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**selective dorsal rhizoto#a20c


Department of Neurosurgery
St. Louis Children's

• 2,500 employees • 700 medical staff • 1,300 auxiliary members • More than 30 pediatric subspecialty departmentsand divisions • Level I Pediatric Trauma Center, the highest level ofemergency care available Founded in 1879, St. Louis Children's
Hospital is one of the premier children's

• Has served patients from 50 states and 60 countries hospitals in the nation. It serves not just
the children of St. Louis, but children across

• Has been recognized as the world. The hospital provides a full
one of the best children's range of pediatric services to the St. Louis
hospitals in the nation by metropolitan area and a primary service
U.S. News & World region covering six states. As the pediatric
Report and Child teaching hospital for Washington University
School of Medicine, St. Louis Children's
• Has received the nation's Hospital offers nationally recognized
highest honor for nursing programs for physician training and
excellence, the Magnet designation, from theAmerican NursesCredentialing Center.
Table of Contents
A Life-Changing Procedure.3 Hope for the Future.4 Understanding Muscle Stiffness.6 Benefits of Dorsal Rhizotomy.8 Could Your Child Benefit?.9 Selective Dorsal Rhizotomy for Adults.12 About Selective Dorsal Rhizotomy.14 Preparing for Surgery.17 Questions and Answers.25 How to Contact Us.26 Our Mission:
We strive to provide
the best possible care
for children and
young adults with
spastic cerebral palsy.

Selective Dorsal Rhizotomy
A Surgical Program to Provide Better Mobility to
Children with Cerebral Palsy Spasticity

A Life-Changing Procedure:
Many children with cerebral palsy have spasticity, which is stiffness inthe muscles of their arms, legs and trunk. Spasticity in children caninterfere with their range and speed of movement and theirdevelopment of walking. In growing children, spasticity is particularlyharmful because it inhibits some muscle growth, and it causes musclecontractures and permanent orthopedic deformities. That's why it'simportant to reduce or eliminate spasticity at an early age. Children with cerebral palsy spasticity who come to St. LouisChildren's Hospital benefit from the latest technology and some of theworld's leading neurosurgery specialists.
Hope for the Future
Spasticity in children with cerebral palsy is treated with physicaltherapy, bracing and orthopedic surgery. Selective dorsal rhizotomy,a neurosurgical procedure, is an additional treatment option. Therhizotomy can reduce spasticity permanently and improve motoractivities. When performed at an early age, the rhizotomy canreduce the number of orthopedic operations patients might otherwiserequire. Over the past 20 years, we have proven the selective dorsalrhizotomy to be a very safe and effective surgery.
About Dr. Park
The procedure is performed by T.S. Park,
MD, neurosurgeon-in-chief at St. Louis
Children's Hospital, Shi H. Huang, Professor
of Neurosurgery at Washington University
School of Medicine, and one of the nation's
leading pediatric neurosurgeons. Learn
more about Dr. Park at http://neurosurgery.
A Winning Team
You'll see the difference the selective dorsal rhizotomy program at St. Louis Children's Hospital offers, from your first experience withour clinic to the follow-through care your child receives from ourexpert, dedicated staff to the smiles and renewed confidence your child brings home. We pride ourselves on the close relationship thatdevelops between parents, our patients and our staff. The depth of our program is unmatched. The selective dorsalrhizotomy team includes the coordinator of the Center for CerebralPalsy Spasticity, physical therapists and physical therapist assistantsexperienced in treating children with cerebral palsy, a physicianassistant and Dr. Park. We also provide coordinated screeningsbefore and after surgery that involve staff members fromneurosurgery, physical therapy as well as the patient's own referringphysician, orthopedist, neurologist, rehabilitation physician andphysical therapist. St. Louis Children's Hospital follows a multi-disciplinary approach topatient care that involves the expertise of physicians and nurses, aswell as other health professionals such as dietitians, social workers,child life specialists and physical and occupational therapists whowork as a team to ensure the best treatment for your child. The familyis considered an important member of the team. We work to providetreatment programs that promote understanding, interaction andindependence for both your child and your family members.
Understanding Muscle Stiffness
in Children with Cerebral Palsy

