Candidates for dorsal rhizotomy

Not all patients with spastic cerebral palsy (CP) benefit from selective dorsal rhizotomy (SDR). At our Center, patients are selected for the surgery on the basis of the following criteria and considerations.

To meet with the cerebral palsy treatment team at St. Louis Children's Hospital, call us at 314.454.KIDS (5437) or 800.678.KIDS (5437) or email us to request an appointment.

Essential criteria 

Children under 18 years of age

  • At least 2 years of age 
  • Diagnosis of spastic diplegia, spastic quadriplegia or spastic hemiplegia
  • Some form of independent mobility; for example, crawling or walking with or without an assistive device 
  • History of premature birth; if born at full term, child must have typical signs of spastic diplegia 
  • No severe damage to the basal ganglia on MRI examination 
  • Patients exhibit potential for improvement in functional skills after dorsal rhizotomy 

Adults between 19 and 50 years of age

  • Diagnosis of spastic diplegia 
  • History of premature birth 
  • Currently ambulates independently without assistive device 
  • Relatively mild fixed orthopaedic deformities 
  • Patients exhibit potential for functional gains after dorsal rhizotomy 
  • Patients exhibit motivation to attend intensive physical therapy and perform home exercise program
  • After the age of 40 a clinic evaluation is required.

We offer dorsal rhizotomy for adult patients on the basis of our accumulated experience with the procedure on pediatric patients. To date, we have observed satisfactory functional gains in adult patients that are similar to those in children.

Our current opinion is that most patients with spastic diplegia or quadriplegia should have spasticity reduced first through SDR before undergoing muscle release or tendon release procedures.

Criteria for patients with hemiplegia

  • Patient must have visible pathology on brain MRI that accounts for cerebral palsy such as periventricular leukomalacia or stroke. If the brain MRI is normal the child will not be considered for selective dorsal rhizotomy. 
  • Patient must have clear spasticity in the involved leg. 
  • Children must be at least 2 years of age and less than 19 years of age. 

Benefits of SDR for children with hemiplegia

  • Improved walking 
  • Improved balance in standing and walking 
  • Improved posture in sitting and standing 
  • Improved movement patterns with less stiffness 
  • If orthopedic surgery is needed it will most likely be less invasive 
  • Some of the expected long term benefits will be improved level of comfort, ability to participate in sports and fitness activities and improved overall quality of life 

Factors to be considered 

Good muscle strength in the legs and trunk. This is demonstrated by the ability to:

  • Support full weight on the feet 
  • Hold a posture against gravity 

Evidence of adequate motor control, or the ability to:

  • Make reciprocal movements for crawling or walking 
  • Move quickly from one posture to another 

History of delayed motor development. The child shows progression in motor development, but spasticity hampers the development of skills and/or causes gait deviations in ambulation. The adult is able to ambulate independently, but spasticity limits energy, flexibility, walking speed and balance and sometimes causes pain/muscle spasms.

Motivation and ability to cooperate in therapy

Commitment to rehabilitation and follow-up:

  • Receives physical therapy currently (in children) 
  • Able to receive physical therapy 4-5 times per week for 3-6 months postoperatively, and with decreasing frequency for an additional year or more 
  • Ability to be followed by St. Louis Children's Hospital treatment team at regular intervals for at least 16 months after surgery 

If there is doubt that the patient has adequate strength to change motor function, a 3-month trial of physical therapy focused on strengthening may be recommended.Progress during this trial period will provide information about the patient's potential to improve motor function after spasticity is reduced.

History of orthopaedic surgery with subsequent recurrence of spasticity. Previous orthopaedic surgery does not preclude candidacy. However, waiting at least 1 year following an orthopaedic procedure allows muscle strength to recover.

Conditions that preclude SDR 

Individuals with CP who possess some conditions would not be candidates for the SDR surgery. They include:

  • Patients who have suffered congenital brain infection, congenital hydrocephalus unrelated to premature birth, head trauma or familial disease 
  • Patients who have mixed CP with predominant rigidity or dystonia
  • Patients who have severe scoliosis
  • Patients who will not make functional gains after surgery 

Clinical characteristics of our patients who underwent SDR From 1987 through June 30, 2018 

Age Distribution
(SLCH 1987- October 16, 2018) 

Age (years) No. of Patients %
2-3 1111 28
4-6 1693 43
7-10 717 18
11-17 318 7
18-50 148 4
Total 3987 100

We recommend early surgery at the ages of 2 to 4 years before children have developed deformities of the legs. The great majority of patients underwent SDR between 2 and 5 years of age. Adolescents and young adults, who had spastic diplegia, benefited from relief of spasticity.

