Selective Dorsal Rhizotomy (SDR)

SDR is a procedure to treat muscle tightness and stiffness known as spasticity in children with cerebral palsy. It can also be performed to treat dystonia, which causes involuntary muscle contractions. SDR involves cutting sensory nerve fibers in your child’s spinal cord to weaken the overactive reflexes that cause muscle tightening. 

Who is a good candidate for SDR?

Your child might be a candidate for SDR if they have severe dystonia or spasticity caused by cerebral palsy and medications are not effective in managing muscle symptoms. SDR can also serve as an alternative to an intrathecal baclofen pump. 

What are the benefits of SDR?

SDR can weaken overactive reflexes that cause spasticity and dystonia, potentially improving your child’s comfort and mobility. It can also make it easier for family members and caregivers to assist your child with everyday tasks and enhance the effectiveness of other treatments, such as physical and occupational therapy.

After your child has been registered, they will be taken to a “holding area” where you will meet your child’s pediatric anesthesiologist and neurosurgeon. Your child’s pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will administer the medications that will make your child sleep during the surgery. At this time, you can ask any questions about the procedure.

After your questions are answered and the operating room is prepared, your child will be taken into the operating room and given an anesthetic to make him or her go to sleep. When your child is asleep, the surgery will begin.

Your child’s neurosurgeon will:

• Make a small incision in your child’s back to access their spine.
• Cut through muscle, bone, and the spinal cord’s protective covering called the dura to access your child’s nerve fibers.
• Locate the sensory nerves, which carry signals from your child’s muscles to the central nervous system and allow them to respond to outside stimuli.
• Separate the sensory nerves from the motor nerves, which control movement.
• Use electrical stimulation to test your child’s sensory nerves and identify which ones are causing spasticity.
• Selectively cut, and in some cases use cautery (heat) on, specific sensory nerve fibers to prevent abnormal signals from affecting your child's muscles.
• Close the opening in your child’s spine and the incision in their back.

What are the risks of SDR?

As with any surgery, SDR comes with some risks, including:

• Bleeding.
• Blood clots.
• Cerebrospinal fluid leak.
• Infection.
• Loss of bowel or bladder control.
• Nerve damage.
• No improvement in symptoms.
• Problems with anesthesia.
• Sensitivity to touch that causes pain.
• The need for future surgery.
• Weakness or loss of mobility.

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery.

One business day before your child’s surgery, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions.

The nurse will give you specific eating and drinking instructions for your child based on your child’s age.

The following are the usual instructions given for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.

For children older than 12 months

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee, and chewing gum or candy.

For infants under 12 months

• Up to six hours before the scheduled arrival time, formula-fed babies may be given formula.
• Up to four hours before the scheduled arrival time, breastfed babies may nurse.

For all children

• Up to two hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the 2 hours before the scheduled arrival time, give them nothing to eat or drink.

Once your child has been registered for the surgery, a member of the anesthesia staff will meet with you to take your child’s vital signs, weight, and medical history.

A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will meet with you before the surgery. They will ask questions about your child’s health and about when your child last ate.

Because your child may have eaten more recently than is usually advised for surgery, the anesthesiologist may make adjustments to your child’s anesthesia. Once admitted, your child will not be able to have anything to eat or drink until after the operation.

• As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
• If your child is very scared or upset, the doctor may give a special medication to help them relax. This medication is flavored and takes effect in about 10 to 15 minutes.
• If you wish, you may be allowed to go with your child to the room where the surgery will be done and stay while the sleep medication is given.
• Younger children will get their sleep medication through a “space mask” that will carry air mixed with medication. Your child may choose a favorite scent to flavor the air flowing through the mask. There are no shots or needles used while your child is still awake.
• Older children may choose between getting their medication through a mask or directly into a vein through an intravenous (IV) line.
• When your child has fallen asleep, you will be taken to the waiting room. If it has not already been done, an IV will be started so that medication can be given to keep your child sleeping throughout the surgery.

While your child is asleep, their heart rate, blood pressure, temperature, and blood oxygen level will be checked continuously. Your child will have a breathing tube placed while they are asleep. Your child might have a sore throat after the surgery.

To keep your child asleep during the surgery, they might be given anesthetic medication by mask, through the IV tube, or both. When the surgery is over, the medications will be stopped, and your child will begin to wake up.

After surgery, your child will be moved to the recovery room. You will be called so that you can be there as they wake up.

• Children coming out of anesthesia react in different ways. Your child might cry, be fussy or confused, feel sick to his or her stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off.
• While your child is in recovery, your surgeon will talk to you about the surgery. That is a good time to ask questions about pain medications, diet, and activity.
• You will be instructed how to care for your child at home before leaving the hospital.
• When your child is awake enough, they might be given a Popsicle® or “slushy” to drink in the recovery room. After the anesthesiologist sees your child can hold down the drink and their pain is controlled, they will be transferred to a hospital room, typically in the Intensive Care Unit (ICU). This usually takes about an hour.

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is for you to stay calm.

• You are encouraged to talk to your child or hold their hand before the surgery, while sleep medication is given, and while in recovery.
• You may bring along a “comfort” item — such as a favorite stuffed animal or “blankie” — for your child to hold before and after the surgery.

Your child will be given pain medication after the surgery, which will help with discomfort when the anesthesia wears off. Your child’s doctor will give you instructions for how to administer pain medication at home after your child is discharged from the hospital.

Your child will need to spend about five days in the hospital after SDR. Your child may spend several days in the Intensive Care Unit (ICU) before being moved to a regular hospital room. After your child is transferred to the ICU, he or she might still be groggy.

Diet

In the hospital, your child’s diet will be restricted to liquids, such as water, Gatorade®, Popsicles®, or Kool-aid® for a couple of hours to ensure their stomach is settled after the surgery. If your child does well with liquids after a couple hours, they may try a light diet and soft foods, such as applesauce, soup, toast, bananas, rice, or hot cereal. Your child may resume a normal diet the next day. 

Activity

Following the operation, activity needs to be somewhat restricted. For the first 24 to 48 hours after surgery, your child must lie flat. After the first few days in the hospital, he or she will start physical and occupational therapy.

Your surgeon will let you know when your child may resume normal activities, including returning to school.

Recovery time

Your doctor will let you know about your child’s expected recovery time. Most children can resume their normal activities within six to eight weeks after the procedure.

Discharge from the hospital

Before you leave the hospital, your care team will tell you how to care for your child’s incision and manage their medications. Your care team will also discuss follow-up care, including ongoing physical and occupational therapy in an outpatient setting.

Follow-up care

To increase the chances of a successful outcome after surgery, your child will need to participate in intensive, daily physical and occupational therapy for at least three to six months. Additional follow up depends on your child’s diagnosis, the need for additional treatment, and his or her symptoms.

You should call your doctor if your child has:

• A fever of more than 100.0° F.
• Clear drainage from their incision site.
• Difficulty breathing.
• Loss of bowel or bladder function.
• New or increasing shortness of breath.
• Pain, redness, bleeding, drainage, or increased swelling at the treatment site.
• Severe pain that does not respond to medication.

If you have any specific questions about your child’s surgery, you should discuss them with the surgeon before the surgery. You may call the Pediatric Neurosurgery Division at UPMC Children’s and ask to speak with your child’s surgeon or speak with them during the presurgical examination on the day of the surgery. Call the division at 412-692-5090.

If your child has any special needs or health issues that the doctor should be aware of, please call the Pediatric Neurosurgery Division at UPMC Children’s before the surgery and ask to speak with a nurse. It’s important to notify us in advance about any special needs your child may have.