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Selective dorsal rhizotomy

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure designed to reduce lower extremity spasticity in children with cerebral palsy by selectively severing abnormal sensory nerve rootlets in the lumbosacral spinal cord, thereby interrupting excessive afferent signals that contribute to muscle tightness without significantly affecting motor function.^[1]^[2] The surgery is primarily indicated for ambulatory children typically aged 3 to 10 years with spastic diplegia or hemiplegia, where spasticity impairs gait and mobility despite conservative treatments like physical therapy or botulinum toxin injections, and candidates must demonstrate the cognitive and physical capacity to engage in intensive postoperative rehabilitation.^[3]^[2] When combined with rigorous physical therapy, SDR can provide sustained reductions in spasticity and improvements in gait and mobility lasting 5 to 20 years or more, with low risks of serious complications such as permanent bladder dysfunction (less than 1%).^[3]^[1]^[2] Recent studies as of 2025 continue to support its efficacy in carefully selected patients.^[4]

Background

Definition and mechanism

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure designed to alleviate spasticity by selectively severing abnormal sensory nerve rootlets within the dorsal (posterior) spinal roots of the lumbosacral region, thereby interrupting excessive afferent signals that contribute to hypertonia while sparing ventral (motor) rootlets to maintain efferent pathways and overall motor function.^[5]^[6] This targeted approach focuses on reducing the excitatory input from Ia afferent fibers to alpha motor neurons in the spinal cord, which diminishes the velocity-dependent increase in muscle tone characteristic of spasticity, particularly in conditions like cerebral palsy.^[7]^[6] Anatomically, SDR targets the dorsal rootlets of the L1-S2 (or L2-S1) nerve roots located in the cauda equina or at the conus medullaris, accessed through a laminectomy typically at levels such as L1-L5 or T12-L1 to expose the nerve rootlets without compromising the spinal cord.^[7]^[5] Intraoperative electrophysiological monitoring, including electromyography (EMG), is employed to identify and isolate hyperactive rootlets exhibiting abnormal reflex responses, with approximately 50-70% of these sensory rootlets sectioned per level, ensuring selectivity based on functional testing rather than uniform ablation.^[7]^[5] This preserves sensory and motor integrity for non-spastic pathways, avoiding widespread deficits. The mechanism of action relies on disrupting pathological reflex arcs in the spinal cord, where excessive sensory feedback from muscle spindles amplifies motor neuron excitability, leading to sustained muscle contraction; by attenuating this afferent barrage, SDR lowers the net excitatory drive on alpha motor neurons, resulting in reduced spasticity and improved voluntary movement without altering descending supraspinal control or peripheral motor output.^[6]^[7] Unlike non-selective ablative procedures such as myelotomy, which broadly interrupt spinal pathways and risk permanent sensory or motor loss, SDR's selective nature—guided by real-time neurophysiological criteria—allows for a more precise, functionally tailored reduction in spasticity with potentially less irreversible impact on non-target functions.^[7]^[5]

Spasticity in cerebral palsy

Spasticity in cerebral palsy arises from upper motor neuron lesions that disrupt the balance of supraspinal inhibitory and excitatory inputs to the spinal cord, resulting in disinhibited stretch reflexes and velocity-dependent hypertonia.^[8] These lesions, often stemming from perinatal brain injury, lead to abnormal spinal sensory processing, including reduced postsynaptic and presynaptic inhibition, which exaggerates the tonic stretch reflex as a velocity-dependent increase in muscle tone.^[8] Additionally, loss of reciprocal inhibition contributes to abnormal co-contraction of agonist and antagonist muscles, impairing selective motor control and smooth movement.^[8] The primary clinical manifestation addressed in this context is spastic diplegia, a subtype of cerebral palsy characterized by bilateral lower limb involvement with relative sparing of the upper extremities.^[9] Key signs include scissoring gait, where tight hip adductor muscles cause the legs to cross during walking; persistent toe-walking due to calf muscle spasticity; and equinus deformity, involving fixed plantarflexion of the ankle from shortened Achilles tendons.^[10] These features typically emerge in early childhood, delaying gross motor milestones such as independent walking.^[9] Untreated spasticity in children with cerebral palsy promotes progressive contractures through chronic muscle shortening and joint misalignment, leading to pain from pressure on joints and reduced range of motion.^[11] It impairs mobility by exacerbating gait abnormalities and balance issues, while also hindering longitudinal muscle and bone growth, potentially resulting in smaller stature and skeletal deformities like hip dislocation or scoliosis.^[12] Over time, these effects compound functional limitations, affecting daily activities and quality of life.^[11] Diagnosis relies on standardized tools to assess tone and function, particularly in ambulatory patients. The Gross Motor Function Classification System (GMFCS) categorizes children with cerebral palsy into five levels based on self-initiated movement, with levels I–III describing ambulatory children: level I walks without limitations; level II walks with limitations; and level III walks using a hand-held mobility device. It helps predict mobility outcomes and guide interventions.^[13] The Modified Ashworth Scale measures spasticity by grading resistance to passive muscle stretch on a 0-4 scale, with higher scores indicating greater velocity-dependent tone, aiding in quantifying lower limb hypertonia.^[14] These assessments, combined with clinical observation, establish the severity of spasticity in spastic diplegia.^[15]