The stiffness of a muscle is called muscle tone. Normally muscles musthave enough tone to maintain posture or movement against the forceof gravity, while at the same time provide flexibility and speed ofmovement. The command to be stiff, or increase muscle tone, goes tothe spinal cord via nerves from the muscle itself. Since these nerves tellthe spinal cord just how much tone the muscle has, they are called"sensory nerve fibers." The command to be flexible or reduce muscletone comes to the spinal cord from nerves in the brain. These twocommands must be well coordinated in the spinal cord for muscles towork smoothly and easily while maintaining strength.
In the child with cerebral palsy, damage to the brain usually hasoccurred. For reasons that are still unclear, the brain damage thatoccurs in these newborns tends to be in the area of the brain thatcontrols muscle tone and movement of the arms and legs. The brain ofthe child with cerebral palsy is therefore unable to influence theamount of flexibility a muscle should have. The command from themuscle itself dominates the spinal cord and, as a result, the muscle istoo stiff, or "spastic." Currently, it is not possible to operate on nerves in the brain andcorrect the brain damage, but it is possible to operate on the sensorynerve fibers that come from the muscle. During rhizotomy each nerveroot is divided into 3 to 5 nerve rootlets. By cutting some – but not all– of these rootlets, it is possible to reduce the message from the muscleto better balance the messages of flexibility (from the brain) withmessages of stiffness (from the muscle). (See Figures 1 and 2 on thenext page). Once the muscle tone becomes more normal, it is easierfor the child to move and gain motor skills like sitting, crawling,standing and walking.
Remember that increased muscle tone or spasticity is only one problem ofmovement in children with cerebral palsy. Reducing spasticity will make iteasier for the child to move but does not eliminate weakness, abnormalmovements or balance problems.
Benefits of Dorsal Rhizotomy
Dorsal rhizotomy reduces spasticity. The child will no longer feel so stiff;muscle tone will be more normal and movement will be easier. Howmuch the child's mobility improves after surgery depends on severalfactors: The developmental level of the child before surgery.
If the child was walking with a walker or crutches before surgery, thesefunctions will likely be regained soon after surgery. Some children – butnot all – will then progress to walk independently. If the child was sittingalone and pulling up to stand (but not walking) prior to surgery, the childwill most likely begin to walk with a walker within about three monthsafter surgery.
The amount of therapy that can be provided after surgery.
Children change very rapidly after surgery. We recommend physicaltherapy four to five times a week for the first six months; three to fourtimes per week for the next six months; and two to four times per weekfor the subsequent year or longer. We have found that this physicaltherapy schedule increases the possibility of your child reaching his orher maximum potential. Therapy is provided by your child's primarytherapist, who is given the post-op physical therapy protocol to followafter surgery to best help your child. Physical therapists are invited to callus any time with questions.
The extent of your child's movement problems due to causes other
than spasticity.

Rhizotomy surgery reduces spasticity but does not have a direct effect onweakness, balance or abnormal movement patterns. These problemsoften improve because the child can move more easily after surgery, andstrengthening is easier with reduced spasticity. These changes take timeand persistence with physical therapy.
The child's motivation, cooperation and intelligence.
These all play an important role in changing mobility. It is also importantfor the family to share the child's enthusiasm as new skills are gainedand to stay involved in the physical therapy program. The child needsopportunities to practice new skills at home, school and in thecommunity.
Could Your Child Benefit From Dorsal

