Considerations in the selection of patients for Selective Dorsal Rhizotomy
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1 Considerations in the selection of patients for Selective Dorsal Rhizotomy The best and the worst surgery I have ever been associated with. A therapist's perspective Dean Morgan, PT
2 Disclosure Statement of Financial Interest I, Dean Morgan, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
3 The best and the worst surgery I have ever been associated with.
4 Comments & concerns, post-op She was getting so strong till they convinced her parents to do that SDR. My patient was able to walk before he had that surgery. It was almost a year before she was able to function like she did prior to surgery. "It took forever for that huge scar to heal" The muscles were still tight after that surgery.
5 Other post-op comments Oh my gosh, it s so easy to move his legs now. We can put on her braces without any crying We have never seen him this relaxed We didn t think we would see a difference so fast.
6 Desirable characteristics for a potential ambulatory SDR patient (Ideal patient) Pure spastic diplegia GMFCS level [I - III] No Dystonia No bracing needs No muscle contractures or lengthening procedures. Strong trunk/abdominal & hip musculature. Able to follow directions and participate in rigorous therapy. Caregivers motivatedy to devote required recovery time.
7
8 The Evaluation -Tone, Modified Ashworth (0-4) -ROM -Posture and trunk control -*Strength measures -*Gait -Potential to improve with therapy
9 Modified Ashworth Scale 0 No increase in muscle tone. 1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension. 1+ Slight increase in muscle tone, manifested in a catch, followed by minimal increase in resistance throughout the remainder (less than half) of the ROM. 2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved. 3 Considerable increase in muscle tone, passive movement difficult. 4 Affected part(s) rigid in flexion or extension. Scoring taken from Bohannon & Smith, 1987
10 ROM measures: Thomas test- Are the lumbar spine, hip(s) and thigh(s) easily aligned for standing? Popliteal angle- How does HS tightness affect knee extension and the position of the pelvis?
11 ROM measures: Ankle DF- (measured in prone when able) Can the patient make sufficient contact with the ground to allow for meaningful work on balance, stability and locomotion? Shoulder, elbow, wrist & hand - Does the available range allow for the use of assistive devices and participation in ADL activities?
12 Positions used to assess trunk control & stability: *Series of seated activities to demonstrate core strength as well as level of control when reaching beyond seated BOS. Stability transitioning to & maintaining tall kneel Can patient achieve ½ kneel -Can the patient get fully upright? -is pelvis neutral or tilted? -is there an obliquely Is the patient stable in this position. How much support is needed?
13 A look at strength When performing standard muscle testing, is the patient able to initiate movement across several target joints? -hip (extension, abduction & flexion) -knee extension -ankle PF/DF Weight bear through UEs? Is there sufficient tricep and shoulder strength & stability to support the use of an assistive device?
14 *Observational Gait Evaluation Ability to stand and bear weight. Alignment in standing. (scoliosis, obliquely, asymmetries) Endurance; effects of fatigue. Ability to weight shift in standing. Balance recovery AP, side-side. **Comprehensive gait analysis through Ortho if needed.
15 Additional contributions by Orthopedics and Neurology Evaluate, track and address scoliosis, contractures, pain associated with subluxations, dislocations & fractures. Assess for presence of dystonia, Rx & titration of meds. Identify genetic or progressive disease processes that might be not amenable to surgical spasticity reduction techniques.
16 Assessment of caregiver(s) Questionnaire on initial evaluation. Describe your child's function? Why are you here? (expectations) Discuss intervention & therapeutics history.
17 PT & OT performing intraoperative patient assessment
18 Delayed or derailed progression to SDR -Poor antigravity control (head, trunk, hips, knees, ankles)** -Underlying Dystonia*!*!*! -Inappropriate referral -Sensory dysfunction -Inability to put together a complete plan
19 The questions! When will my child walk? Will she/he always need braces? Will he still need Botox injections? Will we still need to have Orthopedic surgery in the future?
20 GMFCS IV & V patients (Non-ambulatory) -Ease of care -Pain relief -Prevent occurrence or progression of joint deformity or muscle contracture. -Are there functional uses for the spasticity? -Is the spasticity a bad thing?
21 Once SDR is mentioned as a possible option for yourself or your child, prepare for a discussion of SDR by reading about its rationale, selection process, operative procedures, complications, and outcomes from outside sources so that you are ready to ask detailed questions about a particular center s methods. *Consider a center with an experienced, interdisciplinary diagnostic and management team that might include: neurosurgeon, orthopedic surgeon, physical and occupational therapists, orthotist, developmental pediatrician, pediatric neurologist, and physiatrist. *Ask about details of the procedure at this center and how they might differ from other centers, expected post-operative course, length of hospitalization, and type and extent of physical and occupational therapies, cost and insurance coverage. *Ask whether and why you or your child fit the candidate criteria for SDR. *Ask about other treatment options and why SDR is indicated at this time. What are the expected outcomes specifically for you or your child? Take time to consider alternative options.
22 Thank You
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JOHN M. REDMOND, M.D.
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