import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Typically ends at L1-L2 but can extend to L3 in children, 2-3mm posterior to dura **Protection**: Identify with ultrasound/fluoroscopy before laminectomy; perform laminectomy at or below conus termination **Injury Risk**: Bladder/bowel dysfunction, lower limb paralysis **Location**: L2-S5 nerve roots, 1-2mm diameter each, travel obliquely caudad within thecal sac to exit foramina **Protection**: Gentle microsurgical technique, avoid excessive traction, maintain CSF cushion with irrigation **Injury Risk**: Permanent motor/sensory deficit in root distribution **Location**: 5-7mm ventral to cord in anterior median sulcus, supplies anterior 2/3 of spinal cord **Protection**: Stay posterior to nerve roots, avoid ventral dissection, never manipulate anterior dura **Injury Risk**: Anterior cord syndrome with bilateral motor loss **Location**: Enters typically T9-L2 (usually left side), main feeder to anterior spinal artery **Protection**: Minimize manipulation of upper lumbar roots, avoid excessive cautery near radicular arteries **Injury Risk**: Spinal cord ischemia, paraplegia **Location**: ANTERIOR to dorsal roots, THICKER (2-3mm vs 1-2mm), run obliquely anteriorly to exit foramina **Protection**: Meticulous identification of all roots before division, use EMG to confirm dorsal vs ventral **Injury Risk**: Permanent weakness in muscle territory supplied (if >2% risk = technical error) ### Absolute Indications **Primary Diagnosis** - Spastic diplegia cerebral palsy (bilateral lower limb involvement) - GMFCS Level II-III (ambulatory with or without aids) - Age 3-8 years (flexible: some centers 2-10 years) **Functional Criteria** - Spasticity predominates over weakness (Modified Ashworth Scale ≥2) - Dynamic spasticity (improves with nerve blocks, sleep) - Good selective motor control - Adequate trunk control and upper limb function - Motivated child and family **Failed Conservative Management** - Intensive physiotherapy (minimum 12 months) - Appropriate orthoses (AFOs, KAFOs) - Botulinum toxin injections (multiple cycles) - Oral anti-spasmodics (baclofen, diazepam) - No fixed contractures or minimal contractures that can be addressed with orthopaedic surgery post-SDR ### Relative Indications - Spastic quadriplegia with good upper limb function (carefully selected) - Older children (8-12 years) with preserved motor control - Combined SDR with orthopaedic procedures for mild contractures ### Contraindications **Absolute Contraindications** - **Dystonia or athetosis** (will not improve with SDR, may worsen) - **Severe weakness** predominating over spasticity - **Fixed contractures** requiring extensive orthopaedic surgery first - **Poor trunk control** (GMFCS IV-V) - **Cognitive impairment** preventing rehabilitation participation - **Spine deformity** (severe scoliosis, kyphosis >40°) - **Previous spine surgery** with extensive fusion **Relative Contraindications** - Hip instability or subluxation (address orthopaedically first) - Seizure disorder (poorly controlled) - Severe behavioral issues preventing intensive physiotherapy - Unrealistic family expectations - Age <2 years (spasticity pattern not established) - Age >12 years (neuroplasticity reduced) ### Pre-operative Assessment **Clinical Assessment** - Complete neurological examination - Modified Ashworth Scale (spasticity grading) - Selective motor control testing - Range of motion (passive vs active) - Muscle strength (MRC grading) **Gait Analysis** - 3D motion analysis with kinematics - Electromyography during gait (identify overactive muscles) - Ground reaction force patterns - Energy expenditure measurement - Video recording for comparison **Imaging** - Spine MRI (exclude tethered cord, syrinx, Chiari malformation) - Hip radiographs (assess migration percentage) - Lower limb alignment films (if needed) **Functional Assessment** - GMFCS level documentation - Functional Mobility Scale (FMS) - Pediatric Quality of Life Inventory - Caregiver burden assessment ### Spinal Cord Termination **Conus Medullaris** - Adult: Terminates at L1-L2 disc level (90%) - Children: Can extend to L3 (15-20%) - Neonates: May reach L3-L4 - Clinical relevance: Laminectomy must be at or below conus to access cauda equina safely **Filum Terminale** - Continuation of pia mater from conus to coccyx - Anchors spinal cord - Contains rudimentary neural tissue ### Cauda Equina **Nerve Root Organization** - L1-S5 nerve roots descend within thecal sac - Roots become progressively more oblique at lower levels - L2 root: 30° angle from horizontal - S1 root: 60° angle from horizontal **Root Morphology** - **Dorsal roots**: Sensory, POSTERIOR in thecal sac, THINNER (1-2mm diameter) - **Ventral roots**: Motor, ANTERIOR in thecal sac, THICKER (2-3mm diameter) - **Dorsal root ganglion**: Located in/near foramen, proximal to root division into rootlets **Rootlet Division** - Each dorsal root divides into 3-7 rootlets (average 4-5) - Rootlets coalesce at dural entry zone - Division occurs 5-10mm from dura - Rootlets vary in EMG response characteristics ### Arterial Supply **Anterior Spinal Artery** - Single midline vessel in anterior median sulcus - Supplies anterior 2/3 of cord (including motor tracts) - Fed by 6-10 radicular arteries along length - Most vulnerable at mid-thoracic region **Artery of Adamkiewicz** - Major radicular feeder to anterior spinal artery - Enters at T9-L2 (75% on left side) - Supplies lumbar enlargement - Injury causes anterior cord syndrome **Posterior Spinal Arteries** - Paired vessels on posterolateral cord - Supply posterior 1/3 of cord (including sensory tracts) - Fed by posterior radicular arteries - Better collateralization than anterior **Radicular Arteries** - Accompany nerve roots through foramina - Anterior and posterior branches - Injury during rootlet division can cause bleeding - Usually controlled with bipolar cautery ### Spinal Levels and Target Muscles **L2 Root** - Muscles: Hip flexors (iliopsoas), hip adductors - Clinical: Scissoring gait from adductor spasticity - SDR approach: Divide 30-40% of abnormal rootlets **L3 Root** - Muscles: Quadriceps (knee extension), hip adductors - Clinical: Stiff knee gait, crouch gait - SDR approach: Conservative 25-40% (over-division worsens crouch) **L4 Root** - Muscles: Quadriceps, tibialis anterior (ankle dorsiflexion) - Clinical: Toe drag, foot drop if weak - SDR approach: Divide 30-50% balanced approach **L5 Root** - Muscles: Extensor hallucis longus, peroneals, gluteus medius, hamstrings - Clinical: Gait instability, hamstring tightness - SDR approach: Divide 30-50% based on gait analysis **S1 Root** - Muscles: **Gastrocnemius-soleus** (ankle plantarflexion), hamstrings, gluteus maximus - Clinical: **PRIMARY DRIVER of equinus** (toe-walking) - SDR approach: **AGGRESSIVE 40-60%** most important level **S2 Root** - Muscles: Intrinsic foot muscles, hamstrings (minor contribution) - Clinical: Foot deformities - SDR approach: Conservative 30-40% ### Bony Anatomy **Spinous Processes** - L1-L5: Short, horizontal orientation - Sacrum: Fused posterior elements - Interspinous distance increases with hip flexion **Laminae** - Progressively larger from L1 to L5 - L1 laminectomy: 15-20mm transverse width - Thick cortical bone (use rongeur or high-speed drill) **Facet Joints** - Lumbar: Sagittal orientation (allow flexion-extension) - Sacral: Coronal orientation (limit motion) - Preservation important to prevent instability **Ligamentum Flavum** - Yellow elastic ligament between laminae - Thickest in lumbar spine (3-5mm) - Removal provides dural exposure - Careful dissection to avoid dural tear ### Positioning and Neuromonitoring Setup **Patient Position** - Prone on radiolucent Jackson table or operating table with chest rolls - Arms abducted 90°, padded, on arm boards - Head in neutral