What is SDR surgery (Selective Dorsal Rhizotomy)? Does it help children with Cerebral Palsy?

Does your little one have Cerebral Palsy? You must have noticed that the muscles in the limbs, especially the legs, of such children are unnecessarily stiff and stiff. In medical terms, we call this 'spasticity'. Due to this stiffness, it is very difficult for the child not only to walk, run, jump, but also to do daily tasks. So today we are going to talk about a special surgery that is performed as a permanent solution to this problem. That is Selective Dorsal Rhizotomy, or SDR surgery for short.

Simply put, what is SDR surgery?

Selective Dorsal Rhizotomy (SDR) is a surgical procedure that permanently reduces muscle stiffness (spasticity) in children with cerebral palsy. Although it is a very complex procedure, in simple terms, it involves selectively cutting and removing some of the sensory nerve fibers in the lower part of the child's spine that cause muscle stiffness in the legs.

The most important thing is that this surgery does not cause paralysis in the child's limbs. It also does not directly affect the movement of the legs. It only releases the muscles that are unnecessarily tight.

Who should undergo this surgery? Is it suitable for all children?

SDR surgery is mainly performed as a treatment for muscle stiffness (spasticity) caused by cerebral palsy.

As you know, cerebral palsy (CP) is a condition that affects a child's ability to control their body movements. It is caused by damage to the parts of the brain that control movement and coordination. Many children with CP have a condition called 'spasticity'. This means that some muscles suddenly contract violently when the child tries to move or is just standing still. This can make it difficult for the child to walk, perform daily activities, and sometimes even cause pain.

SDR surgery specifically targets:

• Spastic diplegic cerebral palsy: This refers to children who have muscle stiffness that mainly affects the legs.
• Severe spastic quadriplegic cerebral palsy: This refers to children who have severe muscle stiffness affecting all four limbs.

Okay, how does this surgery reduce muscle stiffness?

To understand this, let's think about our nervous system for a moment. The normal muscle tone of our body's muscles is controlled by the activity of a nervous system located in the spinal cord.

Imagine that our body has a nervous system like a telephone.

1. Sensory Nerves: These carry information from the muscles to the spinal cord.

2. Motor Nerves: These send commands from the spinal cord back to the muscles to "contract like this."

Normally, our brain controls this message flow well. That means we can control our muscles as we want. But in Cerebral Palsy, the brain's ability to control these nerves is reduced. What happens then is that some sensory nerves become overactive and keep sending the wrong signals to the muscles, telling them to "tighten, tighten."

Here's what happens during SDR surgery:

The surgeon selects and cuts only the sensory nerve rootlets that are causing the muscle tightness and are being activated unnecessarily. A special test (EMG) is used to find out which nerves are working properly and which nerves are sending the wrong signals. This allows only the muscle tightness to be reduced without affecting other activities.

This way, when the muscle stiffness is relieved, the underlying muscles can begin to function normally. This improves the child's mobility and function. It also helps prevent deformities in the bones and joints that can occur due to prolonged muscle stiffness.

How do you prepare before surgery?

Since SDR surgery is not suitable for every child, your child will be evaluated by a team of specialists to determine if it would benefit them. The following specialists are usually involved in this process:

All of these people examine the child and come together as a team to make the final decision on whether SDR surgery will benefit the child.

In addition, you may need to have several other tests before surgery:

• Physical and occupational therapists conduct an in-depth evaluation to fully assess the child's physical abilities. They videotape the child's movements and plan any necessary post-operative treatment.
• An MRI scan of the brain to make sure there are no other neurological disorders.
• If you have any other neurological problems, see a pediatric neurologist .
• Meet with the neurosurgeon again to talk about the risks of the surgery and recovery time.
• Visit an anesthesiologist to make sure it is safe for your child to be given anesthesia.

How the surgery is performed step by step

Here's how SDR surgery typically occurs:

1. Anesthesia: First, the anesthesiologist gives the child general anesthesia. So the child sleeps soundly during the surgery and does not feel any pain.

2. Incision: The neurosurgeon makes a small incision in the middle of the child's lower back.

3. Nerve exposure: Through this incision, the dura covering the spinal cord is opened, passing through the muscles and bones, and the underlying nerve fibers are exposed.

4. Nerve Separation: Next, the surgeon separates the motor nerves and sensory nerves from each other. The motor nerves are protected from any damage.

5. Identifying faulty nerves: Now, electrodes are attached to the sensory nerve roots and electrical stimulation is provided using a machine called Electromyography (EMG) . This can identify exactly which nerves are sending incorrect signals that cause muscle tightness, and which nerves are working properly.

6. Nerve cutting: Very carefully, a certain percentage of the identified abnormal sensory nerves is cut. Which nerves and how much are cut varies from child to child.

7. Closing the incision: Once the nerve cutting is complete, the incision is stitched back together layer by layer.

8. Recovery: After surgery, the child is transferred to the intensive care unit (ICU) or a special recovery room and is closely monitored by the medical team.

This surgery usually takes about four or five hours.

What happens after the surgery?

Children will need to stay in the hospital for about five days after surgery. For the first 24-48 hours, the child will need to remain in bed. Physical therapy will begin within a few days of surgery.

What are the benefits of this surgery?

The results of SDR surgery can vary depending on the child's condition. Also, the success of the surgery depends entirely on the intensive physical therapy treatment that is performed after the surgery.

Like every surgery, are there any risks?

Yes, like any surgery, SDR surgery carries some risks, but permanent complications are very rare.

Your child's medical team will discuss all of these risks with you in detail before surgery.

Recovery time and the importance of physical therapy

This is the most important and essential part of the success of SDR surgery. Surgery is only the first step in the journey. Rehabilitation is essential for achieving real results.

Physical therapy and occupational therapy begin within a few days of surgery. The child should attend these treatments several days a week for three to six months after surgery.

• Physical Therapist: Exercises to strengthen, stretch, and improve range of motion in the child's muscles. Initially, the therapist will perform the exercises, and as the child recovers, the child will actively engage in the exercises themselves.
• Occupational Therapist: Helps the child perform daily tasks (e.g., dressing, playing) more easily and independently.

The main objectives of these exercises are:

• Increased energy.
• Developing balance and correct posture while sitting and standing.
• Preparing the feet for standing.
• Training to perform movements, such as standing from a sitting position, more smoothly.

When do you need to talk to the doctor?

If you notice any signs of complications after bringing your baby home from the hospital, call your doctor immediately.

• If the surgical incision is red, swollen, or pus is coming out (signs of infection).
• If the child has a high fever.
• If you lose the ability to control your urine or stool.

If you notice any unusual symptoms like these, seek medical advice immediately.

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