History

Early development

The origins of dorsal rhizotomy trace back to the late 19th century, with Charles Loomis Dana proposing posterior rhizotomy in 1886 and Robert Abbe performing the first such operation in 1889 to manage spasticity and pain, building on early understandings of neural pathways from Charles Sherrington's work in the 1890s.^[16] In the early 20th century, Otfrid Foerster performed the first non-selective dorsal rhizotomies in 1908 to alleviate spasticity by dividing entire dorsal roots from T12 to S2, though this approach frequently resulted in sensory loss, bladder dysfunction, and other complications. In the 1960s, Claude Gros advanced the technique toward greater selectivity by sectioning approximately four-fifths of the dorsal root fascicles at the conus medullaris, guided by intraoperative electromyography to preserve motor function while targeting spastic pathways.^[16] The foundational selective version emerged in 1977 through the work of Victor A. Fasano, who introduced electrophysiological monitoring during surgery to identify and sever only abnormal sensory rootlets in the lumbosacral region, thereby reducing spasticity with minimal disruption to normal neural transmission. Initial clinical trials of selective dorsal rhizotomy for pediatric spastic cerebral palsy began in the early 1980s, notably at Washington University in St. Louis under T.S. Park and colleagues, who reported substantial decreases in lower limb spasticity and improved gait patterns in treated children, without inducing significant muscle weakness or sensory deficits. These studies built on refinements by Warwick J. Peacock, who in the early 1980s adapted Fasano's method with a cauda equina exposure from L2 to L5, emphasizing functional outcomes in ambulatory patients. Pioneering centers established dedicated programs during this period, including Park's initiative at St. Louis Children's Hospital (formalized in 1989 but rooted in prior trials) and the Hospital for Sick Children in Toronto, where multidisciplinary teams conducted early assessments and surgeries; the first long-term follow-up studies, tracking outcomes over five to ten years, were published in the 1990s, validating persistent spasticity reduction and enhanced mobility. Despite these advances, early implementation encountered significant challenges, including high variability in clinical outcomes due to inconsistent patient selection protocols—such as differing age ranges and spasticity severity thresholds—and non-standardized surgical techniques, like variations in rootlet sectioning percentages and monitoring methods across institutions. This heterogeneity complicated comparative efficacy assessments and contributed to occasional reports of suboptimal functional gains or minor complications, such as transient bladder issues, prompting ongoing refinements in the 1990s.

Key advancements and adoption

Since the early 2000s, selective dorsal rhizotomy (SDR) has seen significant technical refinements aimed at enhancing precision and reducing invasiveness. One key advancement is the development of minimally invasive approaches, such as focal or single-level SDR using tubular retractors, which allow targeted nerve root sectioning through smaller incisions compared to traditional multilevel laminectomies. These techniques, introduced in the 2010s, minimize muscle disruption and blood loss while maintaining efficacy in spasticity reduction. Additionally, advanced intraoperative electromyography (EMG) monitoring has become standard, enabling real-time identification of abnormal sensory rootlets by eliciting muscle responses to electrical stimulation, thereby improving selectivity and reducing the risk of over- or under-sectioning.^[17]^[18]^[19] Standardization efforts have accelerated in recent years, culminating in a 2022 worldwide survey of 10 expert centers across continents published in 2025 that highlighted variations and consensus in SDR protocols, including patient selection, surgical techniques, and postoperative rehabilitation. This survey underscored the adoption of variants like conus medullaris deafferentation, which targets sensory roots at the spinal cord's terminal end and has shown feasibility and safety for non-ambulatory patients with severe spasticity, offering benefits such as improved bladder function and reduced autonomic dysreflexia in select cases. These efforts promote uniformity, with many centers aligning on EMG-guided sectioning rates of 30-50% per root level to balance spasticity relief and functional preservation.^[20]^[21]^[22] Adoption trends have expanded SDR beyond pediatric populations to select adult cases, particularly those with longstanding spastic diplegia from cerebral palsy or spinal cord injury, where studies report sustained improvements in gait and quality of life up to 25 years post-procedure. Recent 2024-2025 evidence from minimally invasive techniques demonstrates reduced operating room times and lower complication rates, such as decreased wound infections and shorter hospital stays, compared to open multilevel methods. While direct surgical integration with robotics remains limited, postoperative rehabilitation increasingly incorporates robotic exoskeletons for gait training, and SDR is sometimes combined with neuromodulation therapies like intrathecal baclofen for comprehensive spasticity management in complex cases.^[23]^[17]^[24] Globally, SDR has transitioned from North American dominance—where pioneers like T.S. Park refined the procedure in the 1990s—to widespread programs in Europe and Asia. European centers, including Charité University Hospital in Germany and Alder Hey Children's Hospital in the UK, have established protocols since the 2000s, emphasizing multidisciplinary care. In Asia, adoption began in the 1990s, with ongoing expansions in countries like Japan and Thailand, reporting successful outcomes in spastic cerebral palsy cohorts. Professional societies, such as the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM), have supported these developments through evidence-based discussions and practice variation analyses, fostering international guidelines for optimal implementation.^[25]^[26]^[27]^[28]

