Rhizotomy, also Selective Dorsal Rhizotomy

Selective Dorsal Rhizotomy Surgery at Gillette Children’s Specialty Healthcare

Selective dorsal rhizotomy surgery is one method that Gillette Children’s Specialty Healthcare uses to reduce spasticity, a type of muscle tightness caused by a lack of normal communication between the brain and spinal cord. Many children who have cerebral palsy experience spasticity.

During selective dorsal rhizotomy surgery, a surgeon identifies and cuts individual nerve rootlets that are contributing to a child’s increased muscle tone. We apply electrical stimulation to nerve rootlets that carry messages between the child’s leg muscles and spinal cord. When stimulating a nerve rootlet triggers an abnormal reflex response, we cut that rootlet. We don’t cut rootlets that trigger normal responses when they’re stimulated.

Rhizotomy surgery permanently reduces spasticity. The procedure doesn’t correct muscle contractures, bone deformities, weakness, poor motor control, impaired balance or other problems associated with cerebral palsy.

1. Patient selection
2. Preparation
3. The surgery
4. Follow-up care
5. Important considerations
6. More information

Patient Selection

Because rhizotomy surgery is irreversible, we take great care in selecting who should undergo the procedure. We most often recommend rhizotomies for children who:

• Are 4 to 10 years old
• Have significant spasticity that affects their legs more than their arms

A rhizotomy surgery candidate has reasonably good leg strength and muscle control, plus the ability — or potential — to walk in some manner (with or without an assistive device). It’s also crucial that the child and the child’s family be prepared to participate in a rigorous therapy program after the operation.

Preparation

If your child is scheduled for a rhizotomy at Gillette, we strongly recommend that your family visit our hospital ahead of time. You may tour our facilities and participate in a medical play session with a registered nurse and a child life specialist. During medical play sessions, you and your child see and handle some of the items we use to provide care. By letting your child become familiar with the Gillette environment, we hope to ease fears about the upcoming hospital stay.

Prior to surgery, an occupational therapist evaluates your child’s visual-motor, visual-perceptual, fine-motor and self-care skills. A speech-language pathologist assesses your child’s receptive and expressive language abilities. The screenings help us plan therapy treatments that will occur after the operation. Preparation also might include an evaluation in our Center for Gait and Motion Analysis, where we use video and computer technology to better understand how spasticity is affecting your child’s movement patterns.

The Surgery

A surgeon makes an incision low in your child’s back and creates a window in the spinal canal, near the spinal cord. The incision provides access to sensory nerve roots that carry impulses from muscles to the central nervous system. We separate the nerve roots into smaller rootlets — usually five to 10 per nerve — and stimulate each rootlet with a small amount of electricity. Our surgical team watches for resulting electrical or physical responses in your child’s muscles. When stimulating a nerve rootlet triggers an abnormal reflex response, we cut that rootlet. We don’t cut rootlets that trigger normal responses when they’re stimulated. We might test more than 100 rootlets during a selective dorsal rhizotomy. The procedure can last three to four hours. When complete, it permanently reduces your child’s spasticity.

Follow-Up Care

Immediate Recovery

After rhizotomy surgery, your child must lie in a hospital bed for three days. It’s OK to lie on the back, side or stomach, as long as the head isn’t elevated. For two or three days, your child receives narcotic pain medications. At first, we provide nourishment though an intravenous line, and a Foley catheter drains the bladder. We monitor your child and decide when it’s OK to eat orally again (usually after one to two days) and when to remove the catheter. Knee immobilizers help reduce muscle spasms, which can occur immediately after the operation.

Following surgery, the skin on your child’s legs and feet will probably develop some unusual sensations, such as numbness, tingling, prickling or burning. The sensations usually go away within a few weeks.

We offer toys and games to help make your child’s stay at Gillette more enjoyable. We also recommend bringing some favorite toys, activities or music from home. Such items often provide comfort.

Therapy

We start providing physical therapy at your child’s bedside about three days after rhizotomy surgery. By then, most children no longer feel much discomfort from the operation. Those who are uncomfortable can receive pain medication.