Dr. Park believes children with cerebral palsy spasticity should have anevaluation for potential dorsal rhizotomy before other orthopedicprocedures are performed. All children with spastic diplegia, triplegiaand quadriplegia following premature birth should be evaluated byneurosurgeons for the procedure.
• Diagnosis of spastic diplegia or spastic quadriplegia or spastic • Premature birth or full-term birth with typical signs of spastic diplegia. • Two years of age or more.
• Based on MRI (magnetic resonance imaging)examination, no significantdamage to the key area ofbrain involved in posture andcoordination.
• At least 3 months since last Botox injection.
Factors to Be Considered
• Adequate 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
make appropriate movements to
move quickly from one posture to another
• History of delayed motor development. The child is able to crawl, sit and pull to stand by age 2, but spasticity hampers the development ofskills and/or causes gait deviations.
• Motivation and ability to cooperate in therapy.
• Commitment to rehabilitation and follow-up.
receives physical therapy currently
able to receive physical therapy four to five times per week for six
months after the operation and with decreasing frequency for anadditional one to two years ability to be followed by the St. Louis Children's Hospital rhizotomy
team at regular intervals for at least 16 months after surgery • If there is doubt that the child has adequate strength to change motor function, a three-month trial of physical therapy focused onstrengthening may be recommended. Progress during this trial periodwill provide information about the child's potential to improve motorfunction after spasticity is reduced.
• History of orthopedic surgery. Previous orthopedic surgery does not mean your child is not a candidate for dorsal rhizotomy. However,waiting at least one year following an orthopedic procedure allowsmuscle strength to recover.
Assessing Your Child's Candidacy
If you are uncertain whether your child is a suitable candidate for the
initial evaluation and a physical therapy evaluation, please feel free to
call our office and speak to a physical therapist, or go to our website and click on Patient Information Form to
complete a screening. Dr. Park will determine if more studies are needed,
or if we should see a video evaluation of your child. Our rhizotomy team
will review the videotape produced by the child's home physical therapist,
physical therapy evaluation and hip and spine x-rays to assess the
appropriateness of an initial evaluation. After the videotape and physical
therapy report are reviewed, a St. Louis Children's Hospital physical
therapist will contact you to discuss the rhizotomy team's
recommendations. There is no charge for this assessment.
Children with cerebral palsy who possess certain conditions would not becandidates for the dorsal rhizotomy surgery. They include children who: • have suffered meningitis, congenital infection, congenital hydrocephalus unrelated to premature birth, head trauma or familialdisease • have mixed cerebral palsy with rigidity or poor muscle tone • have severe scoliosis • will not make functional gains after surgery The Initial Evaluation
The initial evaluation consists of anappointment with Dr. Park, aphysician assistant and a physicaltherapist. Before your child'sappointment, our staff will send anextensive evaluation form for youand your primary physical therapistto complete. This form must becompleted and returned to our office with hip and spine x-rays before an appointment is scheduled. At the first appointment a physical therapist will see your child to assessrange of motion, wheelchair needs and discuss pre-operative and post-operative physical therapy. Dr. Park will examine your child and reviewhis or her medical history along with the physical therapy evaluation. A physician assistant will be present during Dr. Park's evaluation.
Occasionally an MRI is requested after the initial appointment with Dr. Park to better determine if your child is an appropriate candidate for the surgery.
Please bring all assistive devices such as braces, a walker, or crutches toyour appointment. Selective Dorsal Rhizotomy for Adults
Adults Can Benefit, Too
Dorsal rhizotomy is also offered for adult patients on the basis of ouraccumulated experience with the procedure on pediatric patients. Todate, we have seen satisfactory functional gains in adult patients similarto those gains in children. Adult patients who are identified as candidates for dorsal rhizotomy will have their surgery at Barnes-Jewish Hospital, which is adjacent to St. Louis Children's Hospital on the Washington University MedicalCenter campus. Most of the information in this brochure applies to bothadults and children except for the following differences: Adult patients, ages 17 through 39, are selected for the surgery on
the following criteria and considerations:

