NumberResearch recommendation
25Does selective dorsal rhizotomy followed by intensive rehabilitation performed between the ages of 3 and 9 years in children who are at GMFCS level II or III result in good community mobility as a young adult?
Why this is important
The available evidence relating to selective dorsal rhizotomy suggests that the procedure results in some short- and medium-term improvements in motor function. The effects reported were not consistent across all studies nor sustained across all durations of follow-up investigated (6–24 months). The GDG considered that if the observed improvements could be maintained through to adult life then the outcomes of selective dorsal rhizotomy would be clinically important and this would be a cost effective treatment option. Further research is urgently needed to evaluate long-term outcomes (including adverse effects) of selective dorsal rhizotomy followed by an intensive rehabilitation programme involving physical therapy (and prioritising targeted strength training) compared with physical therapy alone. The research could be conducted using a range of designs, including randomised controlled trials and audits of outcomes from procedures already performed. The research should focus on selective dorsal rhizotomy performed: between the ages of 3 and 9 years in children with spasticity who are at GMFCS level II or III (because these children are likely to benefit most from selective dorsal rhizotomy) and before the development of significant contractures at the ankles, knees and hips. The following criteria should help to identify children who could be included in the research: abnormal tone (pure spasticity), good leg muscle strength, straight legs and minimal muscle shortening, good selective motor control in the legs, good cognitive skills, and not being overweight. Abnormal tone that is predominantly dystonia, and severe scoliosis or hip dislocation, should form part of the exclusion criteria. The research should be coordinated through a multicentre research programme; use nationally agreed outcome measures (such as incidence of neurological impairment and spinal deformity, the need for additional operations, and assessment of disability, social inclusion, and quality of life) and follow-up periods to facilitate national audit; and include assessment of the child's clinical condition before and after selective dorsal rhizotomy using the same formally validated assessment techniques; consider the timing of selective dorsal rhizotomy in relation to orthopaedic surgery if the child has muscle shortening or torsional abnormalities; consider the involvement of the child, their parents, carers or other family members, and members of the local multidisciplinary child development team in the rehabilitation programme after discharge from hospital; monitor the child's clinical condition regularly until they are fully grown (to detect and manage weight gain and orthopaedic and spinal complications). The following information should be given to children and their parents or carers to facilitate informed decision making about participation in research: selective dorsal rhizotomy is irreversible; there is a risk of serious temporary or permanent postoperative complications (such as deterioration in walking ability or bladder function) and later complications such as spinal deformity; prolonged physiotherapy and aftercare will be needed; additional surgery may be needed; subsequent to selective dorsal rhizotomy epidural anaesthesia will not be possible (for example, during additional surgery or childbirth); the evidence already available in relation to selective dorsal rhizotomy is based on studies involving small numbers of children, and there is currently no evidence from which to assess long-term outcomes (those experienced more than 24 months after performing selective dorsal rhizotomy, and preferably into adult life); confounding factors for long-term outcomes could include the natural history of the condition (for example, the child's condition might deteriorate over time regardless of whether or not selective dorsal rhizotomy is performed).
26What is the clinical and cost effectiveness of selective dorsal rhizotomy compared to continuous pump-administered intrathecal baclofen in children and young people who are at GMFCS level IV or V?

From: 10, Selective dorsal rhizotomy

Cover of Spasticity in Children and Young People with Non-Progressive Brain Disorders
Spasticity in Children and Young People with Non-Progressive Brain Disorders: Management of Spasticity and Co-Existing Motor Disorders and Their Early Musculoskeletal Complications.
NICE Clinical Guidelines, No. 145.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2012 Jul.
Copyright © 2012, National Collaborating Centre for Women's and Children's Health.

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