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Selective Dorsal Rhizotomy (SDR) Surgery
As a regional leader in pediatric neurosurgery, Gillette Children’s Specialty Healthcare is one of the top providers of selective dorsal rhizotomy (SDR) surgery in the U.S. The procedure helps manage spasticity (tightness or stiffness), particularly in patients who have cerebral palsy. We attract patients from across the nation and world.
Why Choose Gillette?
- Gillette is one of the nation’s Best Children’s Hospitals in pediatric neurosurgery, neurology and orthopedics.
- Our team of medical, surgical and rehabilitation specialists evaluates every patient before surgery.
- Ours is one of the world’s busiest and most respected clinical gait and motion analysis centers.
- We believe that comprehensive rehabilitation helps children reach their full potential following surgery.
- Our commitment to clinical research and measurable outcomes promotes the highest standards of care.
Definition of Selective Dorsal Rhizotomy Surgery
Selective dorsal rhizotomy (SDR) surgery is a procedure that treats muscle spasticity caused by abnormal communication among the brain, spinal cord, nerves and muscles.
Spasticity most commonly affects patients who have cerebral palsy. SDR surgery corrects muscle spasticity by cutting the nerve rootlets in the spinal cord that are sending abnormal signals to the muscles.
Selective dorsal rhizotomy has been shown to:
- Reduce spasticity
- Improve gait (walking) patterns
- Help people use energy and oxygen more efficiently
- Improve range of motion and functional mobility
- Make it easier to perform self-care activities, such as getting dressed and grooming
Candidates for Selective Dorsal Rhizotomy Surgery
SDR surgery is typically performed on patients who have spastic cerebral palsy. Because it is irreversible, careful patient selection is critical. At Gillette, every candidate for SDR surgery undergoes a spasticity evaluation, which includes a physical examination and testing in our world-renowned James R. Gage Center for Gait and Motion Analysis.
Our evaluation team includes an orthopedic surgeon, a neurosurgeon, a pediatric rehabilitation medicine physician and a physical therapist. The team considers many factors when evaluating patients for SDR surgery, including:
- Cerebral palsy type: The best candidates for SDR surgery typically have spastic diplegic cerebral palsy that affects the legs more than the arms.
- Gross motor function: Patients who can walk and are expected to continue walking generally are the best candidates for SDR surgery. Such children are generally at levels I, II and III on the Gross Motor Function Classification System (GMFCS).
- Gait analysis data: Gait analysis can indicate whether a patient’s abnormal movement patterns stem from spasticity or another movement disorder. It also quantifies how much energy a patient uses when walking by measuring oxygen consumption. Candidates for SDR surgery often require 200 to 600 percent more energy to walk than typically developing patients do.
- Age: Children between 4 and 7 are typically the best candidates for SDR surgery, but older children can benefit from the procedure as well.
- Cognitive abilities: Because SDR surgery requires extensive rehabilitation, the best candidates are cognitively able to follow directions and participate in therapy.
Preparing for Selective Dorsal Rhizotomy Surgery
SDR surgery involves a three- to four-hour surgical procedure and several weeks of inpatient rehabilitation. Once we’ve determined that a patient is a good candidate for surgery, we help families plan a convenient time for surgery and rehabilitation.
Managing Activity, Diet and Digestion
Overall health can affect how well and how quickly a patient recovers from a selective dorsal rhizotomy.
- Excercise: Before surgery, patients should stay as active as possible. Consider focusing on upper-body strengthening. It might aid progress during rehabilitation after surgery, since a child will frequently use the arms to move the body into various positions.
- Diet: Good nutrition can aid a child’s surgery and recovery. Patients should eat healthy amounts of foods containing iron, calcium and vitamins C and D. Such foods include dairy products and fresh, colorful fruits and vegetables. Protein is also very important for healing. For six weeks before surgery, we suggest increasing the amount of protein a child consumes. Good sources include meats, dairy products, nuts and eggs. A child doesn’t have to eat more food than usual. If weight gain is a concern, substitute servings of protein for servings of carbohydrates a child would otherwise eat. (Many cookbooks include guides to understand how much food equals one serving.
- Bowel Management: If a patient has trouble with constipation before or after SDR surgery, ask your primary health care provider to develop a treatment plan.
Weaning Off Medicines
When we schedule surgery, we ask about medicines a patient takes. Before SDR surgery, patients sometimes need to gradually stop taking some of their medicines, such as these.
- Oral baclofen: Patients must wean off it.
- Valproic acid (Depakote): We might do lab work to determine whether patients should switch to a different medicine to manage seizures.
The amount of time it takes to wean off a medicine can vary. A patient might need to start the process one week before surgery, several months in advance, or somewhere in between. For more information, talk to the clinic nurse or health care provider who prescribes the patient’s medicine.
Alerting Us to Latex Allergies
Even though Gillette doesn't use or allow latex in our buildings, it’s still important to tell doctors if a child has a latex allergy or has had a severe reaction to latex.
