Neurosurgery - Paediatric Neurosurgery
Selective dorsal rhizotomy (SDR) is a surgical procedure that can help cerebral palsy patients with severe muscle spasticity to improve their walking.
Although SDR surgery is not currently available on the NHS, it is offered at Alder Hey on a self-funded basis.
In 2013 Alder Hey performed the first SDR surgery in the north of England on 18 year old Josh who has Spastic Diplegia, a form of cerebal palsy.
Mum Joan said: “Josh’s surgery has given him a chance. This has been life changing for all of us. Josh has become more confident, he is speaking more and he is a lot happier, less frustrated and he looks forward to things a lot more.”
Is selective dorsal rhizotomy the latest treatment for cerebral palsy?
SDR is not widely available as a cerebral palsy treatment in the UK, but has been available for a while in the USA.
There are different surgical techniques available to perform SDR. Alder Hey provides the modified TS Park technique which is less invasive for the child undergoing surgery and reduces the risk of skeletal deformities in the long term.
How does SDR surgery help?
SDR surgery is high risk and irreversible but works by tackling the cause rather than the effects of spasticity. SDR surgery is not a cure for cerebral palsy but it reduces muscle spasticity permanently. Following the procedure, walking, range of motion and body positioning are all also improved.
Muscles send information along sensory nerve fibres to the spinal cord to control their own tone and in neighbouring muscles. The brain informs the spinal cord how much tone or tightness each muscle should have. In cerebral palsy this communication route from the brain to the spinal cord does not function effectively. It is this loss of communication which contributes to spasticity.
The procedure works by identifying, using electrical stimulation, the sensory nerve roots. The nerve roots that generate unusual electrical activity are thought to be those which contribute to too much muscle tone. The remaining nerves, which carry the correct message, will remain as they were.
How is selective dorsal rhizotomy surgery managed at Alder Hey?
SDR is a complex procedure with an intensive rehabilitation period, so Alder Hey provides a multi-disciplinary approach involving a neurosurgeon, neurologist, orthopaedic surgeon, physiotherapists and specialist nurses. This means we are able to offer the best care in terms of surgical procedures, neurological assessment and physiotherapy.
The surgery itself takes between four and six hours and is led by renowned Consultant Paediatric Neurosurgeon, Benedetta Pettorini.
Benedetta Pettorini qualified as a doctor (MD) from the Catholic University of Rome, Italy, in 2002. Her basic surgical and neurosurgical training took place in Rome. Thereafter her advanced Paediatric Neurosurgical training was completed in the UK with a Fellowship in Paediatric Neurosurgery at Birmingham Children’s Hospital and at Great Ormond Street Hospital, London.
Miss Pettorini has been a Consultant Paediatric Neurosurgeon at Alder Hey since 2011 and is Chief of Operative Care, leading the Best in Operative Care Group which is aiming to improve utilization, productivity and safety of the theatres department at Alder Hey.
Benedetta’s clinical interests are all areas of Paediatric Neurosurgery including hydrocephalus (shunts and basic and complex endoscopy), Chiari malformation, spinal dysraphisms, neuro-oncology (brain and spinal tumours), spasticity treatment (Baclofen pump, selective dorsal rhizotomy, peripheral neurectomy), neurosurgery in prematurity.
She is part of the multidisciplinary neuro-oncology team and multidisciplinary spasticity team at Alder Hey.
Benedetta also runs an outreach clinic in Stoke on Trent providing paediatric neurosurgery service for the area, and an outreach clinic in Belfast providing selective dorsal rhizotomy service for Northern Ireland.
Why is physiotherapy an important part of selective dorsal rhizotomy surgery?
Physiotherapy is a key element of our multi-disciplinary approach, and a stretching and strengthening exercise programme will focus on extensor muscle groups and trunk activity, stretching of hip flexors and adductors, knee flexors and calf muscles. This programme will be carried out by your child’s physiotherapist or support worker, and should also be continued at home.
This will help with recovery in the post-operative period, and must be continued following the SDR procedure and discharge from hospital. As children may continue to make progress over a 2 year period following an SDR, a long-term commitment to following a physiotherapy programme, supported by regular physical activity, is important
How much does SDR surgery cost?
We provide SDR for GMFCS Grades I II and III at a cost of £21,000, and, Grade IV and V at a cost of £16,000.
How do I know if SDR is suitable for my child, and how do I arrange it?
When your child is referred to Alder Hey for spasticity management, we will assess their suitability for SDR surgery and arrange a gait analysis, an MRI scan of their brain and spine and a pre-operative assessment involving our multi-disciplinary team – involving a neurosurgeon, neurologist, orthopaedic surgeon, physiotherapists and specialist nurses.
A follow-up appointment to discuss results of the gait analysis and proposed surgery will be attended by a consultant neurologist, neurosurgeon, orthopaedic surgeon, clinical specialist physiotherapist and local physiotherapist. At this appointment you will receive all the information you need to help you decide if you want to proceed with SDR surgery.
We can then arrange a date for surgery and our clinical specialist will begin planning your child’s post-operative care including exercise rehabilitation programmes, training for parents and carers, and arrangements with local services such as your child’s school and therapy providers.
Six to eight weeks before surgery you will attend a detailed pre-operative clinic appointment with our team to review the progress of arrangements and your child’s therapy programme. At this appointment we will also confirm a date for surgery.
Your child will be admitted to Alder Hey the day before the surgery. Following the procedure your child will spend two days recovering and resting in preparation for sitting up on day three. At this point our physiotherapy team will begin to reintroduce a range of strengthening and motion exercises with a view to increasing the frequency and intensity day by day.
Your child will be discharged with a personalised exercise programme that should take place daily until you see your community physiotherapist to continue the rehabilitation programme. We will also schedule outpatient appointments here at Alder Hey to review your child’s progress three, six, 12 and 24 months after surgery.
Information for children
Our cartoon guide, ‘The Story of Neuroman and Spinal Dorsal Rhizotomy’ is available to view or download. It’s an ideal guide to SDR surgery aimed at children but a great resource for the whole family.