• diagnosis of spastic diplegia • history of premature birth • currently walks independently without an assistance device • relatively mild fixed orthopedic deformities (Adult patient criteria, continued) • patients exhibit potential for functional gains after dorsal rhizotomy • patients exhibit motivation to attend physical therapy and perform a home exercise program In adults, the surgical technique requires only a single level laminectomy,which is the surgical chipping away of the thin bony arches of thevertebrae. Adults may have a catheter in after surgery for a longer period thanchildren.
Therapy will be the same as for children immediately following surgerybut the frequency may be reduced more quickly in the longer term. About Selective Dorsal Rhizotomy
Figure 3 shows two groups of nerve roots that leave the spinal cord andlie in the spinal canal. The anterior nerve roots send information to themuscle; the dorsal nerve roots transmit sensation from the muscle to thespinal cord. At the time of your child's operation, the St. Louis Children'sHospital surgical team divides each of the dorsal roots into 3 to 5 rootletsand stimulates each rootlet electrically to identify the dorsal nerve rootletsthat cause spasticity. The abnormal nerve rootlets are selectively cut,leaving the normal rootlets intact. As Figure 3 illustrates, the surgery requires a two- to three-inch incisionalong the center of the lower back just above the waist. Dr. Park'sprocedure uses a smaller surgical site that often provides less pain and afaster recovery. In 1991, we modified our surgical procedure to remove bone from one or two vertebrae instead offive or six. Once the surgery is complete, theskin is closed with glue; no stitches are The advantages of our
required. Surgery takes three to four hours, one- to two-level selective
depending on the age of the patient. Your dorsal rhizotomy over
child will go to the recovery room for a few other techniques include:
hours before being transferred to thepediatric intensive care unit for an overnight • reduced risk of spinal deformities because less bone is removed • less weakness after • less intense and shorter- • less recovery time needed and usually an earlier return to physical therapy Clinical Characteristics of Our Patients
Who Underwent Selective Dorsal
Rhizotomy since 1987
Total: 1,636 patients

