Selective dorsal rhizotomy versus orthopedic surgery: a multidimensional assessment of outcome efficacy

doi:10.1016/j.apmr.2003.05.009

Archives of Physical Medicine and Rehabilitation

Volume 85, Issue 3, March 2004, Pages 457-465

Presented in part at the American Academy of Cerebral Palsy and Developmental Medicine’s annual meeting, September 11–14, 2002, New Orleans, LA, and the European Academy of Childhood Disability, October 24–26, 2002, Pisa, Italy.

https://doi.org/10.1016/j.apmr.2003.05.009 Get rights and content

Abstract

Buckon CE, Thomas SS, Piatt JH Jr, Aiona MD, Sussman MD. Selective dorsal rhizotomy versus orthopedic surgery: a multidimensional assessment of outcome efficacy. Arch Phys Med Rehabil 2004;85:457–65.

Objective

To compare the efficacy of selective dorsal rhizotomy (SDR) and orthopedic surgery using multidimensional (National Center for Medical Rehabilitation Research disablement framework) outcome measures.

Design

Prospective outcome study.

Setting

Pediatric orthopedic hospital.

Participants

Twenty-five children with spastic diplegia. Eighteen participants (mean age, 71.3mo) chose SDR. Seven participants (mean age, 78.6mo) chose orthopedic surgery.

Interventions

Children were evaluated 2 days before surgical intervention and at 6 months, 1 year, and 2 years postsurgically.

Main outcome measures

The Gross Motor Performance Measure, the Gross Motor Function Measure, and the Pediatric Evaluation of Disability Inventory.

Results

The SDR group improved significantly in quality of movement attributes 6 months postsurgically; however, gross motor skills (standing; walking, running, and jumping) gains were seen 2 years postsurgically. The orthopedic group improved significantly in select quality of movement attributes 6 months postsurgically and in standing skills within the first postsurgical year. Self-care skills, mobility, and social function gains were seen earlier and with greater frequency in the SDR group.

Conclusions

Both surgical interventions demonstrated multidimensional benefits for ambulatory children with spastic diplegia. The results suggest that qualitative changes in movement, achieved by spasticity reduction, have a greater effect on the enhancement of functional skill proficiency, thus independence, than recognized.

Section snippets

Participants

Children with a diagnosis of spastic diplegia were recruited from the SDR clinic at the Shriners Hospital for Children, Portland, OR, over a 3-year period. All children were assessed by an interdisciplinary team and determined to be appropriate candidates for SDR before being invited to participate in the study. Inclusion criteria required all participants to meet the SDR selection criteria established by Peacock et al11(table 2) and be appropriate candidates for orthopedic soft tissue

Gross motor performance measure

Between-group differences for the GMPM attributes (dissociation, coordination, alignment, weight shift, stability) were not significant at baseline or postsurgically (table 5). The SDR group demonstrated significant improvement in the attributes of alignment, coordination, and stability at all postsurgical assessment times; in dissociation at 6 months and 2 years postsurgically; and in weight shift at 2 years postsurgically (table 6). The orthopedic group demonstrated significant improvement

Gross motor performance measure

The normalization of movement patterns during transitional movements and in developmental postures after SDR has been described previously in the literature.17, 18 However, the lack of a method to quantify movement quality outside the realm of gait analysis has made substantiation of this finding difficult.19, 20, 21 The GMPM provides clinicians with a standardized measurement tool for assessing changes in the quality of movement during the performance of gross motor skills,13, 22 and our study

Conclusions

A multidimensional approach to assessing the efficacy of SDR and orthopedic surgery indicates that both procedures produce multidimensional benefits to the ambulatory child with spastic diplegia; however, dimensional changes did differ slightly between the procedures. SDR resulted in more prevalent qualitative changes in movement, the mastery of complex motor skills late in the postsurgical period, and greater gains in independence in functional activities. Orthopedic surgery had a lesser,

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Cited by (39)

