A 20 year study shows that selective dorsal rhizotomy benefits patients
MONTREAL, June 11, 2013 /CNW Telbec/ - Selective dorsal rhizotomy (SDR)
is a surgical procedure used to treat spasticity in some children with
spastic cerebral palsy. This procedure appears to be effective, but for
how long? Researchers from Montreal, Quebec, Canada,* set out to find
the answer to this question by studying data from the McGill University
Rhizotomy Database on 102 pediatric patients with long-term follow-up.
The researchers found that, in the majority of children with spastic
cerebral palsy, the benefits of SDR last throughout adolescence and
into early adulthood. Details on the study findings are reported and
discussed in "Long-term functional benefits of selective dorsal
rhizotomy for spastic cerebral palsy. Clinical article," by Dr. Roy W.
R. Dudley and colleagues, published today online, ahead of print, in
the Journal of Neurosurgery: Pediatrics (http://thejns.org/doi/full/10.3171/2013.4.PEDS12539).
Cerebral palsy (CP) is a term used to describe various disorders of
movement, muscle tone, or posture. Caused by abnormal brain development
or an injury that affects the part of the brain that controls motor
activities, CP first appears before, during, or soon after birth, and
can affect a variety of muscles. Spastic cerebral palsy represents the
type of CP that manifests increased muscle tension or tone; this
increased tone makes the affected muscles very stiff and muscle
movements appear spastic. Studies have shown that gross motor
development in young people with spastic CP can plateau during
childhood and may decline during adolescence. It is therefore essential
to improve motor function early in these children and maintain any
improvements in muscle function over time so that these children may
become productive young adults.
Selective dorsal rhizotomy (SDR) is often performed in children with
spastic CP to reduce muscle spasticity. During surgery, nerve fibers
carrying sensory impulses from muscles to the dorsal side (the back) of
the spinal cord are stimulated electronically at their rootlets to
identify which ones are sending messages that induce an exaggerated
tone and reflex state called spasticity. Selectively, the fibers that
cause spasticity are then cut, leaving fibers that carry normal
impulses alone. This is designed to diminish the spasticity of the
muscle involved without injuring muscle function. The procedure has
proved successful in selected patients, but before the present study
there were no published findings on long-term outcomes of SDR based on
validated functional assessments and patient stratification.
An examination of the McGill University Rhizotomy Database led
researchers to identify 102 children with spastic CP who underwent SDR
between the ages of 3 and 10 years and were evaluated by a
multidisciplinary team before surgery and periodically afterward.
Preoperative data were available for all patients, and postoperative
data were available for 97 patients at 1 year, 62 patients at 5 years,
57 patients at 10 years, and 14 patients at 15 years after surgery.
Evaluations were made using ratings of the children's activities of
daily living, the Ashworth Scale for lower-limb tone, the GMFCS (Gross
Motor Function Classification System), the GMFM (Gross Motor Function
Measure), and GBTM (group-based trajectory modeling), among other
In evaluating data following selective dorsal rhizotomy (SDR) in these
children, the researchers found statistically significant improvements
in lower-limb muscle tone, gross motor function, and the ability to
perform activities of daily living in the majority of patients. These
improvements were durable, lasting throughout adolescence and into
early adulthood. The researchers also found that long-lasting
improvements in motor function were more likely to be found in higher
functioning patient groups, specifically: 1) children with better
preoperative gross motor function, such as those who had been able to
walk on their own or with assistive mobility devices (GMFCS Groups I
through III); 2) children whose spasticity involved only two limbs,
rather than three or four; and 3) children whose spasticity involved
the adductor muscles of the hip only moderately (Ashworth score lower
than 3). The researchers also found that following successful SDR,
these children were less likely to need adjunct orthopedic surgeries or
Botox injections to control spasticity.
When asked about the take-home message of the study, the senior author,
Dr. Jean-Pierre Farmer, stated, "This study has allowed us to confirm
that the change in gait pattern induced by the operation is long
lasting (likely permanent) and 'protects' children from the natural
history of their disease. Whereas the study shows that there are gains
in activities of daily living in all patients, it also allows us to
establish ambulatory goals that are stratified by the preoperative
functional level of the child through predictive indices. The ability
to predict the long-term effects of the SDR operation will be extremely
valuable for treating teams and families at the time of therapeutic
*This paper is the result of a joint program between Montreal Children's
Hospital and Shriners Hospitals for Children® — Canada in Montreal. The
authors of this report are from Montreal Children's Hospital, Royal
Victoria Hospital, Shriners Hospitals for Children® — Canada, McGill
University, and Université de Montreal in Montreal, Canada.
