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ADC Online First, published on February 10, 2015 as 10.1136/archdischild-2014-306874
1
Department of Neurosurgery,
Great Ormond Street Hospital
for Children NHS Trust,
London, UK
2
Faculty of Medicine, University
of Sydney, Sydney, Australia
3
The Wolfson Neurodisability
Service, Great Ormond Street
Hospital for Children NHS
Trust, London, UK
Correspondence to
Kristian Aquilina, Department
of Neurosurgery, Great Ormond
Street Hospital for Children
NHS Trust, Great Ormond
Street, London WC1N 3JH, UK;
Kristian.aquilina@gosh.nhs.uk
Received 6 October 2014
Revised 13 January 2015
Accepted 17 January 2015
To cite: Aquilina K,
Graham D,
Wimalasundera N. Arch Dis
Child Published Online First:
[please include Day Month
Year] doi:10.1136/
archdischild-2014-306874
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Review
Selective dorsal rhizotomy: an old treatment
re-emerging
Kristian Aquilina,1 David Graham,2 Neil Wimalasundera3
ABSTRACT
Selective dorsal rhizotomy (SDR) is a neurosurgical
technique developed to reduce spasticity and improve
mobility in children with cerebral palsy (CP) and lower
extremity spasticity. It involves the selective division of
lumbosacral afferent (sensory) rootlets at the conus or at
the intervertebral foramina under intraoperative
neurophysiological guidance. First described in 1908,
early procedures were effective at reducing spasticity but
were associated with significant morbidity. Technical
advancements over the last two decades have reduced
the invasiveness of the procedure, typically from a five-
level laminoplasty to a single-level laminotomy at the
conus. As practised today, SDR is an effective treatment
for young patients with bilateral spastic CP who are
rigorously selected for surgery and for whom realistic
objectives are set. SDR has therefore re-emerged as a
valuable management option for spastic CP. In this
article, the authors review the single-level SDR technique
and its role in the management of bilateral spastic CP,
with particular emphasis on patient selection and
outcomes.
NATURAL HISTORY AND MANAGEMENT OF
CEREBRAL PALSY
Cerebral palsy (CP) affects approximately 2–3/1000
people in Europe.1 Bilateral spastic CP, with pre-
dominant lower limb involvement, is the most
common subtype of CP in Europe, accounting for
over half of the patients.1 The severity of spastic
CP is classified according to the Gross Motor
Function Classification System (GMFCS).2 The
Gross Motor Function Measure (GMFM) has been
used along with GMFCS to describe the natural
history of spastic CP in two landmark studies.2 In
particular, the Adolescent Study of Quality of Life,
Morbidity and Exercise found a decline in GMFM
during the middle to late teenage years for patients
at GMFCS III–V.2 Even though CP is considered a
non-progressive condition, a decline in motor
ability with age is evident. Interventions are direc-
ted at minimising or even halting this natural
decline.
Spasticity and associated spasms cause muscle
stiffness, pain and discomfort, which interfere with
function. Muscles in children with CP are different
compared with children developing normally; they
are smaller, weaker and demonstrate histological
architectural changes. Spasticity contributes to
muscle shortening, contracture development,
torsion of long bones and joint degeneration.
Children with severe spasticity accumulate progres-
sive lower limb muscular, skeletal and joint deform-
ities before reaching skeletal maturity. Without
early intervention to reduce tone, many children
Aquilina K, et al. Arch Dis Child 2015;0:1–5. doi:10.1136/archdischild-2014-306874
require multilevel orthopaedic surgery, which often
includes soft tissue release in combination with
femoral osteotomies and hip reconstruction. Watt
et al3 prospectively studied 74 children with spastic
CP and reported that 61% had already undergone
orthopaedic procedures by 8 years of age.
Moreover, spasticity can interfere with the ability
of carers to look after children with CP.
