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Selective dorsal rhizotomy (SDR) is a one-time spinal operation performed by Boston Children’s neurosurgeons to treat leg spasticity, or increased muscle tone and tightness that limit leg movement. After a careful evaluation, we sometimes recommend SDR to increase mobility in children with spasticity from cerebral palsy when other treatments are no longer helping.
SDR surgery can encourage independent walking and improve a child’s gait. Many children can transition from walkers to crutches or canes and avoid the need for other surgical procedures.
Shenandoah (Dody) Robinson, MD, our neurosurgeon who specializes in the treatment of cerebral palsy and spasticity, uses a less invasive form of rhizotomy than surgeons typically do elsewhere, making a smaller incision and removing less bone from the spinal cord. She is among a handful of neurosurgeons who offer this “single-level” SDR surgery, which helps children recover faster.
Dody Robinson, together with the Boston Children’s Cerebral Palsy Program team, conduct a detailed assessment to determine whether SDR is the right choice and whether your child is ready for the operation and the post-op physical therapy. This evaluation step is very important and is one of the reasons children who undergo SDR at Boston Children’s have had excellent outcomes.
To learn more about Selective Dorsal Rhizotomy (SDR) procedure at Boston Children's Hospital, please click on the links below:
Dody Robinson wants children with cerebral palsy and spasticity to achieve the greatest level of independence, function and comfort. Her practice focuses on assuring these children the best possible quality of life. She feels that SDR can open up a whole range of opportunity for children who are good candidates.
Dr. Robinson is also invested in constantly improving treatments for her patients. Through a hospital grant, she maintains a multidisciplinary Cerebral Palsy Registry that tracks patients every six months to document pain, quality of life and functional ability. The registry data are used to guide practice and establish which interventions, at what ages, bring the best results.
In addition to her neurosurgical practice, Dr. Robinson’s research focuses on the biology of the brain injuries that lead to cerebral palsy. Her ultimate goal is to develop treatments that protect the brain, repair the injuries and prevent or minimize the disability they cause.
Spinal surgery for spasticity: How Adam got to like his legs again
Adam Pendergrass, 6, was angry at his legs for not being able to do things, including keeping up with the other boys. His doctors were concerned his bones would not grow normally because of his leg spasticity and urged his parents to consider selective dorsal rhizotomy (SDR) sooner rather than later. Adam can now go up and down stairs without holding on, walk with a straight gait, kneel, crouch and squat. Read about Adam's SDR surgery on our blog.
Moving on with cerebral palsy: New operation offers more mobility
Will DeMauvise’s cerebral palsy had given him an unsteady, stiff-legged, scissoring gait. Unable to take broad strides, he needed a walker to get around. At 5 years old, Will underwent SDR, which broke the abnormal feedback loop that was signaling his leg muscles to tighten too much. The operation has improved his gait, offering him more long-term independence. Read about Will's SDR journey on our blog.
Selective dorsal rhizotomy (SDR) is offered by a number of medical centers in the United States. Reported results with the operation vary, leading some physicians to believe SDR is not effective. However, the real reason results vary is that SDR is not a “one size fits all” operation. At Boston Children’s Hospital, we take extra steps to ensure that SDR is the right choice for every child with spasticity. If it isn’t, we may recommend other interventions.
Myth: “My doctor doesn’t think SDR will work for my child.”
Reality: It’s true that SDR is not a good fit for every child. Our neurosurgeon, Shenandoah (Dody) Robinson, MD, evaluates each child carefully to determine whether he or she qualifies for SDR. We have found that children are most likely to do well after the operation if they:
Dr. Robinson and our Cerebral Palsy Program team may decide that for some children, conservative treatment such as physical therapy or Botox injections may be the best option, and that surgery is not needed. Other children may have spasticity in their arms as well as their legs, or on just one side of the body, and may get more help from an intrathecal baclofen pump.
Myth: “I heard that this surgery makes children worse.”
Reality: While rhizotomy quickly reduces muscle spasticity, the operation is only the beginning of the journey. Immediately after SDR, your child may seem weaker, because the operation “exposes” underlying weakness that was less prominent because of the spasticity. The operation is only completely successful when combined with intensive physical therapy to enable children to build their strength and mobility.
Our team will help you find a physical therapist or collaborate with a PT in your community. We recommend at least five PT sessions a week, for at least six weeks, requiring a firm commitment from both you and your child. As one of our PTs puts it, “With this operation, you get out what you put in.” It may take up to six months to see significant benefits in strength and gait.
Myth: “We’re not ready for SDR now, but we can wait.”
Reality: Yes and no. It really depends on the child and her situation. She needs to be mature enough and developmentally ready to work hard in physical therapy. However, waiting too long may allow the child to develop a mindset of “not being able to do things” and may allow orthopedic complications of the spasticity to develop. The ideal age for SDR is usually between 3 and 12, but some older children and young adults do benefit too.
Although selective dorsal rhizotomy (SDR) is a one-time operation, we see it as having three stages. Just as important as the operation itself are the evaluation beforehand and the physical therapy afterward.
Neurosurgeon Shenandoah (Dody) Robinson, MD, together with our Cerebral Palsy Program team, carefully assesses each child to determine the nature of her leg spasticity, how she has responded to other treatments, her overall functioning, and her maturity and readiness to take part in rehabilitation after surgery. The child’s physical therapist (PT) is an important part of this evaluation process. The PT will evaluate the child's tone, flexibility, walking and strength, especially core and back strength. The evaluation will help to determine if the child’s spasticity is helping or impairing his function and walking ability.
SDR itself usually requires a hospital stay of four to five days. It is done under general anesthesia. Our “single-level,” minimally invasive operation involves a small cut in the spinal cord to expose the nerve roots. Dr. Robinson then tests and selectively cuts the abnormal nerves to interrupt abnormal signaling between the spinal cord and leg muscles. After surgery, we watch children closely, giving strong IV medications to minimize pain and discomfort.
Physical therapy, or PT, is the last and most critical step of the journey. Children must have the cognitive ability, determination and stamina to participate in at least six weeks of almost daily physical therapy afterward. If they do, then SDR can be of tremendous help in improving gait and mobility. We recommend at least five physical therapy a week after SDR, starting before hospital discharge. Our team works with PT providers in the community to ensure the best outcome.
If children and families can stick to PT faithfully, most children will have greatly improved strength and gait within six months.
When physical therapy, oral meds, and Botox have done all they can for spastic cerebral palsy, two neurosurgical options can improve function and quality of life for certain kids. This briefing for pediatricians describes selective dorsal rhizotomy, a one-time spinal operation, and intrathecal baclofen therapy, in which baclofen is delivered directly into the spinal fluid by a pump.
Contact Boston Children's at 617-355-6008 for more information on SDR evaluation, surgery and rehabilitation.
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