We recommend early surgery between the ages of 2 to 5 years, beforechildren have developed leg deformities. The great majority of patientsunderwent surgery between 2 and 5 years of age; however, adolescents and young adults with spastic diplegia also benefited from relief of spasticity.
Subtypes of
Approximately 78 percent of our patients had spastic diplegia and21 percent had spastic quadriplegia. Less than 1% had hemiplegia.
Prior to SDR
Independent walking Walking with walker Please note that many of our patients were walking independently. These patients walked better after surgery.
About 90 percent of our patients were born prematurely. Patients born atfull term and having spastic CP must not have progressive neurologicaldisorders such as familial spastic paraplegia.
Preparing for Surgery
Physical therapy before surgery shouldfocus specifically on the followingareas: • strengthening the trunk muscles and muscles of the hips and knees andcalves • improving range of motion in the hip abductor, hamstring andgastroenemius muscles • instructing the family in the pre- operative and post-operative homeexercise program • arranging for adaptive equipment to be used after surgery The physical therapy program before surgery prepares you and yourchild for the program after surgery. Your child will learn what to expectimmediately upon returning to therapy after surgery.
If your child develops a fever, chicken pox or other medical problems a
few days before the scheduled surgery, contact us at 314.454.2813 or
toll-free at 800.416.9956. If your child is taking oral Baclofen, he or she
will need to be weaned off the medication at least two weeks before
surgery. During the two weeks before surgery, your child should not take
any pain or fever medication other than plain Tylenol.
Framing the Future
On the day before surgery, our staff will videotape your child as he orshe goes through a standardized test called Gross Motor FunctionMeasure to determine the level of gait and functional skills. We will alsoassess range of motion and muscle tone. This videotape then can becompared with progress after surgery videotaped at four-month and 16-month follow-up visits. Your child will also see a physician assistanton the day before surgery for a history and physical examination.
Possible Surgical Issues
The dorsal rhizotomy is a long and extensive neurosurgical procedure for achild at any age. There are some risks associated with both the generalanesthesia and the surgery, although overall the risks are minimal. Dr. Parkwill discuss the risks with you before surgery and answer any of yourquestions. Parents should also be aware that depending on existing conditions, somechildren may require additional orthopedic surgery following dorsalrhizotomy. Dr. Park will also address these issues before surgery.
Commercial insurance is a complex issue with any hospitalization andsurgery. Generally, most insurance companies provide benefits for theselective dorsal rhizotomy. It is extremely important for you to contact yourinsurance company to notify them of the planned surgery. Be sure to obtaintheir written commitment to provide benefits. If you call your insurancecompany, you will need two code numbers. The diagnosis code (I-CD9) is343.9. The procedure code (CPT) is 63190.
If your insurance company requires additional information, contact the
rhizotomy program secretary, 314.454.2813 or toll-free at
800.416.9956. Another helpful resource is the St. Louis Children's
Hospital financial counseling staff members who work closely with
parents and are experienced in working with numerous forms of
reimbursement. For financial counseling, call 314.454.6081.
After surgery, your child will spend about 24 hours in the St. LouisChildren's Hospital pediatric intensive care unit (PICU) and then betransferred to the hospital's neurology/neurosurgery unit.
When your child is transported from the recovery room to the PICU, he orshe will have a catheter in the bladder and an intravenous line. Thecatheter will be removed before your child leaves the intensive care unit.
After waking from the anesthesia, most children can move their legs butpossibly not as well as before the operation. The legs will be less stiffthan before surgery.
While in the PICU, your child will receive medications to relieve pain andreduce muscle spasms. Your child's face may appear swollen due topositioning during surgery but this swelling will disappear in 24 to 48hours. By the second or third day, your child will begin feeling better andwill begin taking fluids by mouth. He or she will be positioned on theback or in a side-lying posture and will be turned from side to side everyfour to six hours.
Your child will be on bed rest until the third day after surgery, so youmay want to think of activities your child can enjoy in bed. Somesuggestions include a tape recorder and tapes, magnetic boards withletters, numbers or shapes; hand puppets or small dolls for imaginaryplay; and magic markers for drawing and coloring. VCRs are availablefor your use, so you may want to bring your child's favorite videos.
Many of these items are also available from the hospital's Child LifeServices, located on the eighth floor.
Occasionally, children experience a headache after surgery. This can bemedicated with an appropriate dose of Tylenol.
Physical Therapy in the Hospital
Your child will be limited to strict bed rest until the third day after surgery.
On that day, your child will be assisted into a wheelchair for a maximumof one hour; support to keep the trunk straight is essential. A physicaltherapist will begin gentle therapy at this time. When your child isdischarged, we will give you a copy of the pre-operative P.T. report and apost-operative physical therapy protocol to give to the primary physicaltherapist.
Back Care After Surgery
There are no stitches to be removed from the skin. Some activity is
allowed based on what your child can tolerate. The main restrictions are
related to trunk movement. Your child is allowed to sit as tolerated;
however, it is best to change position frequently during long periods of
