Adjuvant Therapies for Spasticity Treated with Selective Dorsal Rhizotomy in Children

Medical or Surgical

• Overall, 33% need additional treatments: In a recent evaluation at 10 years, 67% of patients did not require additional medical or surgical treatment (49).
• 10% require Botox: Approximately 10% of patients benefited from postoperative Botox injections such that 77% of 75 patients were either treated with rhizotomy alone or rhizotomy plus Botox (49).
• 23% require additional orthopedic surgery: 23% of patients who had undergone SDR needed additional orthopedic surgery, with 13% of surgeries being soft-tissue releases and 10% bony corrections due to abnormal bone orientation related to severe spasticity in early childhood (49).

Management of the Child with Persistent Spasticity after SDR

There are some children with residual spasticity after SDR. The most common involved muscles are the triceps surae and feet muscles because of the concerns about including the S2 root in the SDR lesioning and the bladder innervation that are associated.

The strategies to manage these children are fourfold:

• Botox treatment: Continued Botox therapy to those muscles that remain spastic after the SDR.
• Selective peripheral neurotomy: A neurectomy aimed at the muscles specifically responsible for harmful hypertonia can yield functional improvement while confining the effect of the SDR to muscles not responsible for important function..
• Contractures impeding improvements: Very often the functional improvements may not be as great after SDR as expected because of muscle shortening and contractures. This can be addressed by orthopedic surgery and muscle releases (tendon lengthening). This is best done after SDR so the surgery can be tailored to muscle contracture still present that cannot be treated with stretching.
• Intrathecal baclofen for resistant spasticity: Morota and others have also reported using intrathecal baclofen pump therapy in this group of patients with success (47).