Sometimes fears, behavior and expectations related to surgery cause stress for patients and families. We recommend contacting the patent's primary health care provider or Child and Family Services. We can help locate resources that might help reduce anxiety. Our child life specialists can provide emotional support and distractions (such as toys and movies we can bring to the preoperative waiting area before the surgery begins). Child life specialists also can meet with a child’s siblings to address their feelings and concerns.
Scheduling Presurgery Appointments
Several weeks before surgery, we'll call patients to schedule several preoperative appointments, which usually occur the day before surgery. Our goal is to help patients and their families feel as prepared and supported as possible. Appointments typically include:
- A hospital tour and education session
- Occupational therapy assessment
- Fitting for knee immobilizers, which are worn for a while after surgery
- Fitting for a wheelchair, which is used for a while after surgery
Planning Ahead for the Return Home
It’s important to plan well in advance for discharge from the hospital to address needs that might arise during—and after—the trip home. Our staff will help make a child’s transition from hospital to home as smooth as possible.
Wheelchair/Mobility Equipment: Patients will need to use a wheelchair for a while after leaving the hospital. We recommend making some arrangements before the surgery to ensure one is available when it's needed. Sometimes, it takes a while to obtain a child-size wheelchair.
If a patient doesn't own a wheelchair, the rhizotomy team can help arrange to rent one from a local medical equipment vendor. Some insurance policies require patients to rent from a vendor closer to home if they don't live in the Twin Cities metropolitan area. Community physical therapists might also be able to recommend resources nearby.
Patients might also need a walker at home. The rhizotomy team can help arrange to obtain one before leaving the hospital.
Flight Arrangements: Patients flying to the Twin Cities for SDR surgery and a hospital stay should buy plane tickets with some flexibility for the return flight date, if possible. Although our team can estimate the length of stay before arriving at the hospital, sometimes we adjust this estimate after we start working with a child.
Outpatient Therapy: After leaving the hospital, patients will need physical therapy close to home. Appointments will be five days a week at first, then less frequent as progress continues in the months that follow. We recommend exploring options for physical therapy services in a child's community before surgery. Check with health insurance providers to make sure coverage for services at specific locations is available.
During the Hospital Stay for Selective Dorsal Rhizotomy Surgery
Our perianesthesia staff greets patients and their families upon arrival for SDR surgery. We then weigh the patient and ask the patient to change into a hospital gown. We also check the patient’s temperature, pulse and blood pressure. A child life specialist helps prepare patients for surgery and offers toys, crafts or movies to help them feel more at ease.
Next, patients meet with the surgery team: the operating room nurse, neurosurgeon, nurse anesthetist and anesthesiologist. Any questions or concerns can be raised at this time. Also, tell the nurse and anesthesiologist about experiences with pain. Patients can request medicines and other techniques to help decrease anxiety.
The anesthesiologist will explain how we use anesthesia and pain medicines during surgery.
Right before surgery, the neurosurgeon marks the place on the patient’s body where an incision will be made. Patients are then put to sleep using anesthesia inhaled through a mask or through an intravenous (IV) tube. After the patient is asleep, we insert a breathing tube. If we haven’t placed an IV tube yet, we'll do that as well. Patients receive anesthesia and fluids through the IV tube during and after the surgery. Our staff monitors breathing throughout the surgery.
The neurosurgeon makes an incision low in the patient’s back and opens up the spinal canal. Through that space, the surgeon can access the sensory nerve roots that carry messages from the central nervous system to the muscles.
The neurosurgeon separates the roots into smaller rootlets and stimulates each rootlet with an electrical impulse. We then cut the rootlets that cause abnormal responses, leading to a permanent reduction in muscle spasticity. The procedure usually lasts three to four hours, during which we might test more than 100 rootlets. When SDR surgery is complete, the neurosurgeon closes the spinal canal and incision.
Immediately After Surgery
After surgery, patients start out in the Postanesthesia Care Unit (PACU), then move to the Rehabilitation Unit.
Postanesthesia Care Unit (PACU)
SDR patients wake up here. Shortly afterward, nurses ask how much pain the patient is feeling and provide medicine for pain management if needed. The neurosurgeon also meets here to discuss the surgery and recovery process.
Shortly after surgery, temporary changes in a patient's appearance might be noticeable. For example, the patient's face and hands might be puffy due to body position during surgery. There might also be redness around the patient's eyes and lips. That’s because we often place protective tape over the eyes and around the mouth to keep the breathing tube in place.
In most cases, after some time in the PACU, patients go to the Rehabilitation Unit. During the first hours here, a nurse frequently checks blood pressure, pulse, temperature and breathing. We also check circulation in the arms and legs.
We give pain medicines and fluids through an IV tube. We also use a monitor to track vital signs. If, at any time, the patient's heart rate or breathing rate changes significantly, an alarm will sound.
A nurse isn’t at the bedside at all times, but we come into the room often. We closely monitor patients to ensure safety and comfort.
One parent or adult caregiver can stay in a patient’s hospital room at night. We have showers available for family members. Laundry machines and a refrigerator are also available. Parents, caregivers and family members are also welcome to bring a patient's favorite foods to eat during the hospital stay.
We also offer a variety of amenities—including the Ronald McDonald Family Room®—for patients and their families during their stay at Gillette.
