What is Spasticity?
Spasticity is a condition caused by damaged nerve pathways in the brain and spinal cord. It can happen with any type of brain damage or abnormal brain development. Usually, the messages sent from the brain to the spinal cord will tell the muscles to relax when the muscles are too tight. With spasticity, there is a break or interruption in the messages sent from the brain to the spinal cord, so those muscles never relax.
Spasticity can lead to muscle contractures and bone deformities as there is an increase in muscle tone or muscle stiffness. It can interfere with normal movements such as walking, running, even speech.
Symptoms of spasticity range from mild stiffness to painful or severe spasms. Currently, there is no cure for spasticity but there are different ways to treat the problems caused by spasticity.
One way we are helping kids dealing with spasticity is by being the only children’s hospital in the Southwest to offer selective dorsal rhizotomy surgery.
What is Selective Dorsal Rhizotomy?
Selective dorsal rhizotomy (SDR) is a surgery to help decrease muscle spasticity to help increase function.
The goal of this surgery is to increase your child’s movement and comfort. The surgery can also help prevent muscle contractures and bone deformities by eliminating the high muscle tone that causes these causes these problem over time.
During this procedure, a neurosurgeon tests the sensory nerves and then cuts the specific ones (rhizotomy) that will help to decrease the signal sent to the muscles from the spinal cord. This will decrease spasticity and muscle stiffness but will not affect other functions. SDR can allow your child to improve movements and functionality.
More About the Surgery
A selective dorsal rhizotomy usually takes about two hours to complete. The neurosurgeon makes a 1-2” incision to the middle of a child’s back. The neurosurgeon then tests each nerve root with an electrical impulse and watch the corresponding movement in the child’s legs. The neurosurgeon then severs the nerve root that is causing too much muscle movement. The nerves which are normal and cause normal responses will not be severed allowing the child to maintain all feeling or movement in the legs.
To help ease any pain associated with an SDR, an epidural will be used to administer a continuous flow of pain medication. The epidural is placed by inserting a tiny, soft catheter near the spine to receive the pain medication. Once the child is medically ready, the care team will stop the epidural and change over to oral pain medication.
After the surgery, the child’s legs should remain as straight as possible while the hips and trunk extended for the first day or two post-surgery. Knee immobilizers may be used to help maintain the position as well as to keep the hamstring muscles stretched.
Some children may need serial casts (short leg casts that are changed every 3-7 days with the ankle in a new position each time) to help stretch the calf and ankle area.
A few days after the surgery, some children experience tingling or numbness in the feet. This is usually temporary, however, there is medicine available for this if it becomes bothersome or painful.
Who Is Eligible for SDR Surgery?
Not every child with cerebral palsy benefits from a rhizotomy. A team of specialists with Barrow Neurological Institute at Phoenix Children’s Hospital including a neurosurgeon, rehabilitation physician, neurologist, physical therapist and a rehabilitation nurse evaluate potential candidates for this surgery. Although there are always exceptions, patients who are eligible for this surgery generally:
- Are between the ages of 4 to 10 years old
- Have spasticity in the lower extremities
- Have good underlying leg strength and control
- Have good cognitive development and motivation
- Are able to complete the intense rehabilitation needed after surgery
Benefits of this surgery may include:
- Decreased need for surgeries of the hips and lower extremities (legs)
- Decreased overall leg pain
- Easier ability to manage self-care skills (dressing, etc.)
- Improved sitting balance, better gait (longer stride length and easier walking)
- Fewer falls
- Better function and movement of the upper body
Inpatient Rehabilitation Unit
A child will need extensive physical therapy (PT) and occupational therapy (OT) for several weeks after the surgery. The next step is our inpatient rehabilitation unit. Typical rehabilitation for an SDR is physical and occupational therapies for at least three hours a day, six days a week. Each child’s progression post-surgery is different but the average stay in our inpatient rehabilitation unit is three to four weeks.
During physical therapy, our therapists will work with a child on various stretching, strengthening and sitting exercises to promote proper posture. At first, a child may have difficulty standing and/or walking. This is normal and that’s why our therapists are here to help.
In occupational therapy, our therapists will work with a child to help regain self-care skills. Once those are mastered, the therapist will help a child advance those skills now that movement has been expanded and spasticity has been reduced.
The goal for discharging a patient back home is for the child to gain strength and relearn mobility skills. Some children will need to rely on equipment when they first go home such as wheelchairs, braces or walkers.
After inpatient rehabilitation is completed, a child will continue to recover and improve in an outpatient therapy setting. Typically, this rehabilitation schedule consists of three weekly appointments for about six months. A case manager will help to arrange outpatient therapy.
It may take a full year to see the full improvement in a child’s functionality. Every child’s goals and outcomes are unique to them. However, if a child has areas of tightness or deformity that persist after an SDR, he/she could require orthopedic surgery to further facilitate treatment.