Indications and Selection

Primary medical indications

Selective dorsal rhizotomy (SDR) is primarily indicated for children with spastic diplegia or bilateral lower limb spasticity due to cerebral palsy, particularly those classified at Gross Motor Function Classification System (GMFCS) levels I-III who are ambulatory or have potential for improved mobility.^[2]^[1]^[29] This procedure targets dynamic spasticity, which is the velocity-dependent increase in muscle tone characteristic of cerebral palsy pathophysiology, to address symptoms refractory to conservative management such as physical therapy, oral baclofen, or botulinum toxin injections.^[30] Ideal candidates are typically aged 3 to 10 years, as this window allows for optimal postoperative rehabilitation and gait improvement before significant orthopedic deformities develop.^[31]^[32] The main functional goals of SDR in these patients include enhancing ambulatory independence by reducing lower limb spasticity, improving gait patterns such as knee and ankle function, and decreasing the need for orthopedic interventions like tendon transfers or osteotomies.^[2]^[29] It also aims to alleviate associated pain and prevent contractures, thereby promoting better quality of life and reducing long-term reliance on pharmacological treatments for spasticity control.^[1]^[32] Beyond cerebral palsy, SDR has been applied in select cases of spastic hemiplegia, where unilateral lower limb involvement limits function despite conservative therapies.^[32] It is also used for post-stroke spasticity in adults with refractory lower extremity involvement, showing potential to improve motor skills and tone.^[33] Emerging applications include genetic disorders such as hereditary spastic paraplegia, where SDR may benefit patients with predominant lower limb spasticity not responsive to other interventions.^[34]^[35]

Eligibility criteria

Eligibility for selective dorsal rhizotomy (SDR) is determined through rigorous patient-specific assessments to ensure the procedure's benefits in reducing spasticity align with functional potential, particularly in children with spastic diplegia as a primary indication. Functional assessment focuses on ambulatory ability, where candidates are typically independent walkers or those who ambulate with aids, corresponding to Gross Motor Function Classification System (GMFCS) levels I-III. Baseline gait analysis is conducted to identify spasticity-related deviations, such as scissoring or crouch patterns, that impair mobility and are likely to improve post-SDR. A 2025 worldwide survey of neurosurgical centers indicates that SDR is primarily performed in children aged 2-16 years, typically 5-7 years, with bilateral spastic cerebral palsy at GMFCS levels II-III, though level I is also considered; non-ambulant patients (GMFCS IV-V) may be included for comfort and care benefits in select cases.^[36] Diagnostic evaluations include magnetic resonance imaging (MRI) to exclude structural abnormalities like basal ganglia injury or other non-spastic cerebral palsy etiologies, confirming typical periventricular leukomalacia patterns. Electromyography (EMG) is primarily used intraoperatively for guidance in identifying abnormal rootlets. A comprehensive neurological examination is required, evaluating spasticity via the Modified Ashworth Scale, with moderate to severe scores (typically ≥2) in lower limb muscle groups indicating suitability. Optimal timing for SDR is between 4 and 8 years of age to leverage peak neuroplasticity during ongoing brain myelination and growth, while requiring a stable cerebral palsy diagnosis for at least 1 year to rule out progressive disorders. Selection involves multidisciplinary team review, including neurosurgeons, physical therapists, and orthopedists, to verify that spasticity interferes with function despite trials of non-surgical therapies like physical therapy, orthotics, or botulinum toxin injections, ensuring benefits outweigh procedural risks. The 2025 survey emphasizes assessing parental expectations, motivation, and family capacity for postoperative rehabilitation and follow-up, with psychosocial evaluation in some centers.^[36]

Contraindications

Selective dorsal rhizotomy (SDR) is contraindicated in patients with progressive neurological diseases, such as muscular dystrophy, where the underlying condition would negate potential benefits from spasticity reduction.^[37] Untreated hydrocephalus also serves as an absolute contraindication due to its association with poorer postoperative outcomes and increased procedural risks.^[37] Similarly, severe scoliosis greater than 40 degrees is typically excluded, as it complicates surgical access and heightens the risk of spinal instability.^[38] Non-ambulatory status, classified as Gross Motor Function Classification System (GMFCS) levels IV and V, represents an absolute contraindication in cases where the primary goal is enhancing walking ability, although palliative SDR for spasticity management has been reported in select centers.^[39] Relative contraindications encompass fixed contractures that limit passive range of motion, as they hinder postoperative rehabilitation and functional gains.^[37] Other relative factors include mixed movement disorders such as dystonia or ataxia, insufficient antigravity muscle strength, and moderate cognitive impairment, all of which may compromise overall efficacy.^[37] The 2025 survey identifies additional relative contraindications such as mixed tone (e.g., athetosis), prior extensive orthopedic procedures, planned interventions, or unrealistic family expectations.^[36] Poor family commitment to intensive postoperative rehabilitation and active systemic infections further qualify as relative exclusions, as they undermine long-term success and increase complication rates.^[36] Ethical considerations include high perioperative anesthesia risk and the patient's inability to provide informed consent, particularly in young children or those with severe impairments. Recent 2025 international guidelines from surveyed neurosurgical centers underscore the importance of comprehensive psychosocial evaluation to assess family expectations and support structures prior to proceeding.^[36] For patients deemed contraindicated for SDR, alternative interventions such as intrathecal baclofen pumps for spasticity control or orthopedic procedures to address deformities are recommended to optimize symptom management.

