What is Selective Dorsal Rhizotomy?
Selective dorsal rhizotomy is a surgical procedure performed on the lower spinal cord. The nerves are separated then identified via an electrical stimulation. Following identification, certain sensory nerve fibers in the spinal cord are cut. The nerves that lead to too much muscle tone, which is a condition of cerebral palsy and spasticity, are then cut.
Children most suitable for rhizotomy are between 3 and 10 years of age, but older children may be candidates as well. Candidates usually are already involved in an active physical therapy program. Because the procedure involves intensive follow-up therapy, children with cooperative spirit --- who can understand and follow directions - generally are ideal candidates.
There are two groups of children who benefit from selective dorsal rhizotomy.
The first are the "spastic diplegics," also know as the "borderline ambulators." Children with this type of cerebral palsy have some form of forward locomotion - usually walking up on their toes - and can take a few steps solo without falling.
The goals of surgery for these children include better gait and leg function. To make sure that spasticity isn't masking muscle weakness, team members carefully test muscle power prior to surgery.
The second group of candidates are called "severe spastic quadriparetics." These children have spasticity in all four extremities and very limited movement. Rhizotomy may increase their independence, by allowing them to sit more comfortably for longer periods of time, use a potty seat, or power a wheelchair on their own.
Surgery also can ease the daily care of these children. When there is less spasticity to deal with, parents find it easier to change a diaper or use an adaptive feeding device, for example.
For reasons that are not clear, selective dorsal rhizotomy sometimes results in better breath, arm and head control as well as lessened leg spasticity.
Because the surgery is the only effective for some children with cerebral palsy, our special screening clinic teams up medical experts in cerebral palsy to decide which children may benefit.
If you choose to make an appointment at the screening clinic, each team member will individually evaluate your child. Our team includes:
- A pediatric neurosurgeon: a specialist with experience in performing this surgery on children. The pediatric neurosurgeon examines the lower extremities and evaluates the underlying muscles.
- A pediatric orthopedic surgeon: a specialist who examines the child to determine whether any orthopedic (bone or joint) surgery is necessary to help alleviate problems such as bone deformities or contractures (extreme muscle stiffness).
- A physical therapist: an expert in measuring spasticity and muscle function in the legs.
- An occupational therapist: an expert who evaluates the child's current and potential abilities to perform everyday activities such as walking, eating, dressing and playing.
- A rhizotomy-screening nurse: a registered nurse who serves as a resource and support person for parents.
The evaluation usually takes two to three hours. After each team member has individually met with your child, the group jointly discusses whether dorsal rhizotomy might be helpful. Parents usually learn of the decision that same morning, and receive a formal letter with the team's recommendations within three weeks.
Even if your child is not a candidate for the procedure, you can receive helpful information during the screening on caring for your child. For example, Rhizotomy Clinic physical and occupational therapists would be happy to share ideas about your child's therapy program with therapists in your hometown.
Some children who are not immediate candidates for selective dorsal rhizotomy are asked to return in six months to a year for further evaluation. At that time, some children may have progressed to a point where surgery will be recommended.
Muscle tone is controlled by a reflex of nerves located in the spinal cord. This reflex involves a sensory nerve bringing information from a muscle back to the spinal cord, and a motor nerve going back to the muscle and actually causing it to contract.
Normally, messages from the brain reduce this spinal reflex and control the way that muscles contract. But in children with cerebral palsy, control over these spinal nerves is reduced. This causes a state of continuous contraction in some muscles.
Selective dorsal rhizotomy can often release some of this muscle tightness, or spasticity. By cutting only the sensory nerve rootlets causing the spasticity, muscle stiffness is decreased but other functions are not lost. By testing all the dozens of sensory nerve rootlets, the neuro-surgeon knows which ones are causing the problem, and which ones are normal and should be left alone.
With spasticity relieved, underlying muscle groups can start working more normally so that mobility and function improve. This helps prevent the extreme muscle scarring - know as contractures - plus the joint and bone deformities that children with cerebral palsy can develop if spasticity continues over a long period of time.
Since patients with cerebral palsy often have complex problems, further screening is necessary to be sure that selective dorsal rhizotomy will help your child.
Additional pre-operative testing - called "pre-op routing" - might include:
- In-depth evaluations by physical and occupational therapists to assess your child's physical abilities completely. Your child is videotaped moving and performing daily activities such as eating, dressing and playing. Your child's current functional abilities, such as walking, sitting or crawling are measured objectively. A postoperative physical and occupational therapy program is planned, and goals are established. Wheelchair seating is looked at and modifications for after surgery are made. If a wheelchair is needed they can put in the referral for one at this time. Parental input is extremely important in determining goals.
