Which patients are suitable for SDR

Selective Dorsal Rhizotomy - SDR
NHS GGC

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There are only a small number of children and young people with cerebral palsy (CP) that SDR will help. Care is taken to choose the right patients.  

The child's local team are the best people to help decide if SDR is the right choice. There are many options which might improve life outcomes for each child referred to the service.  

Children with CP are not all the same. This is because CP affects any part of the brain. CP has several types, and it is those with spastic cerebral palsy who will be the best patients for SDR.  

Spacticity can cause problems for of all ages in CP:  

  • A feeling of stiff muscles which make moving arms and legs difficult 
  • Pain  
  • Spasm – that can affect sleep and activity in daily life  
  • Body shape changes  
  • Muscle shortening 
  • Pressure which causes open sores 
  • Walking or using hands is hard and the child is not able to balance well.  
  • Carers can find that giving care can be hard with some or all of the above issues.  

(Winston 2023)  

Children with CP will have higher or lower amounts of spasticity.  

If problems are mostly due to weak muscles or poor muscle movement SDR will not be helpful. 

  • Children between 4 and 10 years of age with spastic diplegia can be referred for SDR. This means that they will have stiff muscles in both legs which are not helped much by medicine. 
  • Children with CP who were born before their due date and have periventricular leucomalacia (PVL) tend to have a good response to SDR. This is not the case for all causes of CP.  

There are some important things to think about for SDR based on whether a child is walking or not. 

Children who are walking independently and considering SDR

  • Very young children who are still learning to walk can change quickly. It is best to wait until their walking pattern settles. This is the time to see if SDR is the best option for them.  
  • Can show muscle strength in the legs and trunk.  
  • Can stand up and support their body and posture with little support. They show they are trying to crawl or walk.  
  • Children must know what is happening and do their exercises.  
  • Family members /carers must work with local teams and continue this after surgery. 

Children who are not walking and considering SDR for improvements to care, comfort and pain levels

  • It is likely that seating and finding comfort in bed are hard to find. This will be a problem every day despite taking medicine to help with muscles which feel tight (spasticity). 
  • Takes medicine to make muscles relax to help with care and comfort and personal care. 
  • Shows more spasticity rather than a child who has more dystonia. This can work for children with mixed tone, although they will still have more tone even after SDR. 
  • The child’s tone should be of a high enough level to affect their quality of life.  
  • Children with cerebral palsy which affects their whole body may be better with an intrathecal baclofen pump. 

Exclusion Criteria

Exclusion criteria may include:

  • Children with severe scoliosis, SDR is not recommended as it may make this worse.
  • Children with injury to other areas of the brain which affect balance and co-ordination. 
  • A child with non stable hips.
  • Where restriction of joint movement is due to contracture rather than spasticity.
  • Previous spinal fusion surgery which could be considered a relative contra-indication.

Are there alternatives to SDR?

SDR is just one option in the management children with cerebral palsy. It is the only procedure which will permanently remove the spasticity in the legs. 

Alternatives to SDR for children with spastic diplegia include:

  • medication
  • long-term exercise and activity, with support and advise by a physiotherapist
  • botulinum toxin injections into the spastic muscles
  • orthopaedic procedures

Even following successful SDR surgery some orthopaedic surgery may still be required.

Alternative treatments should be discussed in full by the referring clinical team and may be suggested by the SDR clinical team as an alterative after surgery is considered.

How will a decision be made on whether my child is suitable for this surgical procedure?

If your local team thinks your child is suitable for SDR they will arrange for more detailed testing. This could be external linkgait analysis, a spine external linkMRI and specialist physiotherapist assessment.  Your child may also require external linkx-ray of his/her hips and in some cases a external linkbrain scan.  Your child will also be referred to the SDR service.

The SDR team will then look at all the info given from your local team.

After all the tests the SDR team will talk. Together with your local team they will make a decision. This can be on whether more time is needed for the child to grow or that surgery will be offered.
If things move towards SDR surgery you will receive a clinical appointment. You and your child will meet the surgical team. Treatment goals, what can be expected and questions you have can be discussed.

What will happen if my child is not suitable or I choose not to continue with SDR referral for my child?

Only a very small number of patients will get better control of their legs after SDR. If your child is not going to get help with SDR the team will outline other treatment options. These will be more likely to help your child.
The path to SDR can be a long process. This is to make sure that the right children get treated. Some children can be in the system for a few years before a final decision is made.
You are able to withdraw your child at any stage. If you remove your child from the SDR tests you can opt to change your mind at a later stage.  
Children with CP have different needs. Many children are able to lead full and happy lives with muscle training and movement.