Surgical Procedure

Preoperative evaluation

The preoperative evaluation for selective dorsal rhizotomy (SDR) involves a multidisciplinary assessment to ensure patient suitability, optimize outcomes, and minimize risks, building on established eligibility criteria. This process typically includes imaging, laboratory tests, functional assessments, and planning for anesthesia and perioperative care, often coordinated by teams comprising neurosurgeons, neurologists, physical therapists, and anesthesiologists.^[40]^[41] Imaging studies, such as spinal MRI or CT, are performed to evaluate anatomical structures, including the spinal cord, cauda equina, and any congenital anomalies that could affect surgical access or outcomes. Brain MRI may also be conducted to characterize underlying cerebral palsy-related lesions and predict functional improvements post-SDR. Laboratory evaluations encompass complete blood count, coagulation profile, and basic metabolic panel to screen for anemia, infection, or electrolyte imbalances common in children with cerebral palsy. Additionally, electrocardiography (ECG) assesses cardiac function, while pulmonary function tests evaluate respiratory capacity, given the higher risk of aspiration and restrictive lung disease in this population.^[42]^[43]^[44] Functional testing focuses on quantifying baseline spasticity and mobility to guide rootlet selection and measure postoperative changes. Three-dimensional gait laboratory analysis, often involving instrumented treadmill walking with reflective markers, provides objective data on kinematics, kinetics, and spatiotemporal parameters to identify spastic gait patterns amenable to SDR. Dynamic electromyography (EMG) during gait testing records muscle activity to differentiate spastic from normal patterns, aiding in targeting hyperactive rootlets. Baseline spasticity is quantified using validated scales, such as the Modified Ashworth Scale for lower-limb tone or the Barry-Albright Dystonia/Orthopedic Scale for associated dystonia, alongside the Gross Motor Function Measure to assess overall motor function.^[45]^[46]^[47] Patient optimization emphasizes addressing modifiable factors to enhance surgical safety and efficacy. Orthopedic evaluation may identify deformities requiring correction, with SDR often recommended prior to or concurrently with procedures like tendon lengthening to prevent progression, though a minimum 6-month interval is advised post-orthopedic surgery to allow recovery. Anti-spasticity medications, such as oral baclofen, are generally continued perioperatively, but intrathecal baclofen pumps may be tapered or explanted at least one month prior to avoid withdrawal symptoms like seizures or autonomic instability. Families receive comprehensive education on the procedure, expected recovery trajectory, and the intensive rehabilitation commitment, including home exercise programs to build strength and range of motion, often supported by social workers and pre-surgical tours.^[48]^[49]^[50] Anesthesia planning centers on general endotracheal anesthesia tailored to facilitate intraoperative neuromonitoring, with avoidance of neuromuscular blocking agents to preserve muscle responses during rootlet stimulation. Risks specific to cauda equina manipulation, such as nerve injury or cerebrospinal fluid dynamics alterations, are assessed via multidisciplinary review, including potential for bladder/bowel dysfunction in children with cerebral palsy. Preoperative optimization of nutrition, airway management, and pain control strategies is integrated to support the 4-6 hour procedure duration.^[51]^[52]^[44]

Intraoperative technique

The intraoperative technique for selective dorsal rhizotomy (SDR) begins with the patient positioned prone under general anesthesia, followed by a midline incision over the lumbar spine. The standard surgical approach involves a multilevel laminectomy from L2 to S1 to access the cauda equina, where the dorsal nerve rootlets are exposed after a midline dural incision. A Silastic sheet is often placed to separate dorsal from ventral roots, facilitating identification and isolation of the target rootlets (typically 3-5 per segmental level from L2 to S1).^[53] Intraoperative selection of abnormal rootlets relies on electrophysiological monitoring, with preoperative needle electrodes in lower limb muscles enabling real-time electromyography (EMG) recordings. Each dorsal rootlet is stimulated using a bipolar probe at low current (0.1-1.0 mA) for single pulses and higher frequency tetanic stimulation (50-80 Hz) to elicit responses; abnormal rootlets are identified by criteria such as low stimulation thresholds, sustained clonic contractions, or cross-talk to non-segmental muscles. Selected rootlets, graded by response intensity (e.g., Phillips and Park system), are then sectioned sharply with microscissors, typically transecting 30-50% of rootlets per level to balance spasticity reduction with functional preservation. The H-reflex may be assessed in some protocols, with persistent responses exceeding baseline indicating potential for sectioning.^[53]^[54]^[55] Variations in technique have evolved to reduce invasiveness, including single-level laminectomy or laminoplasty at the conus medullaris (L1-L2), guided by intraoperative ultrasound or MRI to target rootlets from L2 to S2 through a smaller exposure. Minimally invasive approaches, such as keyhole interlaminar or tubular retractor methods developed in the 2010s, limit bone removal and incision size (e.g., 2-2.5 cm), particularly for focal spasticity. Conus-level techniques, increasingly adopted by 2025, offer precision in root identification but require advanced neuromonitoring due to anatomical proximity.^[53]^[20]^[56] The procedure typically lasts 3-5 hours, depending on the approach and extent of rootlet exploration. Closure involves watertight dural repair with fine sutures (e.g., 4-0 nylon), followed by layered fascial and skin closure; drains are generally not used to minimize infection risk.^[2]^[53]