The long-term effects of aggressive spasticity reducing treatment, including selective dorsal rhizotomy, on joint kinematic outcomes of persons with cerebral palsy
2023, Gait and Posture
Selective dorsal rhizotomy (SDR) creates a large and permanent reduction of spasticity for children with cerebral palsy (CP). Previous SDR outcomes studies have generally lacked appropriate control groups, had limited sample sizes, or reported short-term follow-up, limiting evidence for improvement in long-term gait function.
Does aggressive spasticity management for individuals with CP improve long-term gait kinematics (discrete joint kinematics) compared to a control group of individuals with CP with minimal spasticity management?
This study was a secondary analysis – focused on joint-level kinematics – of a previous study evaluating the long-term outcomes of SDR. Two groups of participants were recruited based on a retrospectively completed baseline clinical gait study. One group received aggressive spasticity treatment including a selective dorsal rhizotomy (Yes-SDR group), while the other group had minimal spasticity management (No-SDR group). Both groups had orthopedic surgery treatment. Groups were matched on baseline spasticity. All participants prospectively returned for a follow-up gait study in young adulthood (greater than 21 years of age and at least 10 years after baseline). Change scores in discrete kinematic variables from baseline to follow-up were assessed using a linear model that included treatment arm (Yes-SDR, No-SDR), baseline age, and baseline kinematic value. For treatment arm, 5° and 5 Gait Deviation Index points were selected as thresholds to be considered a meaningful difference between treatment groups.
At follow-up, there were no meaningful differences in pelvis, hip, knee, or ankle kinematic variable changes between treatment arms. Max knee flexion – swing showed a moderate treatment effect for Yes-SDR, although it did not reach the defined threshold.
Aggressive spasticity treatment does not result in meaningful differences in gait kinematics for persons with cerebral palsy in young adulthood compared to minimal spasticity management with both groups having orthopedic surgery.
Changes in gait which occur before and during the adolescent growth spurt in children treated by selective dorsal rhizotomy
2015, Gait and Posture
This paper presents long term follow up results from 17 children (6 girls, 11 boys, GMFCS levels II–IV), treated by means of selective dorsal rhizotomy (SDR). The particular focus is on the effect of the adolescent growth spurt on patients who had previously undergone SDR. The children were all assessed using 3D gait analysis, in combination with clinical examination at three time points–before SDR surgery (PRE), after SDR surgery when pre-adolescent (POST1) and post-adolescence (POST2). The total follow up period to POST2 was 8 years 6 months for girls and 9 years 5 months for boys. All children maintained or improved their GMFCS level. Positive changes in ranges of motion and gait were observed at POST1 and these were generally maintained over adolescence to POST2. The mean Gait Profile Score (GPS) had improved by 3.2 points (14.7–11.5) at POST1, with a non-significant deterioration of 0.3 over the adolescent growth spurt. These positive results reflect the total package of care for the children, involving careful pre-operative selection by a multidisciplinary team and post-operative management including intensive physiotherapy and maintenance in tuned ankle foot orthoses. Fifty-nine per cent of children had some additional orthopaedic surgery, mostly bony procedures. The overall benefits arising from their management need to be considered in the light of the likely deterioration experienced by this patient group. The results of this study support the use of SDR as part of a management strategy for carefully selected children with cerebral palsy with the aim of optimizing gait at skeletal maturity.
Cerebral palsy
2014, The Lancet
Citation Excerpt :
A meta-analysis126 of a series of controlled trials confirmed reduction in spasticity; but whether this reduction led to improved long-term functional goals was contentious. Comparative analysis between different treatment modalities showed little variation in outcomes.127–129 For patients whose motor disorder is purely dyskinetic, researchers are assessing the value of deep brain stimulation, in which quadripolar electrodes are implanted into the basal ganglia.130
The syndrome of cerebral palsy encompasses a large group of childhood movement and posture disorders. Severity, patterns of motor involvement, and associated impairments such as those of communication, intellectual ability, and epilepsy vary widely. Overall prevalence has remained stable in the past 40 years at 2–3·5 cases per 1000 livebirths, despite changes in antenatal and perinatal care. The few studies available from developing countries suggest prevalence of comparable magnitude. Cerebral palsy is a lifelong disorder; approaches to intervention, whether at an individual or environmental level, should recognise that quality of life and social participation throughout life are what individuals with cerebral palsy seek, not improved physical function for its own sake. In the past few years, the cerebral palsy community has learned that the evidence of benefit for the numerous drugs, surgery, and therapies used over previous decades is weak. Improved understanding of the role of multiple gestation in pathogenesis, of gene environment interaction, and how to influence brain plasticity could yield significant advances in treatment of the disorder. Reduction in the prevalence of post-neonatal cerebral palsy, especially in developing countries, should be possible through improved nutrition, infection control, and accident prevention.
Motor measures: A moving target?
2013, Seminars in Pediatric Neurology
Outcome measures may be used for a variety of reasons by clinicians and researchers. This paper provides an overview on motor measures that can be used in research or practice and are classified within the International Classification of Functioning, Disability and Health or ICF. Specifically, body function measures of neuromusculoskeletal and movement-related functions are presented, as are mobility measures within the activity and participation domain of the ICF. Descriptions of measures within these categories and their psychometric properties are provided. Current challenges and future directions for motor measurement are delineated.
Single-event multilevel surgery in children with spastic diplegia: A pilot randomized controlled trial
2011, Journal of Bone and Joint Surgery
Citation Excerpt :
Their study was uncontrolled and included children with GMFCS level IV, who are not expected to be capable of long-term ambulation42. In a comparative study, Buckon et al.42 reported increases in GMFM scores for children who had been managed with selective dorsal rhizotomy or multilevel orthopaedic surgery. However, Gorton et al.14 found no change in GMFM-66 scores in a multicenter, prospective, controlled trial of children who had undergone orthopaedic surgery.
Single-event multilevel surgery is considered the standard of care to improve gait and functioning of children with spastic diplegic cerebral palsy. However, the evidence base is limited. This pilot study is the first randomized controlled trial of single-event multilevel surgery, to our knowledge.
Nineteen children (twelve boys and seven girls with a mean age of nine years and eight months) with spastic diplegia were enrolled. Eleven children were randomized to the surgical group and eight, to the control group. The control group underwent a program of progressive resistance strength training. The randomized phase of the trial concluded at twelve months. The control group then exited the study and progressed to surgery, whereas the surgical group continued to be followed in a prospective cohort study. The primary outcome measures were the Gait Profile Score (GPS) and the Gillette Gait Index (GGI). Secondary outcome measures were gross motor function (Gross Motor Function Measure-66 [GMFM-66]), functional mobility (Functional Mobility Scale [FMS]), time spent in the upright position, and health-related quality of life (Child Health Questionnaire [CHQ]).
A total of eighty-five surgical procedures were performed, with a mean of eight procedures per child (standard deviation, four). The surgical group had a 34% improvement in the GPS and a 57% improvement in the GGI at twelve months. The control group had a small nonsignificant deterioration in both indices. The between-group differences for the change in the GPS (−5.5; 95% confidence interval, −7.6 to −3.4) and the GGI (−218; 95% confidence interval, −299 to −136) were highly significant. The differences between the groups with regard to the secondary outcome measures were not significant at twelve months. At twenty-four months after surgery, there was a 4.9% increase in the GMFM-66 score and improvements in the FMS score, time spent in the upright position, and the physical functioning domain of the CHQ in the surgical group.
This study provides Level-II evidence that single-event multilevel surgery improves the gait of children with spastic diplegic cerebral palsy twelve months after surgery. Improvements in other domains, including gross motor function and quality of life, were not observed until twenty-four months after surgery.
Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.
Clinical functional outcome measures for children with cerebral palsy after gait corrective orthopaedic surgery: A scoping review
2023, Developmental Medicine and Child Neurology