More than 3/4 of our patients had spastic diplegia and less than 1/4 of our patients had spastic quadriplegia. We currently recommend SDR evaluation for patients with pure spastic hemiplegia.

Gestation Age
(SLCH 1987- October 16, 2018)

Gestation Age (weeks) No. of Patients %
<24 159 4
25-29 1434 36
30-38 1831 46
>39 489 12
Unknown 74 2
Total 3987 100

Subtypes of Cerebral Palsy
(SLCH 1987- October 16, 2018)

Subtype No. of Patients %
Diplegia 3146 79
Quadriplegia 500 13
Hemiplegia 63 1
Triplegia 254 6
Other 24 <1
Total  3987 100

More than 3/4 of our patients had spastic diplegia and less than 1/4 of our patients had spastic quadriplegia. We currently recommend SDR evaluation for patients with pure spastic hemiplegia.

Mobility Level Prior to SDR
(SLCH 1987- October 16, 2018)

Mobility No. of Patients %
Independent walking 1488 37
Crutch 250 6
Walking with walker 1738 44
Some locomotion 261 6
Crawling 220 6
No independent mobility 30 1
Total 3987 100

Please note that many of our patients were walking independently. These patients improved the quality of walking after SDR.

Adults post SDR (patients whose surgeries were performed under 18 years of age) from 1987-June 30, 2015

Current Age No. of Patients
18-30 852
31-40 145
Over 40 0

Video presentation of walking and other motor functions 

Those who walk independently before SDR

After SDR all of our patients who were walking independently before surgery, regained the independent walking within a few weeks after surgery. Most of these patients will maintain independent walking for the long term. As with any patients that have cerebral palsy, those who have more difficulty walking independently may eventually need an assistive device.

Spasticity can be eliminated; the quality of independent walking improves; in many patients, physical therapy and braces become unnecessary after SDR. Orthopedic surgery is rarely required in the patients after SDR.

Video 1  |  Video 2  |  Video 3  |  Video 4  |  Video 5

Those who walk with walkers or crutches before SDR

In children who are 2-7 years old and walk with a walker or crutches before SDR, independent walking after SDR is possible. Once they have achieved independent walking, they can maintain it.

In children who are older than 7 years and walk with crutches, independent walking (inside or outside house) is possible. If they walk with walker at the age, they will most likely walk with a walker or crutches after SDR. SDR improves the quality of assisted walking and transition movements, and alleviates deformities of the legs. Many of these patients will need orthopedic surgeries after SDR.

Video 6  |  Video 7  |  Video 8

Video reviews to assess patient's candidacy 

If you are uncertain about a patient's candidacy for the initial evaluation, our treatment team will review a video produced by the patient's home physical therapist to assess the appropriateness of an initial evaluation. If you wish to send us a video for review, please complete the Patient Information Form, contact us via e-mail or by phone (314.454.2813 or toll-free 800.416.9956) to complete a screening. Following the screening we will furnish you with all of the information you will need to send a video evaluation to us including video guidelines and information on the hip and spine x-rays that we will ask you to send. After the video, x-rays and physical therapy report are reviewed, a physical therapist will contact you to discuss the treatment team's recommendations.

Children with hemiplegia

In the past we have not recommended rhizotomy for children with hemiplegia but after several children with hemiplegia recently underwent SDR we see significant improvement in these patients. We feel that the long term benefits of the reduction of spasticity in patients with hemiplegia will be significant. Some patients with hemiplegia who have SDR will also need heelcord surgery and possibly hamstring surgery for the best possible outcomes. If the child is not able to actively dorsiflex the involved ankle, they will most likely require orthopedic surgery to lengthen the calf muscle.

The SDR is done using the same technique as it is for all other patients except the nerve roots are severed only on the involved side.