Postoperative immediate care

Following selective dorsal rhizotomy, patients are typically monitored in an intensive care unit (ICU) or a specialized recovery area for 24 to 48 hours to assess neurological status, including motor function and sensory integrity, while ensuring hemodynamic stability.^[1] Pain is managed multimodally, often with patient- or nurse-controlled analgesia (PCA) using opioids such as morphine or fentanyl, combined with ketamine infusions at doses around 5 µg/kg/hour, achieving mean pain scores of 1.4 on postoperative day 1 via tools like the Wong-Baker FACES scale.^[57] Bladder function is supported with an indwelling urinary catheter, which is usually removed by postoperative day 3 to 5 once oral fluids are tolerated and voiding is confirmed.^[58]^[57] Wound management begins immediately in the postoperative period, with the incision site—typically closed using dissolvable sutures and covered with a sterile dressing such as Primapore—inspected daily for signs of infection or drainage, and dressings changed around day 3.^[58] Antibiotic prophylaxis may be administered perioperatively to prevent surgical site infections, though routine continuation is not always specified beyond the immediate postoperative phase.^[58] Mobilization commences early, often on postoperative day 1 with gentle physical therapy (PT) sessions to promote sitting at 30° elevation and basic exercises, progressing to standing frames or wheelchair transfers by days 4 to 5 under therapist supervision.^[59]^[57] Serial neurological examinations are conducted frequently during the initial hospital stay to detect any weakness, sensory loss, or changes in tone resulting from the rhizotomy, with vital signs and limb assessments (color, sensation, movement) integrated into hourly monitoring for the first few hours post-recovery.^[58] Spasticity medications, such as pregabalin or gabapentin initiated preoperatively, are continued and adjusted based on clinical response, with opioid doses typically peaking on day 2 and weaning by day 6 as pain scores drop below 3/10 and oral intake improves.^[58]^[57] Discharge from the acute care setting generally occurs within 5 to 7 days postoperatively, once vital signs are stable, pain is controlled at less than 4/10, and the patient demonstrates safe transfer ability via wheelchair or walker, with prescriptions for ongoing medications and follow-up appointments arranged.^[1]^[58]

Outcomes and Efficacy

Short-term benefits

Selective dorsal rhizotomy (SDR) leads to substantial short-term reductions in spasticity, typically measured by the Modified Ashworth Scale (MAS), with studies reporting average decreases of 50-70% in lower extremity scores within 3-6 months post-surgery. For instance, in a cohort of children with spastic cerebral palsy, MAS scores for lower limbs dropped from a mean of approximately 3.0 preoperatively to 1.0-1.5 at 6 months, reflecting improved muscle tone and reduced hyperreflexia. This spasticity reduction also enhances range of motion in the hips, knees, and ankles, allowing for better joint flexibility and positioning without excessive stiffness.^[60]^[61] Functional gains emerge rapidly after SDR, including enhanced gait parameters such as increased walking speed and distance covered. Ambulatory children often show improvements in step length and knee extension within the first year, contributing to more efficient locomotion and reduced energy expenditure during movement. Additionally, there is a notable decrease in the need for adjunctive spasticity treatments; a 2024 study observed a significant reduction in botulinum neurotoxin (BoNT) injections, with usage dropping from 77% preoperatively to substantially lower rates post-SDR, alleviating the frequency of invasive interventions. Many patients also experience lessened reliance on orthotics, facilitating greater independence in daily activities.^[61] Improvements in quality of life are evident in the short term, particularly through parent-reported outcomes on the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) scale, where gains in domains such as comfort, personal care, and positioning are common. A 2024 systematic review and meta-analysis found that approximately 70% of children with gross motor function classification system (GMFCS) levels IV-V showed enhanced CPCHILD scores, driven by reduced pain and improved sleep quality due to diminished spasticity-related discomfort. These changes foster better overall well-being and family satisfaction in the immediate postoperative period.^[62] Early efficacy of SDR is assessed using standardized functional tests, including the 6-minute walk test (6MWT) for endurance and distance, and the timed up-and-go (TUG) test for mobility and balance. Post-SDR, children typically demonstrate increased 6MWT distances by 10-20% at 6-12 months and reduced TUG times, indicating quicker transitions and safer navigation, which underscore the procedure's impact on short-term motor performance.^[63]^[64]

Long-term effects

Selective dorsal rhizotomy (SDR) demonstrates durable reduction in lower limb spasticity, with studies reporting sustained decreases in Modified Ashworth Scale scores over 5 to 14 years post-procedure. In a cohort of 35 children with spastic diplegia followed for 5 years, muscle tone reductions in key muscle groups (adductors, hamstrings, dorsiflexors) persisted without recurrence, maintaining statistical significance from baseline (p < 0.001). Similarly, in 19 children evaluated at 10 years, spasticity remained significantly lower than preoperative levels across hip, knee, and ankle muscles (p < 0.03), though mild increases were noted at the knee and ankle (median MAS of 2). A larger group of 44 patients tracked for a mean of 14.4 years confirmed this durability, with an average 0.8-point drop on the Modified Ashworth Scale (p < 0.0001). These findings indicate that approximately 80-90% of patients retain substantial spasticity relief long-term, contributing to prevention of secondary issues like contractures and hip subluxation through preserved joint range of motion gains observed in early follow-up that stabilize over time.^[65]^[66]^[67] Long-term motor development benefits include measurable improvements in gross motor function, as assessed by the Gross Motor Function Measure (GMFM). At 5 years post-SDR, children across Gross Motor Function Classification System (GMFCS) levels I-V showed a mean 9.5-point increase in GMFM-66 scores (p < 0.001), reflecting enhanced standing, walking, and running abilities. Over 10 years, GMFM-88 scores in ambulatory children rose by 11% from baseline (median 62 vs. 51, p = 0.031), despite some decline from peak gains at 3 years, supporting greater independence in daily activities into adulthood. In adults 17-26 years post-childhood SDR, 80% achieved independence across life habits, with 84% mobile independently over short distances and high satisfaction in recreation and social roles. These outcomes correlate with reduced reliance on assistive devices and fewer orthopedic interventions, such as tendon lengthenings, in select cohorts where surgery rates post-SDR were as low as 17-42% over 5-10 years.^[65] For non-ambulatory children (GMFCS IV-V), SDR offers targeted relief leading to improved hygiene, positioning, and comfort without ambulatory gains; in one series, 77% of severe cases showed functional mobility enhancements at extended follow-up. Overall life impacts encompass greater school participation and activity involvement, with adults reporting sustained engagement in community and leisure pursuits due to reduced pain and fatigue. Economic analyses further highlight value, with SDR costs offset by long-term savings in supportive care, yielding cost-effectiveness ratios of £903-£1,382 per unit improvement in quality-of-life metrics over 10 years.^[68]

