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Adolescents and young adults with spasticity: do selective dorsal rhizotomies help in this population?

1. Orthopaedic Surgery, Columbia University Medical Center, New York, NY;
2. Neurological Surgery, Columbia University Medical Center, New York, NY, USA.

Background/Objectives: Life expectancy in individuals with cerebral palsy (CP) has increased while the incidence of CP has not decreased. Seventy to ninety percent of children with CP now reach adulthood. CP care providers have recognized deteriorating function, increased reports of pain and increased apparent tone in adolescent and young adult patients. Selective dorsal rhizotomy (SDR) is a procedure performed to reduce tone in children with spasticity particularly in borderline ambulators between the ages of three and eight without rigidity, dystonia, athetosis and ataxia. There is no little literature describing the benefits of SDR in older children, young adults or non-ambulators. The purpose of this study is to assess whether SDR is an effective way to reduce pain, reduce tone and increase range of motion in adolescents and young adults with CP and can be offered as an alternative to baclofen pumps, botox and other medication.

Design: Retrospective Case Series.

Participants and Setting: Nine patients (spastic quadriplegia n=7, spastic diplegia n=2; age: 18.1±4.1; range: 13.4-27.6) attending the multidisciplinary spasticity clinic were identified through retrospective chart review. Seven (78%) complained of constant pain, 5 (56%) had moderate to severe reactive tone, all had moderate to severe tone (measured by modified ashworth scale) in their hips/knees and all had limited hip/knee range of motion.

Materials/Methods: All children were assessed by an orthopaedic surgeon, a neurosurgeon, a neurologist, a physical therapist and an occupational therapist before and after their procedure. Of the nine children identified, four (spastic quadriplegia n=3, spastic diplegia n=1; mean age: 15.5; range: 13.4-17.1) had completed their first post-operative visit. Pain, tone and range of motion were assessed preoperatively (mean: 2.9 months) and post-operatively (mean=7.0 months).

Results: There was significant improvement of tone in hip extension and adduction, and plantar flexion (see table) after SDR. There were trends toward significant improvement of tone in knee flexion and extension and range of motion in knee flexion. Constant pain resolved in all patients after the procedure.

Conclusions/Significance: Our hypothesis is that selective dorsal rhizotomy is a safe and efficacious method to reduce tone, increase range of motion and reduce pain in adolescents and young adults with CP. This small number of adolescent and adult patients showed significant improvement in tone and pain and a trend toward improved range of motion. These findings justify a prospective study to more carefully document orthopaedic outcomes, quality of life and burden of care.

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