- A magnetic resonance imaging (MRI) scan of the brain to ensure that no other neurological problems are present.
- A visit with a pediatric neurologist to address any neurological problems.
- A meeting with the pediatric neurosurgeon to go over the risks and indications of surgery and what to expect in the pos operative period.
- An appointment at Anesthesia Clearance to ensure your child's health prior to undergoing general anesthesia for surgery. This clearance is usually done at Desk A120 by General Pediatrics where a complete history and physical is performed. These appointments can usually be scheduled over a two-day period, about seven to 10 days before surgery.
Selective dorsal rhizotomy is a standard operation used to treat spasticity and your Cleveland Clinic specialists have a great deal of experience with these procedures. Other experts in our Children's Hospital also work to make your child's stay as comfortable as possible.
Preparing for the Hospital Stay:
Child Life Workers
Trained in child development, education and psychology, Cleveland Clinic child life workers help youngsters and parents learn to minimize the stresses associated with illness, hospitalization and separation from family.
Most importantly, they help young patients understand their medical experiences. When young people understand what is happening to them and why, they can cope more effectively and respond better to medical treatment.
Here are some activities our child life workers offer:
Parent activities - Child life works sponsor weekly parent discussion groups. They arrange special events throughout the year, including birthday and holiday parties, visits from special guests and outdoor picnics. Announcements for all activities, times and locations are posted outside the playroom and teen lounge.
Pre -admission tours-We encourage children and their families to visit the hospital before the day of admission whenever possible. Child life workers offer personal orientation tours before your child is hospitalized. To arrange for a pre-admission tour, call 216.444.5059.
As parents, you are welcome to accompany your child to an area just outside the operating room. One parent may then put on a surgical cap, mask and gown to enter the operating room and stay until your child is "asleep."
During surgery, a 4-to-6 inch incision is made along the lower back to uncover and test tiny nerve rootlets found in the spinal cord. Using a surgical microscope, the neurosurgeon locates, divides and tests the rootlets of each nerve for abnormalities.
Certain sensory (dorsal) rootlets with abnormal responses to testing are cut because they increase muscle tone and cause a "spastic" response. Cutting them reduces spasticity after the operation. Leg movement itself is not affected because only the sensory nerve rootlets are cut. All motor nerve rootlets are preserved.
The procedure takes about four hours. An operating room nurse will call you at the beginning of the operation and the doctor will call you or visit after surgery to update you on your child's condition.
Children generally stay in the hospital approximately five days after surgery. You are encouraged to "room in" with your child. For details, please see our Pediatric and Adolescent Medicine brochure.
For the first 24 hours after surgery, your child will stay in a special intensive care unit in our Children's Hospital. Here, your child will be closely observed and small doses of painkillers will be given intravenously, which works very well for most children.
For 48 hours, your child must lie flat. Then, his or her head may be elevated. Children generally sit up for short periods by the third post operative day.
Physical and Occupational Therapy
Physical and occupational therapy begin on the third day after surgery. Rehabilitation is essential to ensure good results from the operation.
Physical and occupational therapists will work with you and your child to teach normal movement of the body and lower extremities. Therapy will first take place in the hospital room, and later will move to the occupational and physical therapy areas.
The physical therapist will perform exercises with your child to stretch muscles and ease movement. Exercises will be passive at first, becoming more active on the child's part as recovery proceeds. Exercises are designed to increase strength, develop balance and alignment in sitting and standing, prepare feet for standing, and develop more normal transitions, as in moving from sitting to standing.
The occupational therapist will work on range of motion and daily activities to help your child feel more comfortable with is or her body and to increase your child's independence at home and at school. Therapy will last about two hours each day, depending upon your child's tolerance.
Before your child leaves the hospital, the doctor and nurse will review medications and incision care with you. They will let you know what level of activity is permitted for your child and when he or she can return to school.
Follow-up appointments with the doctor are usually scheduled for 6-8 weeks after surgery, six months later, then on a yearly basis in the Spasticity Clinic.
Your child's physical and occupational therapists will discuss follow-up programs with you in detail. Your hometown physical and occupational therapists will review the therapy and exercise before your child is discharged. They will continue home therapy five times a week, for three to six moths.
If inpatient therapy is required because of a family's situation, your child can be referred to a children's rehabilitation center
The Rhizotomy Screening Clinic team hopes you find this information helpful. To learn more about our program or to schedule an appointment, please call the Rhizotomy Screening Clinic nurse at 216.444.5747.
Or write to the:
Rhizotomy Screening Clinic
Department of Neurosurgery S80
The Cleveland Clinic Foundation
9500 Euclid Ave.
Cleveland, OH 44195-5123