Dudley RWR, Parolin M, Gagnon B, Saluja R, Yap R, Montpetit K, Ruck J,
Poulin C, Cantin MA, Benaroch, TE, Farmer JP. Long-term functional
benefits of selective dorsal rhizotomy for spastic cerebral palsy.
Clinical article. Journal of Neurosurgery: Pediatrics, published online, ahead of print, May 28, 2013; DOI:
Disclosure: The authors report no conflict of interest concerning the materials or
methods used in this study or the findings specified in this paper.
Sara: 4 years old from Montreal
Sara was born at term following a normal pregnancy. However, due to
complications at birth Sara had to fight for survival. On her fourth
day of life, she had seizures and it is at this time that her parents
realized that they were facing a new reality, very different one from
what they had imagined. "Until the age of two her parents would tell
themselves, she is still just a baby, she will grow out of it, she will
be able to catch up", recalls Steve Tanguay, Sara's father. He went on
to say: "However, between the ages of two and three, the reality of
what we were facing hit us hard, our little one did not walk, her
capacity was limited. She had cerebral palsy with dysphasia. We had
little hope and even fewer answers. We had to mourn the child that we
had hoped for ".
One evening, Mr. Tanguay saw a news report on television which featured
Dr. Jean-Pierre Farmer who spoke about the type of neurosurgery he
practiced at The Montreal Children's Hospital. "I cried for my child
because it was the first time I saw the potential of what was possible
for her. It was a revelation" recalls Mr. Tanguay.
At a follow up appointment with neurologist Dr. Chantal Poulin, the
family got more information about the selective rhizotomy surgery. Dr.
Poulin then referred the family to Dr. Farmer.
During the first assessment, Dr. Farmer asked that the family return
later as Sara was not yet old enough to undergo surgery. During the
second evaluation, Dr. Farmer confirmed that the operation would be in
a few months. A few weeks later, the family received a call telling
them that the surgery could be advanced if they wished, they did not
"If we had the chance to return to Shriners Hospital for children for
more intensive therapy, we would. We felt good and supported when we
were there. It was not painful experience, it was actually fun ", says
Sara is a girl who has beautiful strengths: she is a tiny ball of love.
She is magnetic and has a lot of determination. She stretches and walks
every day and actively participates in her treatment. She loves
cartoons on television, loves stories books and she like to invent
"The first time I walked hand in hand with my daughter, I felt so happy
because a few months earlier it was something that simply seemed
impossible", concluded Mr. Tanguay.
Ali Ammar from Montreal
Ali Ammar was born in Lebanon in 1989, half of his body paralyzed. His
doctors believed he would never walk and would be confined to a
wheelchair for his entire life. In the early 1990s, when he was only 18
months old, his family fled the civil war in Lebanon to settle in
Canada. Ali was referred to Shriners Hospital for Children®- Canada as a toddler for spastic dysplasia, a type of cerebral palsy.
He was then evaluated by Jean-Pierre Farmer, M.D., neurosurgeon, and it
was determined that Ali was an ideal candidate for a specialized type
of neurosurgery (a new technique at the time), a selective dorsal
rhizotomy. The surgery took place in 1992 at The Montreal Children's
Hospital of the McGill University Health Centre and was followed with
six weeks of intense rehabilitation at Shriners Hospitals for Children®- Canada, where Ali took his first steps at three years old.
In 2004, in order to improve his gait, Ali had additional surgery on his
ankles and Marie-Andrée Cantin, M.D., orthopaedic surgeon at CHU
Sainte-Justine and accredited surgeon at Shriners Hospitals for
Children, completed two surgeries on his right foot. The surgeries,
rehabilitation and Ali's efforts proved to be extremely successful and
now Ali walks completely unaided.
Today, Ali heading to University. He has also overcome the real-life
obstacles of spastic dysplasia and has even played the lead role in
Romeo Eleven, an award-winning film by Montreal director Ivan Grbovic.