Evidence from clinical studies

Randomized controlled trials have provided foundational evidence for the efficacy of selective dorsal rhizotomy (SDR) in managing spasticity in children with cerebral palsy. A meta-analysis of three 1990s RCTs, involving 90 children with spastic diplegia, demonstrated that SDR combined with physical therapy (PT) was superior to PT alone in reducing spasticity, as measured by the Ashworth scale (mean change score difference -1.2, p<0.001), and improving gross motor function via the Gross Motor Function Measure (GMFM; difference in change score +4.0, p=0.008).^[69] These trials, led by researchers including T.S. Park, highlighted sustained functional gains in ambulatory children at Gross Motor Function Classification System (GMFCS) levels II-III.^[69] A 2025 systematic review and meta-analysis of five studies, including four RCTs, further confirmed SDR's effectiveness in treating lower limb spasticity in children with cerebral palsy, with significant reductions in modified Ashworth scale scores and improvements in GMFM scores indicating enhanced mobility, particularly in ambulatory patients.^[70] These gains were most evident up to 12 months post-SDR, though the predominance of single-arm designs introduced potential selection bias as a limitation.^[70] Cohort studies have reinforced these findings through long-term follow-ups. In a St. Louis cohort of 95 adults who underwent childhood SDR (mean follow-up 24.3 years), 91% reported positive impacts on quality of life, 88% would recommend the procedure, and 42% noted improved ambulation, with no late complications observed.^[71] A 2024 study from Nationwide Children's Hospital, tracking 35 ambulatory children post-SDR (average age 7 years), reported significant GMFM-66 score increases over two years, alongside reduced reliance on adjunct spasticity treatments like baclofen or botulinum toxin.^[72] Systematic reviews integrating efficacy with safety data underscore SDR's role while noting methodological challenges. A 2023 review of 30 studies on post-SDR complications in cerebral palsy patients also affirmed efficacy through reported spasticity reductions but highlighted limitations such as selection bias in patient cohorts, which may overestimate benefits in non-randomized designs.^[73] Recent advances, including a 2025 worldwide survey of 10 centers across five continents, reveal consistent efficacy outcomes despite variations in techniques, such as multi-level versus single-level approaches and rootlet transection rates (17-83%).^[20] All centers reported effective spasticity reduction in bilateral spastic cerebral palsy patients (GMFCS II-III), with electrophysiological monitoring ensuring comparable short-term functional improvements globally.^[20]

Complications and Risks

Common adverse events

Postoperative pain and dysesthesia are among the most frequent adverse events following selective dorsal rhizotomy (SDR), affecting a significant proportion of patients in the immediate recovery period. Back and leg pain is common in the early postoperative phase, typically managed with opioid infusions and multimodal analgesia, though long-term pain occurs in 29-71% of children.^[74] Transient sensory changes, including numbness, hypersensitivity, or dysesthesia in the lower limbs, are reported in approximately 50% of cases acutely, with most resolving spontaneously over time, though a small subset may persist.^[74] These sensory disturbances arise from temporary nerve irritation during rootlet sectioning and are generally mild and self-limiting.^[75] Mild, temporary lower limb weakness affects 20-30% of patients postoperatively, often unmasking underlying muscle imbalances in cerebral palsy and contributing to short-term mobility challenges.^[74] This weakness is usually transient, improving with intensive physical therapy within 1-3 months. Bladder dysfunction, particularly urinary retention due to decreased bladder tone, occurs in about 10% of cases and typically resolves without intervention as reflex arcs recover.^[76] Wound-related issues are less common but notable, with superficial infections reported in around 1-5% of patients, often managed with antibiotics.^[74]^[77] Cerebrospinal fluid (CSF) leaks are reported in 2-11% of procedures, presenting as clear drainage from the incision site and usually sealing with conservative measures like bed rest.^[74] Adverse events following SDR are reported in 2% to 56% of children across studies, predominantly manageable and not requiring reoperation.^[78] Long-term complications include structural deformities such as scoliosis (20.5%), hyperlordosis (18.2%), spondylolysis (9.5%), and kyphosis (8.4%), as identified in a 2023 systematic review of over 1,000 cases.^[75]

Serious complications

Serious complications following selective dorsal rhizotomy (SDR) are infrequent, with major complication rates reported as low as 0.3% in some series but varying up to 5% in others.^[79] These events typically involve neurological, infectious, or hemorrhagic issues that may necessitate additional interventions or lead to lasting impairments. Neurological deficits represent a key category of severe outcomes, including permanent sensory loss, which occurs in approximately 4% of cases, and foot drop, which is rare.^[80] Bladder and bowel incontinence, potentially linked to excessive root sectioning in lumbosacral levels, is documented in approximately 5.1% of patients long-term, though most instances resolve with conservative management.^[80]^[74] Rare case reports highlight paralysis arising from over-sectioning of dorsal roots, underscoring the importance of precise intraoperative selection to avoid such catastrophic deficits.^[81] Infectious complications, while uncommon, include meningitis and deep wound infections at rates of 0.2% to 1%, with one large review noting deep infections in 0.18% of 553 cases.^[74] Hardware-related infections may arise if SDR is combined with spinal fusion, though this is not standard practice.^[82] Other serious risks involve reoperation for hematoma, required in fewer than 0.5% of procedures, often due to postoperative bleeding in the surgical site.^[74] Common adverse events like cerebrospinal fluid leaks can occasionally precede these severe outcomes, such as progressing to meningitis if untreated.^[2]