Rehabilitation Following SDR Surgery
SDR surgery reduces muscle spasticity permanently. As a result, patients must learn new patterns of walking and moving. Because the first weeks after surgery are critical for establishing those new patterns, Gillette provides intensive inpatient rehabilitation care following every SDR surgery.
Patients typically spend about three days in a hospital bed recovering from SDR surgery. Initially, pain medication and nourishment are administered through an IV. A catheter drains urine from the bladder. Nurses closely monitor patients to ensure safety and comfort. Later, nurses play an important role in helping patients practice what they learn during rehabilitation therapy.
Pediatric rehabilitation medicine physicians direct the rehabilitation plan, which begins about three days after surgery. Physical therapists work with patients on basic skills, such as head and trunk control. Later skills include crawling, standing and walking. Slowly building on skills is vital. If patients perform advanced activities too soon, they risk reverting to the abnormal movement patterns they used before surgery.
Occupational therapy and therapeutic recreation services begin about five days after surgery. Occupational therapy helps patients learn self-care skills (such as washing, eating and getting dressed). Therapeutic recreation services help patients learn and practice skills using activities like sports or games. Some patients also receive speech therapy while in the hospital.
In addition to undergoing comprehensive rehabilitation therapy, patients have access to Gillette’s full range of child and family support services and to collaborative medical, surgical, rehabilitation and assistive technology specialists.
Going Home After SDR Surgery
We begin planning for a successful return home as soon as patients and families arrive at the hospital. Throughout the inpatient rehabilitation stay, a Gillette team discusses outpatient therapy plans with Gillette specialists or community providers.
Patients will have a family conference shortly before leaving the hospital. We'll provide recommendations for:
- Supporting recovery at home
- Scheduling follow-up appointments
When leaving the hospital after a rhizotomy, most patients ride home in the same vehicle seats they used before the surgery. Be sure to use appropriate child safety seats or seat belts. If that's not possible, Gillette has E-Z-ON Vests available to loan. E-Z ON Vests allow a child to be safely secured in a vehicle while in a reclined position. If an E-Z-ON Vest is available, the rehabilitation team will help obtain one if it's appropriate and safe for the patient.
Our team might recommend adaptive equipment—such as a wheelchair, a standing device or a walker—for patients to use when they first go home. (When most patients leave our inpatient program, they are walking only during therapy sessions.)
Therapy schedules after SDR surgery vary, but we typically recommend starting with five sessions per week after leaving the hospital. Therapy might take place at Gillette or in a child’s community, depending on where the family lives, insurance coverage and the available resources.
Start scheduling the physical therapy appointments as far in advance as possible. During the patient's hospital stay, the Gillette rehabilitation team can help determine when the appointments should start.
If, before the rhizotomy, a patient was having occupational therapy, speech therapy, or therapy related to emotional or behavioral functioning, recommendations for those therapies usually don’t change as a result of the surgery. After returning home, the patient can resume those therapies at the same frequency as before the surgery.
Most patients are ready to return to school when they come home from the hospital after rhizotomy surgery. Contact the patient’s school to arrange for any necessary accommodations. For example, ask about the accessibility of school facilities if the child needs to use a wheelchair for a while.
A Gillette psychologist or social worker serves as a liaison between Gillette and a patient’s school. Our therapists and doctors also make recommendations about school accommodations.
Follow-Up at Gillette
Whether or not a patient has ongoing therapy at Gillette, follow-up visits with Gillette’s team are critical. A typical follow-up schedule includes:
- One month after surgery: A pediatric rehabilitation medicine physician performs an evaluation and updates therapy recommendations. The physician and family also discuss a schedule for additional follow-up visits.
- Three, six and 12 months after surgery: At each visit, a pediatric rehabilitation medicine physician might perform an examination and adjust therapy recommendations. In addition, a physical therapist might record video footage to track progress. Patients who can walk might undergo motion analysis approximately one year after surgery to assess changes in movement and energy consumption. An orthopedic surgeon also will evaluate the patient’s outcome approximately one year after surgery.
For information about planning for surgery at Gillette, visit Patient Preparation and Support.
Our SDR Services
Successfully selecting patients, performing surgery and providing rehabilitation care require the collaboration of a highly skilled team. At Gillette, our patients have access to a full range of services and extensive family support. Together, we promote the highest standards of patient care.
Services and specialties most often associated with SDR planning and rehabilitation include:
- Assistive technology
- Gait and motion analysis
- Rehabilitation medicine
- Rehabilitation therapies
- Therapeutic recreation
In addition, Gillette offers a vast array of child and family support services to help patients cope with their hospital stays and make the most of their rehabilitation care. Some of our services include:
For more information about our collaborative services, search Conditions and Care. For information about our hospital amenities, visit Patient Preparation and Support.
Publications and Resources
Gillette offers resources to help families understand and prepare for selective dorsal rhizotomy (SDR) surgery. We want patients and families to feel prepared and supported throughout their experience with us.
- There are many tasks to complete while preparing for SDR surgery, a rehabilitation hospital stay, and care after leaving Gillette. These planning checklists can help keep track of what patients need to do.