Multidisciplinary goal-oriented early intervention
promotes disease modification rather than symptom
management and is preferable for positive long-term
functional outcome. Occupational therapy, physio-
therapy and speech therapy are first-line interven-
tions and aim to improve activities of daily living
(ADL). Adjunct pharmacological interventions for
bilateral spastic CP can be either oral (baclofen,
diazepam or clonazepam) or intramuscular (botu-
linum toxin A or phenol). Surgical treatment
options include intrathecal baclofen (ITB) or select-
ive dorsal rhizotomy (SDR) for tone management,
and orthopaedic surgery to improve lower limb
alignment.
EVOLUTION OF SELECTIVE DORSAL
RHIZOTOMY
Lumbosacral dorsal rhizotomy for spasticity was
first advocated by Foerster in 1908. He observed
that patients with tabes dorsalis who had hemiple-
gia did not develop spasticity, so he hypothesised
that division of the dorsal (sensory) roots could
relieve spasticity.4 Working with Tietze, his tech-
nique involved complete division of the dorsal
roots of L2, L3, L5 and S1, sparing the ventral
(motor) roots, leading to marked improvement in
spasticity but also significant muscle weakness as
well as loss of sensation and proprioception.4
Forty-five operations were conducted from 1908
using Foerster’s technique; surgical complications
were frequent, and eight patients died as a result of
meningitis.4
The complications of deafferentation led to the
disuse of SDR until the 1960s when division of
only a fraction of the dorsal rootlets, maintaining
sufficient afferent input to preserve sensation and
proprioception, was considered.5 Partial sectioning
of the dorsal nerve roots on the basis of intraopera-
tive electrophysiological stimulation was introduced
by Fasano in 1978 and is still used today. Nerve
rootlets producing sustained muscle activation with
abnormal widespread involvement of unrelated
muscles in the trunk and upper limbs on stimula-
tion were assumed to be contributing to spasticity
and were divided. This led to good long-term
results. The technique was adopted and popularised
by Peacock and Arens in the 1980s.5 Surgery
involved a multilevel laminectomy or laminoplasty,
1
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Review
typically from L1 to L5. The nerve roots were identified at their
individual foramina. The sensory nerve roots were dissected
from the motor ones at the foramen; the afferent roots were
then further dissected into rootlets, evaluated electrophysiologi-
cally and divided. However, concerns about the potential
impact of extensive spinal surgery in ambulant children with CP
led to the development of a single-level technique involving div-
ision of dorsal rootlets at the level of the conus.6
This single-level technique, as it is often practised today,
involves identification of the conus on intraoperative ultrasonog-
raphy through a small T12–L1 midline fenestration (figure 1).
The conus is then exposed by removing the spinous process and
central component of the appropriate lamina. At this level,
removal of a single lamina allows exposure of the dorsal
(sensory) and ventral (motor) nerve roots, from L1 to the sacral
roots, as they enter and leave the conus. The dorsal (sensory)
nerve roots are located superficially and the ventral (motor) ones
lie deeper ; there is a clear identifiable plane between the two.
The motor roots are protected throughout the procedure. The
L2 to S1 dorsal nerve roots are identified, divided into rootlets
and systematically stimulated to determine their threshold
Figure 1 Intraoperative ultrasound is essential to locate the conus
intraoperatively in the single-level procedure. These ultrasound images
demonstrate (A) sagittal view defining the triangular shape of the
conus (white arrow); thin parallel lines around the conus represent the
nerve roots that constitute the cauda equina within the hypoechoic
cerebrospinal fluid. (B) An axial view showing the circular hypoechoic
conus; the white arrow defines the boundary between the dorsal
sensory nerve roots (single asterisk) and the ventral motor roots
(double asterisks).
2 Aquilina K, et al. Arch Dis Child 2015;0:1–5. doi:10.1136/archdischild-2014-306874
amplitude (figure 2). Electromyographic (EMG) responses to
50 Hz tetanic stimulation at threshold amplitude are graded for
each nerve rootlet (figure 3). Rootlets with diffuse responses
beyond their segment (grade 3 and 4) are divided; in total, up to
60–70% of the sensory roots are divided. Fifty per cent of the L1
sensory nerve root is then divided as it exits its foramen.
