17458 Selective Dorsal Rhizotomy

Overview

Selective dorsal rhizotomy (SDR) is an operation on the lower part of the spinal cord. It is used mainly for children with cerebral palsy whose leg muscles are very tight and stiff — a problem doctors call spasticity (say: spass-TISS-ih-tee), which means muscles stay clenched and resist being stretched. During SDR, the surgeon finds a selected group of tiny nerve fibres in the spine that carry the 'stay tight' signals to the leg muscles, and cuts only some of them. Because the surgeon picks (selects) the fibres carefully, normal feeling and useful muscle strength are protected. The aim is to loosen stiff legs so that walking, standing, sitting and everyday care become easier. SDR does not cure cerebral palsy. It is one option that may help a carefully chosen group of children, alongside physiotherapy and other care.

SDR is not a common operation. It is only done at specialist children's hospitals by teams who do it regularly. Around the world it is offered to a small share of children with cerebral palsy — those whose stiffness mainly affects the legs and who meet strict selection criteria.

SDR is almost always considered for children, most often between about 4 and 10 years old, who have spasticity that mainly affects both legs (sometimes called spastic diplegia). The child needs to have some walking ability and enough strength and control in the trunk and legs, and must be able to take part in physiotherapy afterwards. Adults are rarely offered SDR, although adults with cerebral palsy can have long-term stiffness and joint problems that need other kinds of care.

Symptoms

Common symptoms

• Legs that feel stiff, tight or 'springy' and resist being bent
• Walking on tiptoes, or legs that scissor or cross over each other
• A stiff, wide-legged walk with frequent tripping or falling
• Muscle tightness that gets worse during effort, excitement or a growth spurt
• Tight heel cords (the tendon at the back of the ankle), so the heel does not touch the floor
• Difficulty with everyday things such as sitting on the floor, dressing, washing and nappy or pad changes
• Muscle or joint pain, and early tiredness when walking

Symptoms in children

• Late walking, or walking that looks different from other children of the same age
• Stiffness first noticed in the baby's legs during nappy changes or bathing
• Tightness that interferes with crawling, sitting balance or learning to walk
• Joints that gradually become fixed in a bent position (contractures) as the child grows
• Needing walking aids, or finding it harder to keep up at school or in the playground

Symptoms in older adults

• SDR itself is very rarely performed in adults; this section describes the long-term stiffness it is designed to help
• Adults with cerebral palsy may notice increasing stiffness, joint pain and tiredness with age
• Muscles and joints can become tighter after years of use, which may affect walking and balance
• Older adults with long-standing spasticity should have their mobility, pain and joint health reviewed regularly

Causes

Main causes

• SDR is a treatment, not a disease, so it does not have 'causes' of its own.
• The stiffness it treats comes from damage to the brain's movement pathways, most often from cerebral palsy.
• That brain damage can happen before, during or shortly after birth, or in early childhood.
• In many children the exact cause of the brain injury is never found.

Risk factors

• Being born prematurely or with a low birth weight
• Complications around the time of birth, such as a shortage of oxygen or blood flow to the brain
• Infection in the mother during pregnancy, or infection in the newborn baby
• A stroke or bleeding in the brain in a baby or young child
• Some genetic conditions or brain malformations
• Being male, or being part of a twin or multiple pregnancy, is linked with a higher chance of cerebral palsy

When to see a doctor

See a doctor urgently if:

• Any child with new or worsening leg stiffness, toe-walking, or a walk that is changing — ask for an early review rather than waiting
• After SDR: fever, wound problems, leaking fluid from the wound, or new weakness — contact the surgical team straight away or go to emergency care
• Sudden difficulty passing urine, or loss of bladder or bowel control after surgery
• A joint that becomes fixed and cannot be straightened, or pain that stops your child moving or sleeping

Book a routine appointment if:

• Your child's doctor or health visitor mentions tight muscles, delayed walking or an unusual walk
• You want to discuss whether SDR might be an option for your child
• You need advice about physiotherapy, splints, footwear or equipment
• Your child is due a growth-spurt review, because tightness often changes quickly at these times
• You would like to talk about school support, respite, or financial help

Diagnosis

SDR is not something you are 'diagnosed' with. Instead, your child is assessed to see whether the operation is likely to help, and whether the benefits are worth the risks. This is usually done by a children's team that may include a paediatrician, a children's brain and nerve surgeon, an orthopaedic surgeon, a physiotherapist and other specialists. They look at how your child moves, how much stiffness comes from the spinal cord rather than from joints or muscles, and how well your child would cope with the surgery and the physiotherapy afterwards.

Tests that may be done

• A physiotherapy assessment of muscle tone, strength, balance and range of movement
• Video or computer gait analysis, where your child walks while being filmed or measured to look at the walking pattern in detail
• MRI scans of the brain and sometimes the spine, to look at the underlying brain injury and the structure of the spine
• X-rays of the hips and spine to check for joint problems or curvature
• Sometimes a temporary test using a local anaesthetic near the spine to see how much stiffness is coming from the spinal cord
• Discussions with your child, and with you, about goals, expectations and what recovery involves

What to expect at your appointment

The assessment usually takes place over one or more clinic visits and may include a short stay for tests. Expect lots of questions and lots of watching your child walk, run, sit and stand. You may be asked to keep a video diary at home. The team will then meet together to talk about whether SDR is suitable, and will explain the possible benefits, the risks and the alternatives. It is completely fine to take time to think, ask for a second opinion, or say no.