on horseshoe headrest or Mayfield pins - **Hip flexion 30-45°** (table break) - CRITICAL to open interspinous spaces - **Abdomen hanging free** - reduces epidural venous engorgement - Padding all pressure points (knees, chest, iliac crests) - Secure patient with tape across back/pelvis **Neuromonitoring Setup** - **SSEPs** (somatosensory evoked potentials): Posterior tibial nerve stimulation - **MEPs** (motor evoked potentials): Transcranial magnetic/electrical stimulation - **EMG electrodes** in key muscles bilaterally: - Hip adductors (L2-L3) - Quadriceps (L3-L4) - Tibialis anterior (L4-L5) - Extensor hallucis longus (L5) - Gastrocnemius (S1) - Hamstrings (L5-S1) - Anal sphincter (S2-S4) - **Baseline recordings** established before incision - Alert criteria: >50% SSEP amplitude drop, MEP loss **Exam Response**: "I position the patient prone with 30-45° hip flexion to open the interspinous spaces and abdomen free to reduce venous pressure. Comprehensive neuromonitoring with SSEPs, MEPs, and multi-channel EMG is essential. The EMG allows me to stimulate individual rootlets and identify those contributing to spasticity based on response patterns." - Inadequate hip flexion = tight interspinous spaces, difficult laminectomy - Abdominal compression = epidural venous engorgement, excessive bleeding - Pressure injuries from prolonged prone position (3-4 hours typical) - Ensure all monitoring electrodes functioning before prep and drape --- ### Incision and Muscle Elevation **Skin Incision** - Midline posterior incision from L1 to S1 (12-15cm length) - Palpate spinous processes to confirm levels - Use fluoroscopy if needed to mark L1 and S1 - Incise skin and subcutaneous tissue with knife **Fascia and Muscle** - Incise thoracolumbar fascia in strict midline (avascular plane) - Subperiosteal elevation of paraspinal muscles bilaterally using Cobb elevator - Elevate muscle from spinous processes, then laminae - Extend dissection laterally to facet joints (but preserve joint capsules) - Self-retaining retractors (e.g., Weitlaner, Taylor retractor) **Hemostasis** - Meticulous bipolar cautery throughout muscle dissection - Bone wax on exposed cancellous bone edges - Pack muscle gutters with thrombin-soaked Gelfoam if needed **Exam Response**: "I make a midline posterior incision from L1 to S1. Strict subperiosteal dissection preserves muscle attachments for robust closure and minimizes bleeding. I carefully preserve facet joint capsules to reduce instability risk." - Excessive muscle stripping = postoperative pain, kyphosis risk - Facet joint violation = long-term instability, need for fusion - Muscle avulsion from spinous processes = difficult closure - Maintain strict midline to avoid entering spinal canal prematurely --- ### Laminectomy Technique **Modern Approach: Single-Level L1 Laminectomy** - Remove L1 lamina and cranial 1/3 of L2 lamina - Provides access to entire cauda equina (all roots accessible in thecal sac at L1) - Minimizes bone removal = lower kyphosis risk (10-15% vs 20-25% multi-level) - Use Leksell rongeur or high-speed drill with footplate attachment **Alternative: Multi-Level Mini-Laminoplasty** - Create "windows" at L2, L3, L4, L5, S1 - Preserve interspinous ligaments - Replace bone chips at closure (laminoplasty) - More visualization but higher deformity risk **Ligamentum Flavum Removal** - Identify ligamentum flavum (yellow, elastic) - Use Kerrison rongeur to carefully remove - Start at superior edge, work inferiorly - Avoid plunging into epidural space (dural tear risk) - Remove ligament flush with medial pedicle bilaterally **Epidural Hemostasis** - Epidural veins often engorged in children - Bipolar cautery with continuous irrigation - Avoid excessive cautery near nerve roots - Thrombin-soaked Gelfoam or hemostatic agents (Floseal, Surgiflo) **Exam Response**: "I perform a single-level L1 laminectomy which provides access to the entire cauda equina while