Recovery following the single-level technique is rapid, and chil-
dren typically resume physiotherapy after 2–3 days of bed rest.
PATIENT SELECTION FOR SELECTIVE DORSAL RHIZOTOMY
The decision as to whether SDR is the optimal procedure for a
particular child at that stage of motor development is not easy
and needs to be made within a multidisciplinary context.
Agreement by all involved, including carers, on the goals of
treatment for the individual child is crucial. The principal goals
of SDR depend on a child’s motor abilities and include
improved motor function, increased mobility and independence,
improvement in ease of care and reduction in pain.
The general selection criteria defined by Peacock in 1987 still
apply.5 Our current criteria are shown in table 1. Currently, most
children selected for SDR are between 3 and 14 years of age.
As illustrated in a recent review, selection criteria for SDR
vary between centres and have not been generally validated.7
They are primarily based on clinical rationale rather than clinical
evidence. In many centres, several inclusion and exclusion cri-
teria are not based on standardised or reproducible measure-
ments. Most centres, however, use a multidisciplinary approach
that evaluates some or all of the International Classification of
Function domains, particularly the body structure and function,
activity and personal and environmental factors. Very strict
selection criteria may influence outcome. In the Oswestry series,
only 35% of referred children satisfied the selection criteria and
underwent SDR.8 In this series, children consistently showed
improvement in the GMFCS level after SDR; this was not
reproduced in other large series, where children tended to
improve only within the same GMFCS level. It is important to
remember that as children with CP get older their mobility diffi-
culties include more orthopaedic-type musculoskeletal difficul-
ties rather than just spasticity, which can explain differences in
outcome post-SDR. Although a trial of oral baclofen is not
necessary prior to making a decision on SDR, targeted botu-
linum toxin injections to reduce spasticity in some muscle
groups are useful in evaluating the potential functional impact
of SDR.
OUTCOMES OF SELECTIVE DORSAL RHIZOTOMY
SDR is a permanent and effective treatment for spasticity in
children with bilateral spastic CP.9 Several studies show there is
no loss of gross motor control in patients with bilateral spastic
CP, with most patients showing sustained improvement in gait
and spasticity.5 8 10–14 There is high-level evidence that SDR
combined with physiotherapy has better results than physiother-
apy alone, although patients are unlikely to decrease GMFCS
grade.9 14–17 This conclusion is largely based on the results of
three well-designed randomised controlled trials (RCTs) con-
ducted in North America (Toronto, Vancouver and Seattle) in
1997 and 1998.15–17 In the Toronto study,15 evaluation at
12 months showed significant improvements in GMFM scores,
knee and ankle tone, passive ankle range of motion, soleus
EMG reflex activity on forced dorsiflexion and foot-floor
contact pattern. In the Vancouver trial,16 significant improve-
ments were observed at 1 year in GMFM, spasticity and range
of movement in the group undergoing SDR combined with
physiotherapy. At 24 months in the Seattle study,17 the
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Review

Figure 2 Intraoperative photomicrographs demonstrating intradural exposure at the level of the conus, typically through an L1 laminotomy in the
single-level procedure. (A) Following a midline longitudinal durotomy, the afferent nerve roots on the right (white arrow) and the conus (asterisk)
are evident. (B) The afferent nerve roots, from L2 to S1, are mobilised medially to expose the ventral motor roots (asterisk). (C) A small protective
cottonoid is placed over the motor roots (asterisk). (D) A sling is passed deep to the sensory nerve roots, and Peacock probes are used to stimulate
the roots systematically (white arrow) from lateral, corresponding to L2, to medial, corresponding to S1.

Figure 3 Intraoperative electromyography showing responses to tetanic stimulation of individual nerve roots to 50 Hz stimulated at their own
threshold. In (A), the response is restricted to a single muscle group on stimulation of S1 (hamstrings) (grade I). In (B), a response from an adjacent
muscle group on stimulation of L3 is recorded (vastus lateralis; adductor longus stimulated also) (grade II). In (C), there is diffuse activation of
several muscle groups on the same side on stimulation of S1 (hamstrings) (grade III). In (D), there is a diffuse and bilateral muscle group response
on stimulation of L5 on the left ( peroneus longus) (grade IV). The objective of the procedure is to divide 60–70% of the sensory nerve roots
between L2 and S1, including as many grade III and grade IV roots as possible. Also, 50% of the L1 sensory root is subsequently divided at its
intervertebral foramen.