The film offers a rare glimpse into the life of someone with a physical
disability and the struggles portrays a shy teenager looking for love
on the Internet. The film has been presented in twenty festivals around
the world, has won six international awards and brought Ali in Paris
and Lyon in France, Karlovy Vary in Czech Republic and Toronto in
Canada. Ali`s motto: "When you really want something, you can
Jayden, 3 ½ from Chicoutimi
Jayden was born premature at 30 weeks. When he turned one, he began
daycare where some of his developmental delays became apparent. He was
unable to stand or even sit by himself. This worried his parents
Marie-Michèle and Alex, and they were not sure what the future held for
Shortly after his entry in daycare, Jayden began physiotherapy at the
local rehabilitation center in their community. This is when his
therapist informed the parents about a hospital in Montreal that could
potentially perform surgery that could help their son. During the time,
they also met a family whose son had undergone the surgery close to 20
years ago, with positive results.
The day of February 5, 2013 was marked with excitement and anxiety for
the family. The family went to Shriners Hospital for Children - Canada
so Jayden could be evaluated and a decision would be rendered if he
would benefit from the surgery. The evaluations lasted all day and in
the end, it was confirmed that Jayden was in fact an ideal candidate
for a selective dorsal rhizotomy.
Jayden had surgery on June 5, 2013 at The Montreal Children's Hospital
and was transferred on June 10, 2013 to Shriners Hospitals for
Children-Canada for post-operative rehabilitation which lasts 6 weeks.
Jayden's family has created a Facebook page for people to check on his
progress under: Jayden, le petit combatant or www.facebook.com/JaydenParalysieCerebrale. (French only).
Video with caption: "Video: Jayden". Video available at: http://stream1.newswire.ca/cgi-bin/playback.cgi?file=20130611_C7010_VIDEO_EN_27843.mp4&posterurl=http://photos.newswire.ca/images/20130611_C7010_PHOTO_EN_27843.jpg&clientName=H%26%23244%3Bpital%20Shriners%20pour%20enfants%20%28Canada%29&caption=Video%3A%20Jayden&title=H%26%23212%3BPITAL%20SHRINERS%20POUR%20ENFANTS%20%28CANADA%29%20%2D%20Groundbreaking%20techniques%20brought%20forth%20in%20the%201990s%20change%20the%20lives%20of%20children%20and%20allow%20them%20to%20grow%20to%20be%20autonomous%20adults&headline=Groundbreaking%20techniques%20brought%20forth%20in%20the%201990s%20change%20the%20lives%20of%20children%20and%20allow%20them%20to%20grow%20to%20be%20autonomous%20adults
Video with caption: "Video: Sara". Video available at: http://stream1.newswire.ca/cgi-bin/playback.cgi?file=20130611_C7010_VIDEO_EN_27844.mp4&posterurl=http://photos.newswire.ca/images/20130611_C7010_PHOTO_EN_27844.jpg&clientName=H%26%23244%3Bpital%20Shriners%20pour%20enfants%20%28Canada%29&caption=Video%3A%20Sara&title=H%26%23212%3BPITAL%20SHRINERS%20POUR%20ENFANTS%20%28CANADA%29%20%2D%20Groundbreaking%20techniques%20brought%20forth%20in%20the%201990s%20change%20the%20lives%20of%20children%20and%20allow%20them%20to%20grow%20to%20be%20autonomous%20adults&headline=Groundbreaking%20techniques%20brought%20forth%20in%20the%201990s%20change%20the%20lives%20of%20children%20and%20allow%20them%20to%20grow%20to%20be%20autonomous%20adults
Video with caption: "Video: Ali Ammar". Video available at: http://stream1.newswire.ca/cgi-bin/playback.cgi?file=20130611_C7010_VIDEO_EN_27845.mp4&posterurl=http://photos.newswire.ca/images/20130611_C7010_PHOTO_EN_27845.jpg&clientName=H%26%23244%3Bpital%20Shriners%20pour%20enfants%20%28Canada%29&caption=Video%3A%20Ali%20Ammar&title=H%26%23212%3BPITAL%20SHRINERS%20POUR%20ENFANTS%20%28CANADA%29%20%2D%20Groundbreaking%20techniques%20brought%20forth%20in%20the%201990s%20change%20the%20lives%20of%20children%20and%20allow%20them%20to%20grow%20to%20be%20autonomous%20adults&headline=Groundbreaking%20techniques%20brought%20forth%20in%20the%201990s%20change%20the%20lives%20of%20children%20and%20allow%20them%20to%20grow%20to%20be%20autonomous%20adults
SOURCE: Hôpital Shriners pour enfants (Canada)
For further information:
Public Relations and Communications
The Montreal Children's Hospital
Shriners Hospitals for Children-Canada