Surgical Spasticity Clinic Offers Definitive Therapy Without Unnecessary Delays

For some children with cerebral palsy, medication and physical therapy for severe spasticity may not be enough to provide lasting benefit. A new multidisciplinary clinic at Cincinnati Children's Hospital Medical Center fast-tracks the surgical evaluation process to identify patients who are most likely to benefit from intrathecal baclofen therapy or selective dorsal rhizotomy.

The idea for such a clinic began with a realization. “We were finding that many of these children didn't have timely access to surgical evaluation for their spasticity. We just weren't identifying them as early as we could have been," says Charles Stevenson, MD, a pediatric neurosurgeon at Cincinnati Children's. “It became apparent that more aggressive intervention at an earlier age could have improved their long-term tone control and, in many cases, their functional outcome."

Dr. Stevenson began working closely with Doug Kinnett, MD, a physical medicine and rehabilitation specialist at Cincinnati Children's, to create a surgical evaluation clinic for these patients. The process involved far more than finding clinic space or scheduling the clinic itself. The real challenge was in raising awareness. “We reached out to everyone who had occasion to see spasticity patients, particularly our colleagues in the hospital's large Cerebral Palsy Clinic, area pediatric orthopaedic surgeons, and all of the therapists in our outlying clinics," Dr. Stevenson says. “We reinforced the idea that certain patients likely will benefit from a more aggressive approach in treating their spasticity at an earlier age, and we reviewed the eligibility criteria we use to assist providers in identifying appropriate patients for referral."

Appointments typically last 60-90 minutes, during which time the patient sees Dr. Stevenson, Dr. Kinnett and a physical therapist for a thorough examination and evaluation. “We sit down with families at the end of the visit to review our recommendations, thoroughly discussing the treatment options we feel would be most appropriate for their child, and making certain we answer all of their questions," Dr. Stevenson says. “We recommend surgery for most of the patients who are evaluated in the clinic, in large part because they are prescreened so effectively by the referring providers. Surgery is a big step for these patients and their families, but the benefits are often dramatic."

Children undergoing selective dorsal rhizotomy or implantation of a baclofen pump typically experience significant spasticity relief after surgery. As such, oral spasticity medications are generally able to be discontinued in the weeks following the procedure. The chief side effect of most of these medications is sleepiness, so discontinuing them can greatly improve a child's quality of life both at home and at school.

Surgeons at Cincinnati Children's offer a minimally invasive approach to selective dorsal rhizotomy, accessing the nerve rootlets through a one- to two-inch incision in the mid-back. This offers many benefits, including a shorter recovery time and reduced risk of spinal deformities in later years. It is available at only a small number of pediatric institutions in the country.

“Children who undergo selective dorsal rhizotomy experience an immediate improvement in spasticity, but the key to long-lasting benefit and gait improvement is intensive physical therapy to improve muscle strength and function," Dr. Stevenson says. “We maintain long-term follow up with these patients to track their progress and address any concerns. By the one year mark, most have experienced significant improvement in their mobility."

To learn more about the multidisciplinary Surgical Spasticity Clinic or refer a patient, please email Dr. Stevenson or call him at 513-636-4726.