Aquilina K, et al. Arch Dis Child 2015;0:1–5. doi:10.1136/archdischild-2014-306874 3
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Review
Table 1 General selection criteria for selective dorsal rhizotomy
Type of CP Spastic without significant ataxia or dystonia
Classically spastic diplegic CP
Severity of CP A degree of ambulation with or without assistive devices;
currently most patients are GMFCS grade II or III
MRI No injury to basal ganglia, brainstem or cerebellum on
MRI; typical periventricular leucomalacia
Musculoskeletal Good trunk control, good lower extremity antigravity
strength on clinical examination
No significant femoral head subluxation on pelvic
radiograph (Riemer’s index up to, or less than, 40%)
No significant scoliosis
Previous Preferably at least 6 months after the last botulinum toxin
interventions A injection
Preferably at least 1 year after orthopaedic surgery
Child and family Ability to cope with rehabilitation process (cognitive and
factors emotional)
Supporting environment with access to rehabilitation
facilities
CP, cerebral palsy; GMFCS, Gross Motor Function Classification System.
combined SDR/physiotherapy group showed a significant reduc-
tion in spasticity compared with the physiotherapy-only group.
However, improvements in GMFM were not significant. This
result could be attributed to the fact that only a mean of 25%
of dorsal roots were divided in the Seattle study, which is in
contrast to the currently accepted SDR technique, in which
between 50% and 70% of the sensory nerve roots are divided.
Other studies have shown SDR to be superior to other inter-
ventions in the management of spastic CP. In their RCT compar-
ing SDR with botulinum toxin A injections, Wong et al18 found
that the effectiveness of SDR was of a longer duration than
botulinum toxin A. Moreover, patients with SDR have reduced
requirements for orthopaedic interventions and intramuscular
botulinum toxin A injections.10 18–21 In their non-randomised
patient series, Kan et al compared two groups of age and
GMFCS score-matched children; an SDR group underwent
surgery prior to 1997, and an ITB group underwent surgery
after 1997. The SDR group showed significantly better improve-
ments in Ashworth scale, lower extremity passive range of
motion and GMFM scores.22 The SDR group had a significantly
reduced need for orthopaedic surgery compared with the ITB
group. A study evaluating the rate of orthopaedic surgery after
SDR showed that in all age groups 25% of independent walkers
and 44% of assisted walkers required orthopaedic surgery over
a 9-year follow-up.19 Those undergoing SDR at a young age
demonstrated the lowest requirement for orthopaedic surgery
after SDR.21
Evidence on the long-term effects of SDR is emerging and is
generally positive.5 10–12 Nordmark et al11 reported on a group
of 35 children with spastic diplegia over a 5-year postoperative
period. SDR resulted in immediate reduction of tone in adduc-
tors, hamstrings and dorsiflexors, with no recurrence of spasti-
city over 5 years. Similarly, there was significant improvement in
passive range of movement in hip, knee and ankle joints, as well
as significant improvements in GMFM. In a 10-year follow-up
study of 24 children, undertaken by the same group, additional
improvement was evident in the functional skills, mobility and
caregiver assistance (both self-care and mobility) domains of the
Paediatric Evaluation of Disability Inventory (PEDI) scores
between 5 and 10 years after SDR.12 This was particularly
evident in children in the GMFCS I to III subgroups. Children
in the GMFCS IV and V subgroups demonstrated only small
changes between 5 and 10 years after SDR.