minimizing bone removal. This reduces the long-term kyphosis risk from 20-25% with traditional multi-level laminectomy to 10-15%. All lumbosacral nerve roots are accessible in the thecal sac at the L1 level." - Dural tear during ligamentum flavum removal (most common complication at this step) - Epidural venous bleeding can be brisk in children - Excessive bone removal = progressive kyphosis (10-15% overall risk) - Conus injury if laminectomy extends too cephalad (confirm level with fluoroscopy) - Facet joint disruption = instability --- ### Dural Opening **Preparation** - Identify conus medullaris level with intraoperative ultrasound (optional) - Clear all epidural bleeding - Irrigate with warm saline - Identify midline raphe on dura (avascular) **Dural Incision** - Pick up dura with fine forceps (confirm CSF pulsation) - 15-blade scalpel to create 2-3mm opening in strict midline - Microscissors to extend cranially and caudally - Total opening length: 8-12cm (L1 to S1) **Dural Retraction** - Place 4-0 or 5-0 silk tacking sutures to dural edges - Secure sutures to wound drapes or retractors - Keeps dural sac open and provides visualization - Maintain CSF pool with frequent warm saline irrigation **Operating Microscope** - Switch to microscope for all intradural work - Magnification 6-10x typical - Coaxial illumination essential - Assistant helps with irrigation and retraction **Exam Response**: "I open the dura in strict midline to avoid dural venous sinuses laterally. The conus typically ends at L1-2 in adults but can extend to L3 in young children, so I identify this landmark before proceeding. I place tacking sutures to the dural edges and work under the microscope for all intradural dissection." - Off-midline dural incision = troublesome bleeding from dural venous sinuses - Conus injury if mistaken for cauda equina nerve root - CSF leakage if inadequate closure later (CSF fistula, pseudomeningocele) - Arachnoid adhesions may need sharp dissection --- ### Nerve Root Identification and Separation **Systematic Root Identification** - Identify conus medullaris and filum terminale - Follow nerve roots from conus to exit foramina - Use anatomical landmarks: L2 root at L1-2 disc level - Confirm levels with fluoroscopy if uncertain - Count roots cranially to caudally: L2, L3, L4, L5, S1, S2 **Distinguishing Dorsal from Ventral Roots** - **CRITICAL SKILL** for SDR success - **Dorsal root**: POSTERIOR in thecal sac, THINNER (1-2mm), sensory - **Ventral root**: ANTERIOR in thecal sac, THICKER (2-3mm), motor - Roots merge 5-15mm lateral to midline before exiting foramen - Dorsal root ganglion palpable just proximal to merger **Dorsal Rootlet Separation** - Use microsurgical technique (fine forceps, microscissors) - Separate dorsal root into 3-5 individual rootlets - Division occurs 5-10mm proximal to dural entry zone - Gentle technique to avoid avulsion - Place colored background (blue/green) for contrast **Exam Response**: "I systematically identify each nerve root level from L2 to S2 using anatomical landmarks and fluoroscopy. The key distinction is that dorsal roots are POSTERIOR and THINNER (sensory) while ventral roots are ANTERIOR and THICKER (motor). I never divide ventral roots. I separate each dorsal root into 3-5 individual rootlets for EMG testing." - Misidentification of root level = inappropriate treatment - Confusion between dorsal and ventral roots = catastrophic motor weakness if ventral divided - Traction injury to nerve roots during manipulation - Rootlet avulsion during separation (bleeding from radicular vessels) - Operating in bloodstained CSF = poor visualization (irrigate frequently) --- ### EMG Testing and Rootlet Selection **Stimulation Technique** - Place hook electrode under individual rootlet - Stimulate at 50Hz (tetanic stimulation) - Start at 0.5mA, increase to 2mA maximum - Observe EMG response in all monitored muscles - Grade response 0-4 **EMG Response Grading Scale** - **Grade 0**: No response (normal - preserve) - **Grade 1**: Brief twitch in appropriate muscle territory, unilateral, rapid fatigue (normal - preserve) - **Grade 2**: Sustained contraction in single muscle territory (borderline) - **Grade 3**: Sustained contraction with spread to multiple muscles (abnormal - divide) - **Grade 4**: Sustained bilateral response, recruitment of distant muscles (most abnormal - definitely divide) **Selection Criteria** - Target 30-50% of rootlets per level for division - Divide Grade 3-4 responses preferentially - May divide some Grade 2 if need to reach 30-50% target - Always preserve some Grade 0-1 rootlets for sensation **Documentation** - Record which rootlets divided vs preserved - Document EMG grade for each rootlet - Photograph or video for surgical record **Exam Response**: "EMG testing is the foundation of SDR. I stimulate each rootlet at 50Hz and grade the response 0-4. Normal rootlets show brief, localized, fatiguing responses (Grade 0-1). Abnormal rootlets show sustained, spreading, bilateral responses (Grade 3-4) - these contribute to spasticity and are divided. I target 30-50% division per level." - Accidental stimulation of ventral root = muscle contraction, but if divided causes permanent weakness - Inadequate testing = either insufficient spasticity reduction or excessive sensory loss - Equipment malfunction = unable to identify abnormal rootlets (abort procedure) - Over-division (>60%) = significant proprioceptive loss, gait instability - Under-division (<25%) = inadequate clinical improvement --- ### Level-Specific Rootlet Division (L2-S2) **L2 Dorsal Root (Hip Flexors, Adductors)** - Target: 30-40% of abnormal rootlets - Clinical goal: Reduce scissoring gait from adductor spasticity - Typical: 1-2 rootlets divided out of 4-5 total - EMG: Look for sustained adductor magnus, adductor longus response **L3 Dorsal Root (Quadriceps, Adductors)** - Target: **25-40% (CONSERVATIVE)** - most conservative level - Clinical goal: Reduce stiff knee gait without causing quadriceps weakness - **CRITICAL**: Over-division worsens crouch gait - Typical: 1-2 rootlets divided out of 4-5 total - EMG: Look for abnormal rectus femoris, vastus medialis response **L4 Dorsal Root (Quadriceps, Tibialis Anterior)** - Target: 30-50% balanced approach - Clinical goal: Reduce knee/ankle spasticity, preserve dorsiflexion strength - Typical: 2 rootlets divided out of 4-5 total - EMG: Assess both quadriceps and tibialis anterior responses **L5 Dorsal Root (EHL, Peroneals, Gluteus Medius, Hamstrings)** - Target: 30-50% based on pre-operative gait analysis - Clinical goal: Address hamstring tightness, lateral hamstring vs medial hamstring balance - Typical: 2 rootlets divided out of 4-5 total - EMG: Multiple muscle groups assessed (complex patterns) **S1 Dorsal Root (Gastrocnemius-Soleus) - MOST IMPORTANT** - Target: **40-60% (AGGRESSIVE)** - most aggressive level - Clinical goal: **Primary correction of equinus** (toe-walking) - **THIS IS THE MAIN DRIVER** in diplegic CP - Typical: 2-3 rootlets divided out of 4-5 total - EMG: Sustained gastrocnemius-soleus response is hallmark of spastic diplegia - Insufficient S1 treatment = persistent toe-walking **S2 Dorsal Root (Intrinsic Foot, Minor Hamstring)** - Target: 30-40% (slightly conservative) - Clinical goal: Foot posturing correction - Typical: 1-2 rootlets divided out of 4-5 total - Note: S2 also has bladder/bowel association (though this is ventral root-mediated) **Exam Response**: "I treat each level individually based on EMG findings and pre-operative gait analysis. L3 is the most conservative (25-40%) because over-division weakens quadriceps and worsens crouch. S1 is the most aggressive (40-60%) because gastrocnemius spasticity is the primary driver of equinus in diplegic CP. This is the most important level for toe-walking correction." - **L3 over-division** = quadriceps