Therapy is an extremely important component of a successful rhizotomy procedure. Our goal is to help children learn how to control their bodies after they’ve had spasticity reduced. Your child needs to strengthen muscles and start using them in ways that might be unfamiliar. We focus first on basic skills, such as head and trunk control. Later, we work on crawling, standing, walking and performing self-care activities (such as eating, washing and getting dressed). If children try advanced activities too soon, they risk reverting to the abnormal movement patterns they used before their surgery.

About five days after the operation, we add occupational and recreational therapy to your child’s schedule. We might include sessions in our therapy pool if that suits your child’s needs. We also begin speech therapy if our earlier assessment indicated it would be helpful.

Our psychologists and child life specialists can help prepare your child for upcoming procedures and transitions that might be difficult. While at the hospital, your child can attend on-site school sessions, which we provide through a partnership with St. Paul Public Schools.

Leaving the Hospital

Before we discharge your child, a Gillette therapist discusses postoperative therapy plans with your child’s community-based therapist. We might recommend your child use adaptive equipment, such as a wheelchair, a standing device or a walker. When most children leave our inpatient program, they aren’t yet walking (except during therapy sessions).

After leaving the hospital, your child continues to need extensive physical therapy. We typically recommend starting with five sessions per week. We tailor all therapy programs to a child’s specific needs. A pediatric rehabilitation medicine physician monitors your child’s progress.

Results

A selective dorsal rhizotomy reduces spasticity in the legs. Children who have cerebral palsy might still have spasticity in their arms or hands, and they might have problems related to expressive and receptive language, visual-perceptual skills, visual-motor skills, fine-motor skills, and motor planning — none of which a rhizotomy corrects. Your child’s abilities after surgery depend on many factors, including how your child participates in and responds to therapy.

Return Appointments

Follow-up programs vary, depending on each child’s needs. A typical schedule includes the following appointments.

• One month after surgery: A doctor reviews your child’s status and updates therapy recommendations. We also determine needs for additional follow-up visits.
• Three, six and 12 months after surgery: At each of those times, a doctor might see your child again. Our physical therapists might periodically update therapy recommendations or record video footage of your child to track progress. If your child can walk, we might conduct motion analysis approximately one year after surgery to assess how the muscles, joints and nerves are working together. At about the same time, it might be helpful for your child to see an orthopaedic surgeon for a new evaluation.

Important Considerations

Potential Risks

Like any surgical procedure, a selective dorsal rhizotomy poses some risks. The risks, however, are small when compared to those of other major procedures involving the central nervous system. The most significant potential consequence of a rhizotomy is infection. However, even that risk is very small. Fewer than 1 percent of rhizotomy patients develop infections as a result of the procedure.

The second most common risk associated with a rhizotomy is that of blood loss during the surgery, making a blood transfusion necessary. The risk is quite small, and we take precautions during surgery to prevent such a complication. A rhizotomy also poses a slight risk of causing muscle weakness, ranging from some weakness in one muscle to paralysis of both legs. Paralysis of two legs is a very rare complication because, during a rhizotomy, we operate only on nerve rootlets, not on the spinal cord.

Disturbances of bowel and bladder functions also are possible, but extremely uncommon, because our surgeons avoid nerves that go directly to the bowel and bladder. Some health-care organizations report seeing scoliosis develop in some children after they’ve had selective dorsal rhizotomies, but such an outcome also is highly unlikely.

Additional Surgeries

After a rhizotomy, your child might undergo muscle stretching and therapy programs to help reduce muscle contractures resulting from spasticity. Exercises, however, can’t correct all contractures, nor can they repair bone deformities (such as severe flat foot, femoral anteversion and tibial torsion), which also can accompany spasticity. Therefore, we might recommend orthopaedic surgery for your child.

At Gillette, we’ve found that children who have both a selective dorsal rhizotomy and orthopaedic surgery to correct muscle and bone deformities experience better overall outcomes than do children who undergo just one of the procedures. More than half of the children who undergo rhizotomy surgery at Gillette eventually require orthopaedic surgery.

More Information

For more information about selective dorsal rhizotomy surgery and other methods of spasticity management at Gillette Children’s Specialty Healthcare, contact our Center for Cerebral Palsy at 651-290-8712 or 800-719-4040 (toll-free). To refer a patient, or to schedule an appointment for a new patient, call 651-290-8707 or 800-719-4040 (toll-free).