4 Aquilina K, et al. Arch Dis Child 2015;0:1–5. doi:10.1136/archdischild-2014-306874
Dudley et al10 reviewed long-term follow-up data of children
who were evaluated by a multidisciplinary team preoperatively
and at 1, 5, 10 and 15 years after SDR. After SDR, through
adolescence and early adulthood, statistically significant and
durable improvements in lower limb muscle tone, gross motor
function and performance of ADL were identified. Only 28% of
children required further lower extremity orthopaedic surgery
after SDR during the follow-up period, a significant improve-
ment compared with the expected 61% intervention rate for
similar children by the age of 8 years.3 The multidimensional
benefits of SDR, reflected in the PEDI score, were also evident
in this study, where significant gains in self-care and mobility
persisted to early adulthood. However, a recent systematic
review of interventions for CP found no clear evidence that
SDR improves general activities and participation, which argu-
ably should be the primary goal of the procedure.9 Although
there are enduring improvements in GMFM after SDR, most
children will remain within their GMFCS grade following
surgery, with the exception of the Oswestry experience.
Nevertheless, the majority of former patients with SDR report
improvements in their ADL and that they would recommend
SDR, with very few reporting negative impressions of the pro-
cedure.21 Indeed, the Cape Town experience found that none of
Peacock’s original cohort of patients required help with ADL.5
Some studies have reported less satisfactory long-term out-
comes, thus contributing to decisions on patient selection.
Children with spastic quadriplegia had poorer outcomes com-
pared with those with diplegia.23 Children over 10 years of age
were demonstrated to have better long-term outcomes with
multilevel orthopaedic surgery than with SDR.24 This underlines
the particular challenges related to patient selection in this age
group, where the primary difficulties with mobility often arise
from weakness and structural lower limb deformities rather than
pure spasticity. It is now generally agreed that good long-term
results are achieved in young children, who are diplegic rather
than quadriplegic, and those whose GMFCS grade is II–III. A
recent study of 54 children followed up for 2 years confirmed
that children between 4 and 7 years old with preoperative
GMFM scores between 65% and 85% benefit most from SDR.13
Permanent complications are now rare after SDR. In their
review of long-term adverse effects of SDR, Grunt et al25
reported that back pain and spinal abnormalities were common,
including kyphosis, scoliosis, lumbar lordosis, spondylosis and
spondylolisthesis. But they found insufficient evidence to con-
clude such abnormalities are the direct result of SDR rather
than related to the natural history of spastic CP. A large patient
series has shown that limited laminectomies at the level of the
conus are not associated with long-term spinal deformity.6
Transient dysaesthesiae are common, but permanent hypoesthe-
sia is rare. Transient urinary retention was frequent during the
earlier days of the resurgence of SDR, while permanent urinary
incontinence was rare. Most centres now advocate pudendal
monitoring and limitation of the division of the S2 nerve root
in order to limit adverse effects related to detrusor function. As
a result, the current risk of incontinence is very low.
In practice, the importance of setting appropriate specific
objectives with families, within the context of the surgical risks
and the need for intensive postoperative rehabilitation, cannot
be overemphasised. In our experience, in ambulant children,
SDR leads to improved mobility, increased stamina, better
balance and fewer falls. Children who walk with assistance
become more independent. Sitting and standing posture
improves. In addition, the pain associated with spasticity
responds well to SDR.
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CONCLUSIONS
SDR is an effective treatment for young patients who are rigor-
ously assessed for suitability. The evidence supports the use of
SDR in the management of spastic CP by significantly reducing
spasticity. This reduces need for further surgical interventions
and improves independence in ADL and quality of life. The
current single-level technique, involving midline laminotomy at
the conus, represents a significant improvement on older techni-
ques. Nevertheless, realistic goals must be set as GMFCS levels
are unlikely to advance, which is a limitation that must be
clearly understood by patients, their parents and practitioners.
Acknowledgements The authors are indebted to Ms Ivana Jankovic and Dr
Matthew Pitt for assistance with provision of figures related to intraoperative
electromyography.
Contributors All authors contributed equally to the drafting and revision of the
manuscript.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
Data sharing statement This is a commissioned review article.
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Selective dorsal rhizotomy: an old treatment

re-emerging
Kristian Aquilina, David Graham and Neil Wimalasundera

Arch Dis Child published online February 10, 2015

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