weakness, worsening crouch gait (most common technical error) - **S1 under-division** = persistent equinus, inadequate clinical improvement (most common cause of poor outcome) - Ventral root injury at any level = permanent weakness (should be <2% if technique correct) - Unbalanced division = new deformity patterns (e.g., valgus from excessive medial hamstring reduction) - Bleeding from radicular artery during division (usually controlled with bipolar) --- ### Hemostasis and Dural Closure **Intradural Hemostasis** - Irrigate thecal sac thoroughly with warm saline - Identify any bleeding rootlet stumps - Gentle bipolar cautery to rootlet stumps (low power) - Avoid cautery near intact nerve roots - Ensure no blood clots in CSF **Dural Closure Technique** - Remove tacking sutures - Close dura with 4-0 or 5-0 braided non-absorbable suture (Tevdek, Ethibond) - Running continuous suture technique - Small bites (1-2mm from edge) - Keep suture line watertight **Leak Test** - Valsalva maneuver (anesthesiologist increases airway pressure to 30-40cm H2O) - Observe for CSF leak along suture line - Reinforce any leaks with additional interrupted sutures - Overlay with dural sealant (DuraSeal, Tisseel) if available **Final Irrigation** - Irrigate epidural space - Ensure hemostasis - Consider Gelfoam over dural closure **Exam Response**: "Watertight dural closure is critical to prevent CSF leak and pseudomeningocele. I use a running 4-0 non-absorbable suture and test with Valsalva maneuver before proceeding. Any leaks are reinforced with interrupted sutures. I overlay with dural sealant for extra security." - CSF leak = pseudomeningocele (5-8% incidence), meningitis risk, prolonged hospitalization - Inadequate hemostasis = epidural hematoma causing cauda equina compression - Nerve root entrapment in dural closure = radicular pain, motor/sensory deficit - Torn dura edges from excessive tension = difficult repair --- ### Wound Closure and Immediate Post-Op **Fascial Closure** - Re-approximate paraspinal muscles over midline - Close thoracolumbar fascia with heavy absorbable suture (0 or 1 PDS/Vicryl) - Running or interrupted technique - Robust closure essential (substantial CSF pressure) **Layered Closure** - Deep fascia: 0 or 1 Vicryl - Scarpa's fascia: 2-0 Vicryl - Subcuticular skin: 3-0 or 4-0 Monocryl - Skin adhesive (Dermabond) or Steri-Strips **Drain Consideration** - Generally NOT placed (increases infection risk) - Consider subfascial drain only if extensive epidural bleeding - Remove drain at 24-48 hours **Dressing** - Sterile dressing - Consider transparent dressing to monitor for CSF leak **Immediate Assessment** - Neurological exam when awake - Motor power: Should be unchanged or improved (reduced co-contraction) - Tone: Dramatically reduced (immediate effect) - Sensation: Should be intact (may have some dysesthesias) - Bladder function: Foley catheter in place initially **Exam Response**: "I close the fascia robustly with heavy absorbable suture to withstand CSF pressure and reduce seroma risk. I assess motor function, tone, and sensation immediately post-operatively. Tone should be dramatically reduced. Power should be preserved or better with reduced co-contraction. Any motor loss suggests ventral root injury, which should be <2% if technique is correct." - Inadequate fascial closure = wound dehiscence, CSF fistula - Seroma formation (common, usually resolves spontaneously) - Surgical site infection (2-3% risk) - Unrecognized neurological deficit - Bladder retention (usually temporary from anesthesia) - Delayed epidural hematoma (rare but catastrophic if missed) ### Immediate Post-Operative Period (Day 0-2) **ICU/HDU Monitoring** - Admit to ICU or High Dependency Unit overnight - Neurological observations every 2 hours - Monitor for signs of epidural hematoma (increasing back pain, neurological deterioration) - Monitor for CSF leak (clear fluid from