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^☆: Supported by the Shriners Hospital for Children (grant no. 15969).

¹: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

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ArticleSelective dorsal rhizotomy versus orthopedic surgery: a multidimensional assessment of outcome efficacy 1☆,

Abstract

Objective

Design

Setting

Participants

Interventions

Main outcome measures

Results

Conclusions

Section snippets

Participants

Gross motor performance measure

Gross motor performance measure

Conclusions

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Research plan for the National Center for Medical Rehabilitation Research

Functional measures and pediatric assessment

Phys Occup Ther Pediatr

Instrumented gait analysis after selective dorsal rhizotomy

Dev Med Child Neurol

Comparison of the Gross Motor Function Measure and Paediatric Evaluation of Disability Inventory in assessing motor function in children undergoing selective dorsal rhizotomy

Dev Med Child Neurol

Selective dorsal rhizotomyefficacy and safety in an investigator-masked randomized clinical trial

Dev Med Child Neurol

Evaluation of selective dorsal rhizotomy for the reduction of spasticity in cerebral palsya randomized controlled trial

Dev Med Child Neurol

A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy

Dev Med Child Neurol

Muscle-tendon surgery in diplegic cerebral palsyfunctional and mechanical changes

J Pediatr Orthop

Conceptualization and measurement of disablement in infants and young children

Infants Young Child

Evaluating research in developmental disabilitiesa conceptual framework for reviewing treatment outcomes

Dev Med Child Neurol

Cerebral palsy spasticity. Selective posterior rhizotomy

Pediatr Neurosci

The Gross Motor Performance manual

Development of a quality of movement measure for children with cerebral palsy

Phys Ther

Article
Selective dorsal rhizotomy versus orthopedic surgery: a multidimensional assessment of outcome efficacy ¹☆,