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Selective Dorsal Rhizotomy (SDR)

What is SDR? Selective dorsal rhizotomy (SDR) is an operation used to improve spasticity (muscle stiffness) in cerebral palsy.

The Selective Dorsal Rhizotomy service at The Portland Hospital is the only fully private service of its kind in Europe. Led by Mr Kristian Aquilina Paediatric Neurosurgeon (Frenchay Hospital, Bristol and Great Ormond Hospital for Children, London) the specialist multidisciplinary team also consists of a consultant paediatrician specialising in neurodisability, a neurophysiologist, specialist physiotherapists and (where appropriate) a paediatric orthopaedic surgeon.  Mr Aquilina worked with Dr TS Park at the Center for Cerebral Palsy in St Louis. He set up the selective dorsal rhizotomy service in Bristol in May 2011 and subsequently at Great Ormond Street Hospital for Children in 2013, and at The Portland Hospital in 2014.

This revolutionary treatment is offered to children with spastic diplegic cerebral palsy to improve their ability to walk more normally.

Spastic Diplegia is a condition that affects around 25% of children born with cerebral palsy. Children with this condition can find it very difficult to walk due to a constant stiffness (spasticity) in both lower limbs. The initial criteria for SDR are as follows:

  • Children usually between the ages of 4 and 12 years of age with a diagnosis of spastic diplegia
  • There should be no significant injury to the areas of the brain involved in posture or coordination; this will need to be confirmed by MRI scan.
  • Children need to demonstrate adequate muscle strength, be able to comply with intensive physiotherapy post-operatively, and have a definite plan for post-operative physiotherapy in place.

Appropriate selection for SDR is key to its success and at The Portland Hospital we carry out a comprehensive assessment to ensure that this procedure is right for your child. We will ask you to fill in a screening/referral form including details of your child’s age, type of CP, GMFCS level and other information which will help the team to assess your child’s suitability to attend the clinic. We have a skilled multidisciplinary team which includes a paediatric neurosurgeon, a consultant paediatrician specialising in neurodisability and a number of physiotherapists specialised in children’s movement disorders. The team also includes a neurophysiologist and a paediatric orthopaedic surgeon.

If you wish to make an appointment to discuss SDR for your child, we would need to see some of your child’s medical records, including a recent physiotherapy report, an MRI scan of the brain and a recent hip x-ray. Children with limited medical records may require a physiotherapy evaluation to be carried out by our Paediatric Physiotherapy Team and may require imaging (MRI and x-ray) which, if not done previously, can be arranged at The Portland Hospital.

If the multidisciplinary team feels that your child may be suitable for SDR, the next step is to book an assessment which will involve Mr Aquilina, a consultant paediatrician specialising in neurodisability and a physiotherapist. The child will undergo a full assessment and there will also be a discussion on the expected benefits and risks of SDR as well as a review of post-operative physiotherapy needs. 

SDR Criteria

SDR is a permanent procedure and cannot be reversed. Spasticity management can be complex and therefore if it is felt that your child is not suitable for SDR then other options will be considered. These include botulinum toxin injections in conjunction with physiotherapy, baclofen pump insertion and orthopaedic surgery, all of which will be carefully discussed before progressing with further treatment.

If the decision to proceed with SDR is taken we will work with you to plan a date for your child’s surgery. This date will be tailored to your family’s needs to ensure that treatment is offered at a time to suit you.

A few weeks before the operation you will need to come in for a full assessment of your child’s functioning including GMFM-66, video of walking, muscle strength and range of movement measurements. You will come in the day before the operation and be fully acquainted with the hospital and team.

SDR Pathway

Selective Dorsal Rhizotomy (SDR) is a surgical procedure that involves dividing and cutting some of the nerves in the spinal cord that contribute to the spasticity in the lower limbs. The procedure is performed under general anaesthesia and takes around 4 hours. The technique used involves a single-level spinal opening and is the same as that developed in St Louis in the USA. The nerve roots to the legs are identified as they enter the lower end of the spinal cord. The roots are systematically tested using intra-operative neurophysiology. Those nerve roots that contribute most to the spasticity are divided. The objective of the procedure is to divide 60 to 70% of the sensory nerve roots.