Treatment

Care for children with spasticity is put together piece by piece, and SDR is only one part of it. Most children use a mix of physiotherapy, splints or orthotics (supportive devices worn on the legs or feet), medicines that relax tight muscles, and sometimes orthopaedic surgery for joints that have become fixed. The right mix depends on your child's age, walking ability, goals and preferences. The aim is always to help your child move more comfortably, stay active and take part in everyday life.

Self-care at home

• Keep up daily stretching and the home exercise programme your physiotherapist sets — little and often works best
• Wear splints, braces or footwear exactly as advised, and check skin for redness or rubbing
• Keep a simple diary of tightness, pain, sleep and falls, so you can see patterns and share them with the team
• Encourage activity your child enjoys, such as swimming, cycling or playing in water, which is easy on stiff joints
• Plan for growth spurts, which often bring a temporary increase in tightness — ask your team for a review
• Make sure school and carers know about exercises, equipment and what to do if your child has pain

Medical treatments

Treatment is described generally here because every child is different. Options include: physiotherapy to stretch, strengthen and practise movement; occupational therapy for everyday skills; splints and casts to hold muscles in a better position; medicines taken by mouth or delivered by a small pump under the skin that help relax tight muscles; injections given by a specialist to temporarily loosen particular tight muscles; nerve blocks; and orthopaedic surgery to release or lengthen tendons and to correct hip or foot problems. SDR is one of these options, and it is usually combined with ongoing physiotherapy. Your specialist team will explain which of these might suit your child and what the possible benefits and drawbacks are.

When is surgery considered?

SDR may be considered when a child has clear spasticity that mainly affects both legs, is between roughly 4 and 10 years old, can walk with or without aids, has good enough strength in the trunk and hips, and is able to take part in months of intensive physiotherapy afterwards. It may also be considered for children with severe spasticity where the main goals are comfort, easier sitting and easier care, rather than walking. It is usually not advised if the stiffness comes mostly from fixed joints, if there is severe scoliosis (curvature of the spine), or if the child's general health would make a long operation and anaesthetic risky. The decision is always made together with your child's specialist team, and a second opinion is always reasonable.

Living with this condition

In the first weeks after SDR, children need plenty of rest, gentle handling and pain relief, and the wound needs to heal. After that comes the hard but rewarding part: a structured physiotherapy programme, often daily at first, to build strength and learn new movement patterns. Many children use a walking frame, sticks or a wheelchair for a while as they recover. Progress is usually gradual — families often notice easier movement and less stiffness over the first 6 to 12 months, and sometimes beyond. Life at school, hobbies and family routines carry on, with some planning around appointments and exercises.

Lifestyle tips

• Build exercise into the week in a way your child enjoys — swimming, cycling, horse riding therapy or playing in the park all count
• Keep a regular physiotherapy routine, and ask for a review if it stops feeling useful
• Check feet, skin and splints every day, especially where devices press on the skin
• Plan travel and school days around equipment needs, and ask about support at school
• Make time for rest — tiredness is common and can make stiffness worse
• Keep the whole family involved, including brothers and sisters, so nobody feels left out

Diet and exercise

There is no special diet for cerebral palsy or after SDR. A balanced, varied diet with plenty of fibre and fluids helps avoid constipation, which is common when movement is limited and can make stiffness and discomfort worse. Staying at a healthy weight takes strain off the hips, knees and ankles. Regular movement — as much as your child can manage comfortably — helps keep muscles and joints flexible. A physiotherapist or dietitian can give advice tailored to your child.

Mental health and emotional wellbeing

Stiffness and surgery affect feelings as well as bodies. Children may feel anxious before an operation, frustrated during recovery, or upset about being different from friends. Parents and carers often carry a lot — worry, exhaustion, guilt and grief are all common and understandable. These feelings matter and deserve attention. If you or your child feel overwhelmed, low for weeks, or unable to cope, please talk to your doctor or a mental health professional. If you or your child are in crisis or having thoughts of harming yourselves, contact your local crisis support service or your local emergency number immediately.

Prevention

SDR is an elective operation, so it is something families choose rather than something to prevent. The underlying cerebral palsy usually cannot be prevented, because the brain injury often happens before anyone can intervene. What can be prevented, or at least reduced, are the complications of long-standing stiffness: regular stretching, splints, physiotherapy reviews and good foot and skin care help keep joints flexible and prevent fixed contractures and pressure sores. Good antenatal care, avoiding smoking and alcohol in pregnancy, and preventing infections are general steps that support a healthy pregnancy.

Screening programmes

There is no screening test for SDR suitability. Suitability is judged through the specialist assessment described above, usually when a child's stiffness is affecting walking, comfort or care. Children with cerebral palsy should have their muscle tone, joints and walking reviewed regularly as they grow, so that changes are picked up early.

Complications

If left untreated

• Muscles and tendons can shorten and joints can become fixed (contractures), making walking and care harder
• The hip joint can slip out of place, which may need major orthopaedic surgery
• Curvature of the spine (scoliosis) can develop or worsen
• Pressure sores and skin problems can occur where devices or body positions press on the skin
• Long-term pain, tiredness and reduced walking ability are common when stiffness is not managed
• Children may need more aids, more support and more operations later on

Long-term outlook

The outlook for children with spasticity is generally positive, especially when care starts early and continues steadily. Many children walk more easily, have less pain and find daily care simpler after SDR, though results vary and no operation can promise a particular outcome. Some children still need splints, aids or further orthopaedic surgery later. Others find that non-surgical treatments suit them better. Either way, with a good therapy team, sensible goals and family support, most children can stay active, take part in school and enjoy life. Your specialist team can talk honestly with you about what is realistic for your child.

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