilitation, some children may improve their walking, balance, coordination and overall mobility. Children who use walkers, braces or other assistive devices may continue to use them after surgery.
Fewer problems from muscle tightness: Reducing spasticity may help decrease some of the unusual forces placed on growing bones and joints. However, some children may still need orthopedic treatment or surgery as they grow.
Greater independence and participation: Improved comfort and movement may make it easier for your child to participate in everyday activities at home, school and in the community. These changes may also support confidence, independence and quality of life.
Key takeaways for parents
Selective dorsal rhizotomyis not a cure for cerebral palsy, but for the right child, it can be an important part of a long-term treatment plan. The goal is not simply to reduce muscle tightness, it is to help your child move more comfortably, participate more fully in daily life and reach their goals.
The best results come from a partnership between your child, your family and the multidisciplinary care team. With careful patient selection, dedicated rehabilitation, and ongoing support, SDR may help your child build on their abilities and become as comfortable and independent as possible.
Note: Paola Maria "Lala" Mendoza-Sengco, MD, also contributed to this article.
About Dr. Cornea
Christiana Cornea, MD, is a fourth-year neurosurgery resident at the University of Cincinnati. She earned her medical degree from the University of North Carolina School of medicine. She is planning on pursuing a complex spine fellowship at the University of Cincinnati at the end of her residency.
About Dr. Patel
Smruti Patel, MD, FAANS, FCNS, FACS, FAAP, is an associate professor in the division of pediatric neurosurgery at Cincinnati Children’s Hospital Medical Center and co-director of the Surgical Spasticity Clinic. She is an active member of the AAP Section on Neurological Surgery. Her clinical research interests focus on surgical tone management of patient with cerebral palsy and other neurological disorders, the full spectrum of congenital spinal dysraphism and related pathologies, particularly in the framework of multidisciplinary care models.
About Dr. Mendoza-Sengco
Paola Maria "Lala" Mendoza-Sengco, MD, is an associate professor in the division of pediatric rehabilitation medicine at Cincinnati Children’s Hospital who serves as the medical director of the hospital’s multidisciplinary CP clinics. Her clinical and research interests focus on ambulatory CP care including early detection, medical and surgical tone management and shared decision-making in care delivery.