Risk mitigation strategies

Intraoperative safeguards play a critical role in minimizing neurological risks during selective dorsal rhizotomy (SDR). Real-time electromyography (EMG) monitoring is routinely employed to identify and selectively section abnormal dorsal rootlets based on their abnormal responses to stimulation, thereby preserving functional sensory and motor pathways.^[19] Multimodal intraoperative neurophysiological monitoring, including motor evoked potentials (MEPs) akin to D-wave assessment, further enhances precision by detecting potential spinal cord compromise in real time, allowing surgeons to adjust techniques dynamically.^[83] Conservative sectioning, typically limited to less than 60% of rootlets per level—often 25% to 40%—reduces the likelihood of over-resection and associated deficits in strength or sensation.^[84]^[85] Postoperative protocols emphasize infection prevention and mobility restoration to mitigate common recovery challenges. Prophylactic antibiotics are administered perioperatively to lower the risk of surgical site infections, which remain a primary concern despite overall low complication rates.^[86] Early ambulation, initiated within days of surgery under physical therapy guidance, promotes circulation and prevents complications such as deep vein thrombosis while facilitating spasticity management.^[87] Multidisciplinary surveillance involving neurosurgeons, physiatrists, and therapists ensures prompt detection and intervention for issues like cerebrospinal fluid leaks or wound healing delays through standardized monitoring schedules.^[88] Patient selection criteria are refined to exclude high-risk individuals, thereby optimizing safety and outcomes. Candidates with severe scoliosis (e.g., Cobb angle >30°) are typically avoided due to heightened progression risk post-SDR, with preoperative imaging and gait analysis integral to this process.^[89] Informed consent processes highlight major risks, such as infection or neurological injury, occurring in less than 5% of cases, alongside discussions of irreversible effects to align expectations with evidence-based benefits.^[2]^[90] Recent advances incorporate 2025 institutional guidelines promoting minimally invasive SDR techniques, which use smaller incisions to reduce tissue trauma compared to traditional open approaches.^[58]^[56] Structured follow-up algorithms, including serial gait assessments at 1, 3, 10, and 20 years, enable early identification of residual spasticity or deformities, guiding timely interventions.^[91]

Rehabilitation and Follow-up

Initial rehabilitation protocols

Following selective dorsal rhizotomy (SDR), initial rehabilitation protocols emphasize intensive physical therapy (PT) and occupational therapy (OT) to leverage the immediate reduction in spasticity and promote motor recovery. Therapy typically begins within the first few days post-surgery, often during the inpatient stay, with mobilization starting as early as the first postoperative day to facilitate sitting, standing, and basic transfers.^[92] Outpatient sessions then commence upon discharge, occurring 4 to 5 times per week for the first 3 to 6 months, focusing on daily or near-daily practice to build strength and retrain movement patterns.^[87] Key components of these protocols include targeted stretching exercises to maintain and expand range of motion, preventing the development of new contractures in the lower extremities. Daily passive and active-assisted stretches for the hamstrings, hip flexors, and calf muscles are standard, often supplemented with orthotic devices such as ankle-foot orthoses (AFOs) or knee splints to support positioning. If significant contractures persist, serial casting may be applied for 2 to 3 weeks post-discharge to gradually improve joint alignment without aggressive manipulation. Gait training incorporates treadmill walking with partial body-weight support to enhance endurance, step length, and symmetry, typically introduced 2 to 3 weeks after surgery once initial wound healing allows.^[87]^[92]^[93] The primary goals of initial rehabilitation are to restore balance and coordination while fostering independent mobility. Strengthening exercises target isolated muscle groups, such as the quadriceps and gluteals, to counteract temporary postoperative weakness, alongside balance training on unstable surfaces to improve postural control. Functional electrical stimulation (FES) may be integrated after 6 weeks to 6 months, depending on individual progress, to facilitate muscle activation during gait and reduce abnormal patterns.^[87]^[94] Evidence from clinical protocols, including those aligned with guidelines from organizations like the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM), supports an optimal intensity of intensive therapy over the first 6 months to achieve measurable motor gains, such as improved gross motor function and reduced knee flexion during walking. Studies demonstrate that this early, high-frequency approach leads to significant enhancements in ambulatory function, with gross motor scores improving in the initial year when combined with SDR.^[92]^[95]