wound) **Positioning** - **Flat bed rest for 24-48 hours** (reduce CSF pressure, promote dural healing) - Log roll for position changes - Gradually elevate head of bed after 24 hours **Bladder Management** - Foley catheter initially - Monitor urine output - Trial of voiding at 24-48 hours - Temporary retention common (bladder tone affected by anesthesia, positioning) - Persistent retention >48 hours = evaluate for cauda equina issue **Pain Management** - Multimodal analgesia - Regular paracetamol - NSAIDs if no bleeding concerns - Opioids as needed (oral codeine or morphine) - Avoid excessive muscle spasm (may need muscle relaxants) **Wound Care** - Monitor dressing for CSF leak (clear fluid, glucose-positive on test strip) - Keep dressing dry and intact for 48 hours - Remove drain (if placed) at 24-48 hours ### Early Mobilization (Day 2-5) **Physiotherapy Initiation** - Start gentle range of motion day 1-2 - Sit at edge of bed day 2 - Stand with assistance day 2-3 - **Early mobilization capitalizes on tone reduction** - Expect initial weakness/instability (must relearn motor control without spasticity) **Orthoses Adjustment** - AFOs may need adjustment for new foot position - Reduced plantarflexion tone = may need less dorsiflexion support - Orthotist review within first week **Neurological Assessment** - Daily neurological exam - Monitor for: - Motor power (should be stable or improving) - Sensation (mild dysesthesias common, resolve in weeks) - Tone (should be dramatically reduced) - Bladder/bowel function (should normalize by day 2-3) ### Hospital Discharge (Day 5-7) **Discharge Criteria** - Independent bladder/bowel function - Mobilizing with assistance (appropriate for pre-op GMFCS level) - Pain controlled on oral medications - Wound healing well, no CSF leak - Family confident with care **Discharge Medications** - Oral analgesia (paracetamol, NSAIDs) - Stool softeners (prevent constipation, reduce straining) - No anti-spasmodics needed (spasticity resolved) **Wound Care Instructions** - Keep wound dry for 2 weeks - Sponge baths only - Remove sutures/Steri-Strips at 2 weeks (if not absorbable) - Monitor for signs of infection, CSF leak ### Intensive Rehabilitation Phase (Week 1 to Month 6) **Physiotherapy Protocol** - **INTENSIVE** therapy essential (capitalize on neuroplasticity) - 3-5 sessions per week minimum - Focus areas: - Strengthening (especially quadriceps, ankle dorsiflexors) - Balance and proprioception - Gait re-education - Stretching (prevent contractures) - Functional mobility training **Occupational Therapy** - ADL retraining - Upper limb function (if affected) - School/home adaptations **Orthotics** - Serial adjustments to AFOs as foot position changes - May need different orthosis type (less restrictive) - Some children wean off orthoses completely **Gait Analysis** - Repeat 3D gait analysis at 3 months and 6 months - Document improvements in kinematics - Identify any new gait deviations ### Late Follow-Up (6 Months to 2 Years) **Functional Outcomes** - Peak improvements typically 6-12 months post-op - May continue improving up to 2 years - GMFCS level may improve by 1 level in some patients **Orthopaedic Surgery Planning** - Assess for residual contractures at 6-12 months - Fixed contractures (if present) now addressable with tendon lengthenings, osteotomies - Common procedures post-SDR: - Gastrocnemius recession (if residual equinus from fixed contracture) - Hamstring lengthening - Femoral/tibial derotational osteotomy - Hip reconstruction (if subluxation) **Spinal Deformity Monitoring** - Annual spine radiographs for 5 years - Assess for progressive kyphosis (10-15% risk) - Assess for scoliosis progression (5-10% risk) - Bracing if curves <40° - Fusion if progressive curves >40-50° **Long-Term Quality of Life** - Most families report high satisfaction (80-90%) - Improved mobility, reduced pain, easier care - Better participation in activities - Reduced