Selective dorsal rhizotomy for children with cerebral palsy: the Oswestry experience

Background: Although three randomised control trials have shown that selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy, a meta-analysis of the results demonstrated that the procedure conferred only small functional benefit on the patient. Aim: To determine whether applying strict criteria for patient selection as practised in Oswestry leads to improved outcomes, using gait analysis as an outcome measure. Methods: Ambulant children with cerebral palsy were selected for SDR using very strict clinical criteria. Instrumented gait analysis was used as the main outcome measure. Results: Of 53 children referred for the procedure, only 19 (35%) fulfilled our strict criteria for selection. These children underwent surgery and when pre- and post-SDR data were compared, they showed improvement in cosmesis of gait, clinical examination and temporal, kinetic and kinematic parameters of gait. After SDR the children walked, on average, 0.15 m/s faster, with a step length improvement of 0.11 m. Changes were seen at hip, knee and ankle, with those at the knee being most marked. A 0.3 grade improvement in knee extensor power on clinical examination led to a 13 degrees improvement in stance phase knee extension. Knees also became less stiff, with an 82 degrees/s improvement in the rate of flexion into swing phase. A functional tool (the GMFCS) applied retrospectively also confirmed post-operative improvement, with 15 of the 19 children improving by at least one level. Conclusion: Application of strict selection criteria when considering children for SDR leads to encouraging results as demonstrated by gait analysis and other measures.