Long-term management

Long-term management following selective dorsal rhizotomy (SDR) emphasizes sustained monitoring and adaptive interventions to preserve reductions in spasticity and optimize functional outcomes in patients with spastic cerebral palsy. This phase begins after initial recovery and focuses on preventing complications like contractures or gait deterioration while promoting independence. Regular assessments ensure that the benefits of surgery, such as improved mobility, are maintained over years or decades. Follow-up schedules typically include annual neurological and orthopedic examinations to evaluate muscle tone, reflexes, joint range of motion, and spinal alignment, allowing early detection of any musculoskeletal changes. Gait re-analysis is performed at structured intervals—commonly at 1 year, 5 years, and 10 years post-surgery—to quantify improvements in spatiotemporal parameters, kinematics, and overall gait efficiency using tools like the Gait Deviation Index. These evaluations, often conducted in specialized motion analysis labs, guide adjustments to therapy and inform decisions on additional supports. For instance, long-term studies have tracked patients up to 30 years post-SDR, confirming persistent gait enhancements in selected cohorts.^[91] Adaptive strategies are tailored to the patient's age, growth, and functional level to support daily living and prevent secondary issues. Home exercise programs form the foundation, featuring daily routines of stretching, strengthening, and balance activities (e.g., bridging exercises or heel-toe walking) to reinforce motor patterns developed during intensive rehabilitation; these programs are customized by physical therapists and reviewed quarterly initially, then biannually. Orthotics adjustments, such as modifying ankle-foot orthoses for better alignment, occur every 6-12 months or as growth dictates, ensuring optimal support without restricting natural movement. As adolescents approach adulthood, transition to adult care involves coordinated handoffs to specialized clinics, including vocational rehabilitation and community-based services, to address lifelong needs like employment and independent living; this process typically starts at age 16-18 with joint pediatric-adult team meetings.^[96]^[97] Recurrence or persistence of spasticity can occur in some patients due to growth or disuse; management prioritizes non-invasive options to avoid repeat surgery. Booster physical therapy sessions, lasting 4-6 weeks every 1-2 years, focus on intensive strengthening and selective motor control to counteract gradual tone increases, often incorporating functional electrical stimulation for enhanced results. If partial spasticity returns in focal areas (e.g., hamstrings or calves), integration with botulinum toxin (Botox) injections provides targeted relief, reducing muscle hyperactivity for 3-6 months while allowing concurrent therapy to build on gains; this combined approach is preferred for ambulatory patients to minimize downtime.^[2]^[98] Integration of long-term outcomes reinforces the efficacy of proactive management, with data from a 2025 study indicating that 58.5% of patients achieve significant gross motor function improvements (e.g., one-level gains on the Gross Motor Function Classification System) at 12 months post-surgery, and a majority require fewer interventions like repeated injections or orthopedic procedures compared to non-SDR cohorts. This sustained reduction—evident in follow-ups up to 30 years—highlights SDR's role in lowering the lifetime burden of spasticity management, though individual results vary by preoperative status and adherence to protocols.^[99]^[100]

Multidisciplinary care

Selective dorsal rhizotomy (SDR) relies on a collaborative multidisciplinary team to optimize patient selection, surgical execution, and postoperative management, ensuring comprehensive care for individuals with spastic cerebral palsy. This approach integrates expertise from various specialists to address the complex interplay of neurological, musculoskeletal, and psychosocial factors, leading to enhanced functional outcomes and reduced complications.^[44]^[101] The core team typically includes a neurosurgeon responsible for the procedure, a physiatrist or physical medicine and rehabilitation physician for overall functional assessment, physical and occupational therapists for mobility and daily activity training, an orthopedist to evaluate skeletal deformities, and a psychologist or social worker for emotional and family support. Family involvement is integral, providing insights into the child's daily challenges and ensuring adherence to care plans. In specialized centers, additional members such as pediatric neurologists, neurophysiologists, nurse practitioners, and orthotics experts contribute to gait analysis and customized interventions.^[44]^[102]^[101]^[20] Team roles emphasize coordinated decision-making, beginning with preoperative evaluations like 3D gait analysis and physical exams to confirm candidacy, extending through intraoperative monitoring, and into rehabilitation planning. Psychosocial support from psychologists and social workers addresses adherence barriers, such as family stress, while therapists tailor rehab to individual needs, fostering long-term mobility gains. This integration supports holistic care, with evidence indicating that multidisciplinary coordination improves gross motor function and quality of life.^[44]^[101]^[20]^[99] Best practices involve integrated clinics within cerebral palsy centers, where teams convene in movement disorder conferences to standardize protocols and share electronic records for seamless transitions. A 2025 worldwide survey of SDR centers underscored the value of such teams in refining selection criteria and rehabilitation, promoting consistent outcomes despite variations in techniques. These models, exemplified by programs at institutions like Johns Hopkins and Texas Children's Hospital, facilitate early intervention and ongoing follow-up.^[101]^[20]^[44]^[102] Challenges in multidisciplinary care include access barriers for patients in non-urban areas, where limited specialized centers and transportation issues hinder timely evaluations and rehab. Telehealth expansions have emerged to mitigate these, enabling remote assessments and follow-up consultations, particularly for cerebral palsy management, though disparities persist in rural U.S. populations as of 2025.^[103]^[104]^[105]

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Apr 30, 2024 · Selective dorsal rhizotomy is a nerve surgery that permanently decreases high muscle tone, or spasticity.
[103]
Electronic health record and patterns of care for children with ...
Mar 25, 2021 · Previous work demonstrated the feasibility of using telemedicine for various aspects of care for children with CP, including presurgery ...
[104]
Rural patients in the United States still face barriers to telehealth ...
Sep 9, 2025 · Study shows persistent telehealth disparities among rural US populations, highlighting need for policy reform and digital health equity ...Missing: selective dorsal rhizotomy
[105]
Barriers to Telehealth in Rural Areas - RHIhub Toolkit
Mar 12, 2025 · This section provides an overview of barriers to establishing, expanding, and sustaining telehealth programs in rural communities.Missing: selective dorsal rhizotomy