Management of Spasticity with Selective Dorsal Rhizotomy in Children

Initial Management at Presentation

• Consider timing of surgery: This is best done through multiple clinical visits. , There no need to rush to surgery; careful patient selection and preparation of the family and the rehab team, as well as the patient, is important. The ideal age for children will be 5-8 years, with some units performing SDR as early as 3 years. We recommend waiting at least 6 months after the last Botox administration to allow for the effects of the injection to be completely reversed. This allows a better examination of the child’s spasticity and function.
• Prepare child for surgery: A consultation with an anesthesiologist is very helpful for preparing a child with CP  for a general anaesthesia of long duration (most SDRs take between 4 and 7 hours). TIVA is used to allow mapping to take place so intravenous access is confirmed preoperatively. Careful evaluation of the child’s airway is important to allow safe intubation and to identify risks for branchospasm. Some children with CP may have poor lung capacity or function related to their prematurity, and this can lead to the need for ventilatory support after surgery.
• Prepare for postoperative rehabilitation: The parents and the child need to be prepared for the weakness (baseline weakness unmasked) and transient decrease in function after SDR because of its elimination of spasticity that had been augmenting strength and leg function. Clear strategies for rehabilitation, ancillary testing or additional procedures need to be discussed and planned. Complete commitment is important, and the parents and the child should be prepared for and “on board” with the process of rehabilitation.

Adjunctive Therapies

• Additional treatments after SDR: By 10-year follow-up after undergoing SDR, 33% of such patients had undergone additional treatments for hypertonia or related problems (49). Botox to augment SDR: In the same study, 10% of patients were found to benefit from Botox injections after undergoing SDR.
• Additional orthopedic surgery: 23% of patients who had undergone SDR required additional procedures for contractures or skeletal abnormalities (49).

Follow-up

• Immediate postoperative care: Meticulous wound care. In general, the wound is kept closed, and sutures will be absorbable. Some children may experience neuropathic pain in their legs.  Children may find relief from this by wearing socks and many units will use gabapentin prophylactically for a 6-week period. After about 3 weeks, light massage of the wound is initiated, and adjuncts like coconut oil, vitamin E oil, or silicon-based ointments may be  applied to aid in keloid prevention
• Observe rehabilitation and support family: Regular contact with the rehabilitation team is important. Avoid forced rotational movements of the trunk for 6 weeks. Active free movement and rotation of the trunk is allowed. Focus on muscle power and stability of core stabilizer muscle, hip extensors, hip abductors, and knee extensors, especially.
• Stretch calves and hamstrings regularly. Keep motivating the family and celebrate the small victories.
• Continue monitoring skeletal alignment: Monitor spinal alignment and hip alignment as per protocol in children with spasticity.