The procedure is performed under an operating microscope. At the end of the procedure, the cover of the spinal cord is closed again, the back muscles are re-approximated and the skin is closed with absorbable sutures.

Complications after SDR are rare but you need to be aware of them. Complications can include infection, leak of cerebrospinal fluid from the wound, development of a fluid collection below the skin, severe leg weakness and incontinence. As all the nerve roots are carefully checked by stimulating them during the operation and monitoring their response, severe weakness and incontinence are very rare complications. In addition, there are risks associated with general anaesthesia but these, as well as the risk of long-term spinal deformity, are very rare.

Physiotherapy will be an integral part of the build up to surgery and particularly post procedure in order to optimise the effects of the surgery. Following the procedure your child will stay in hospital for 6 days and an intensive inpatient physiotherapy programme is commenced. This will involve strengthening of muscles of the trunk and legs, increasing range of movement and to develop and improve walking. After discharge we ask you to stay locally for two weeks so that your child can continue their physiotherapy programme for 14 days on an outpatient basis. At The Portland Hospital we will work with your community team to develop a pre-surgery strengthening programme and to ensure post-surgical rehabilitation is supported. If needed we are able to provide this in house on an inpatient and outpatient basis. Follow-up physiotherapy is essential and should be provided several times a week in the first 6 months post-operatively.

In line with NICE Guidelines we aim to participate in a coordinated Nationally agreed programme to collect information on short term and long term outcomes for all patients that come through our Selective Dorsal Rhizotomy Service, whether or not surgery is carried out.

Post surgery we will repeat outcome measures at 3 6 and 12 months but would also like to follow our patients through beyond this, in order to continue to monitor progress and provide advice and support as appropriate.

SDR is not a cure for cerebral palsy but can reduce spasticity immediately but full benefit of the procedure can take up to 2 years. However, it can unmask weakness which is why the physiotherapy programme is essential. By its nature SDR is irreversible; however SDR has been shown to have long term benefits including a reduction in spasticity and improved movement and gait. This ultimately leads to an improved quality of life for both the child and their family. One study has shown that the benefits obtained one year after SDR were maintained twenty years after surgery.

The Selective Dorsal Rhizotomy service at The Portland Hospital is the only fully private service of its kind in Europe, and the Portland Hospital SDR programme complies with NICE guidelines. Please visit http://guidance.nice.org.uk/IPG373/Guidance/pdf/English for further information.

Mr Kristian Aquilina - Consultant Paediatric Neurosurgeon

Consultant in Paediatric Neurodisability

Stacie Ahern - Clinical Specialist Paediatric Physiotherapist

Nicole Cash - Clinical Specialist Paediatric Physiotherapist

Margaret Mayston – Clinical Specialist Paediatric Physiotherapist

We also have a number of Orthopaedic Surgeons who are available to support the clinic and provide surgical opinion as needed.

More detailed information on local hotels can be found here. We also work with Graham Properties, a local serviced apartment provider who have over 100 apartments in close proximity to The Portland Hospital. Their apartments vary in price from £650 a week to £1,200 a week and can be booked directly on 020 7637 4782 or steve@grahamproperties.co.uk. Please quote The Portland Hospital if booking.

Should you wish your child to be considered for SDR at The Portland Hospital and for details of prices please contact Laura Smith on SDRportland@hcahealthcare.co.uk or call our dedicated team on 020 7390 6553. If you wish to discuss your child’s suitability with a member of the team before arranging an appointment please call the same number.

Tree of Hope is a national children's medical charity which supports children with complex needs. It assists families with fundraising for medical treatments, therapies and equipment.

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