Selective dorsal rhizotomy mediating multidimensional improvement in ambulatory children with spastic cerebral palsy: a longitudinal case series.

OBJECTIVE: Selective dorsal rhizotomy (SDR) is a gain-of-function procedure that involves selectively sectioning dorsal rootlets to decrease pathologically active myotatic reflexes mediating spasticity. SDR with physical therapy is supported by level I evidence as a treatment for ambulatory children with spastic cerebral palsy (CP). The Gross Motor Function Classification System (GMFCS) is a clinical assessment tool for gross motor function focused on ambulation and mobility, defined by categories graded on a scale from I, most ambulatory, to V, nonambulatory. The GMFCS is intended to provide a general overview of mobility and ambulation. Institutional practice variation in performing SDR coexists with a clinical consensus that ambulatory school-age children with GMFCS levels I through III derive the most benefit from the procedure, with limited evidence supporting SDR in nonambulatory children with CP (GMFCS levels IV and V). While there are several assessment systems to describe the motor functionality of patients with spasticity, they inadequately identify what aspect of motor function or gait improves after SDR. To investigate this, the authors conducted a retrospective study in a single-institution cohort of ambulatory children with spastic CP, comparing tone, gait parameters obtained from gait analysis data, and patient-reported outcomes before and after SDR.

METHODS: All consecutive pediatric patients with spastic CP who, between February 2019 and August 2021, underwent both an SDR procedure and pre- and postoperative gait mapping at a single institution were included in the study. The gait parameters of step and stride length for each foot, stride velocity, and toe-in/-out angle were collected. Patient outcomes were determined via chart review.

RESULTS: Ten ambulatory patients, 7 of whom were male, had serial gait mapping data and were included in the study. The mean age at surgery was 5.6 years, and the median preoperative GMFCS level was III. There were no major perioperative complications, and the patients were followed up with serial gait mapping for a mean of 2.8 years. The patient- and family-reported outcomes were improved in all patients. The mean ambulation velocity, step length, and stride length all increased, whereas the mean toe-in/-out angle differed in improvement bilaterally.

CONCLUSIONS: Children with spastic CP benefit from SDR in multiple dimensions including better patient-reported outcomes, tone control, and improved gait parameters. Improvements in step length, stride length, and velocity are asymmetrical, and the functional impact on gait should be explored in future studies.