Is 15 too old for Selective Dorsal Rhizotomy?

Charles Stevenson, MD, FAANS, FACS, FAAP, a pediatric neurosurgeon at Cincinnati Children’s, talks about a recent experience with a patient whose cerebral palsy was associated with significant spasticity in his lower extremities.

What was the patient’s history?

I met this patient when he came to our multidisciplinary Surgical Spasticity Clinic for a second opinion in early 2017, when he was 15 years old. This young man had been using a walker for many years, but his lower extremity spasticity was a source of discomfort to him, significantly limiting his range of motion and ability to improve his ambulation. He had initially been evaluated by a spasticity team elsewhere, and he and his family had been told that he was not a candidate for selective dorsal rhizotomy (SDR) due to his age and a concern that he might not have the capability to walk afterward. As such, he had undergone surgery for implantation of a baclofen pump to treat his spasticity, but it subsequently became infected and was removed.

What was the evaluation like?

The patient came to our clinic for a comprehensive evaluation with me; Doug Kinnett, MD, a physical medicine and rehabilitation specialist; and Molly Thomas, PT, DPT, a physical therapist specializing in the care of patients with cerebral palsy and spasticity. We were all in the exam room at the same time with the patient and his family while we analyzed his leg strength, range of motion, spasticity and gait pattern. We agreed that we could try intrathecal baclofen therapy again. However, we also felt that SDR had the potential to satisfactorily treat his spasticity and permanently improve his ambulatory ability. A few months later, we successfully performed the SDR via a 1-level laminectomy through a 1.25-inch incision.

Is it unusual for an adolescent patient with spasticity to undergo SDR?

It is not unusual at Cincinnati Children’s. Surgical outcomes are better when a patient’s spasticity primarily affects the legs, and when the patient has at least some ability to bear weight on their legs and take steps preoperatively. Additional factors are of course important and are taken into consideration on a case-by-case basis, but patient age does not figure prominently in our decision-making process.

I believe this case demonstrates the importance of being evaluated by an experienced team familiar with SDR. Each patient is different and unique in their spasticity and gait patterns, but over time we see similar presentations and develop a sense of who is likely to most benefit from SDR

What was the patient’s surgical outcome?

The patient’s outcome was excellent—just as good as we typically see in younger children. He experienced an immediate improvement in his spasticity, as all patients do. But key to achieving long-lasting benefit and gait improvement was his participation in about a year of intensive physical therapy to improve muscle strength, range of motion, and ambulation. Within a few months after surgery, he transitioned from his walker to forearm crutches. At his 12-month follow up appointment, he was walking unassisted. The procedure has dramatically improved his independent mobility and overall quality of life.

Was this patient’s outcome unusual for your clinic?

No. However, not all patients are so straightforward in their presentation. Many patients face additional challenges and impediments to their mobility, such as pre-existing contractures. These children frequently require additional orthopaedic procedures, before or after SDR. Helping patients achieve their full ambulatory potential generally takes time, commitment and implementation of a very personalized approach. That said, it is always so rewarding to help them achieve a level of independence they have never experienced before.

Watch a before-and-after video of this patient

For more information about SDR at Cincinnati Children’s, or to refer a patient, contact Charles.Stevenson@cchmc.org