caregiver burden ### Additional Complications **Wound Infection (2-3%)** - Superficial: cellulitis, wound erythema - treat with oral antibiotics - Deep: requires surgical debridement, IV antibiotics (6 weeks if spine involved) - Prevention: prophylactic antibiotics, meticulous sterile technique **Epidural Hematoma (<1%)** - Presents with severe back pain, acute neurological deterioration, cauda equina syndrome - Emergency MRI for diagnosis - Treatment: urgent surgical evacuation, dural re-opening **Painful Dysesthesias (2-5%)** - Neuropathic pain in lower limbs - Management: gabapentin, pregabalin, amitriptyline, physiotherapy desensitization **Scoliosis Progression (5-10%)** - Lower risk than kyphosis - Monitor with annual radiographs - Management: bracing if progressive, fusion if >40-50° **Tethered Cord (Rare)** - Scar tissue at laminectomy site - Presents with pain, neurological deterioration, bladder changes - Requires surgical untethering ## References 1. Peacock WJ, Arens LJ. Selective posterior rhizotomy for the relief of spasticity in cerebral palsy. South African Medical Journal. 1982;62(5):119-124. - *Landmark paper describing the original SDR technique and patient selection criteria* 2. Park TS, Johnston JM. Surgical techniques of selective dorsal rhizotomy for spastic cerebral palsy. Technical note. Neurosurgical Focus. 2006;21(2):e7. - *Detailed technical description of modern SDR technique with single-level laminectomy approach* 3. Grunt S, Fieggen AG, Vermeulen RJ, et al. Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature. Developmental Medicine & Child Neurology. 2014;56(4):302-312. - *Comprehensive systematic review of patient selection criteria and outcomes* 4. Tedroff K, Löwing K, Åström E. A prospective cohort study investigating gross motor function, pain, and health-related quality of life 17 years after selective dorsal rhizotomy in cerebral palsy. Developmental Medicine & Child Neurology. 2015;57(5):484-490. - *Long-term outcomes study demonstrating sustained benefits of SDR at 17-year follow-up* 5. Langerak NG, Lamberts RP, Fieggen AG, et al. A prospective gait analysis study in patients with diplegic cerebral palsy 20 years after selective dorsal rhizotomy. Journal of Neurosurgery: Pediatrics. 2008;1(3):180-186. - *20-year follow-up gait analysis demonstrating maintained improvements in spasticity and function* 6. Ailon T, Beauchamp R, Miller S, et al. Long-term outcome after selective dorsal rhizotomy in children with spastic cerebral palsy. Child's Nervous System. 2015;31(3):415-423. - *Multi-center study of long-term outcomes including complications (kyphosis, sensory changes)* 7. Munger ME, Aldahir BM, Miller PE, et al. Spinal deformity after selective dorsal rhizotomy in ambulatory patients with cerebral palsy. Journal of Neurosurgery: Pediatrics. 2017;20(5):453-459. - *Analysis of spinal deformity rates comparing single-level vs multi-level laminectomy techniques* 8. Engsberg JR, Ross SA, Wagner JM, Park TS. Changes in hip spasticity and strength following selective dorsal rhizotomy and physical therapy for spastic cerebral palsy. Developmental Medicine & Child Neurology. 2002;44(4):220-226. - *Study examining the relationship between spasticity reduction and strength gains post-SDR* 9. Farmer JP, Sabbagh AJ. Selective dorsal rhizotomies in the treatment of spasticity related to cerebral palsy. Child's Nervous System. 2007;23(9):991-1002. - *Comprehensive review of SDR indications, techniques, and outcomes with emphasis on neurophysiological monitoring* 10. Dudley RW, Parolin M, Gagnon B, et al. Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy. Journal of Neurosurgery: Pediatrics. 2013;12(2):142-150. *Long-term functional outcome study demonstrating GMFCS improvements and quality of life benefits*

Selective Dorsal Rhizotomy (SDR) for Spastic Cerebral Palsy

Selective Dorsal Rhizotomy (SDR) for Spastic Cerebral Palsy