sitting, such as when traveling. If you have questions or concerns about
your child's back, contact a physical therapist at 314.454.4166 or toll-
free at 800.416.9956.
Heading Home: The Future in Motion
When it's finally time to go home, you and your child may be feeling bothexcited and a little uncertain of what's to come. The first few weeks ofrecovery may be tiring for everyone involved. Rest assured, however, thathope is on the horizon and many smiles await you.
Your child will tire easily for the first few weeks at home. The muscleweakness that was hidden by the spasticity is unmasked by the rhizotomy,and strength development will take time. In addition, because of bed restand limited activity for several days, it will take a while for normalstrength and activity to return. For these reasons, your child should notreturn to school for three to four weeks after surgery.
Comforting Your Child
It's normal for your child to complain of discomfort in the lower back,particularly when lifted or changing position. The inpatient physicaltherapist will demonstrate the proper methods to transfer and lift your child.
Your child also may complain of pain if the feet dangle while sitting. Werecommend using a stool to support feet and eliminate discomfort.
Activity and Play
Most children quickly resume sitting, crawling and kneeling if these skillsexisted prior to surgery. However, even if your child walked before surgery,it may take several weeks to walk after surgery due to weakness and poormuscle control. Encourage your child to be active on the floor – crawling,sitting and playing. Consult with your physical therapist if your child beginsto stand or walk before this has been introduced as part of the physicaltherapy program.
Occasionally, muscle spasms may disturb your child's sleep. These can berelieved using a muscle relaxant prescribed at the hospital. We stronglyencourage parents to fill this prescription and a prescription for painmedication before even leaving the hospital to prevent any unnecessarydiscomfort for your child.
Toilet Use
Some children's toilet habits change temporarily. This may be due tonormal swelling or healing in the area of nerves that go to the bladder. Be patient. While this can be frustrating both to the child and parents, itdoes resolve.
Most children will have hypersensitivity on the bottoms of their feet aftersurgery. The child may complain of tingling, itching or funny sensations.
This can be alleviated by wearing shoes and socks. Standing is often more comfortable when ankle-foot orthotics areworn in addition to shoes. Place your handsfirmly on the child's feet when dressing orbathing. Do not touch lightly or move yourhands lightly over the skin. This problemusually resolves in the first few weeks. Home Program
At least for the first few months after surgery,your child's schedule will revolve around thephysical therapy program. Home exerciseprograms are provided at discharge. Your therapist will give you specific activities and methods. Most of thisprogram is learned during the pre-operative and inpatient physicaltherapy. It is expected that families will perform a home exerciseprogram in addition to the outpatient physical therapy. Recovery and Progress
Encourage your child to be active, but respect that he or she may tireeasily. It takes time and repetition to produce consistent new movements.
Some days your child will be frustrated because he or she has not yetlearned new ways to control muscles and movements. Your child will notyet understand how to make the "new body" work. An image of a bodywithout spasticity must be developed, and that takes time. The work isintense, but the rewards are tremendous.
Every child progresses at an individual pace, and learning new skills isfollowed by a plateau while those skills are practiced. Other factors maycause setbacks or plateaus. When your child goes through a growthspurt, there may be increased difficulties. Being tired or under stress willaffect the child's muscle coordination and movement patterns. Expect this;don't be overly concerned. However, if the child plateaus or regressesand it does not resolve in a week or two, discuss this with your therapist.
It may require a change of program frequency or a review of otheractivities in the program. If you have any concerns about your child'sprogress after surgery, please contact a physical therapist at our office.
Outpatient Physical Therapy
The St. Louis Children's Hospital rhizotomyteam works to achieve an outpatient-basedphysical therapy program for patients whohave undergone selective dorsal rhizotomy.
The program includes an intensive outpatienttherapy protocol in coordination with thechild's primary home therapist. The goals forthe physical therapy program are to: • increase strength in the trunk, hips and legs • develop alignment of pelvis, trunk and • increase range of motion of the legs • develop isolated movements of the legs as well as opposing movements • improve balance • develop the ability to move in and out of position • develop and improve walking • incorporate new patterns of moving in and out of position for functional skills • increase endurance of functional activities such as walking or bicycle Post-op appointment at four months after surgery
• The Children's Hospital treatment team will examine the child four months after discharge. This appointment is mandatory for families residing in the United States and families are expected to return for that appointment.
• If the family doesn't agree to or is unable to return for this post-op visit, the rhizotomy surgery will not be considered for the child.
• Prescriptions will be given for patients up to one year following the last appointment at the Rhizotomy Clinic.
Follow up appointment one year after post-op appointment
• At the four month post-op appointment the family will discuss with Dr. Park and the rhizotomy team whether another appointment is needed one year later.
• If the family, Dr. Park and the rhizotomy team agree that another visit in a year is not necessary, the patient and family will be counseled regarding follow-up by an orthopedist, rehabilitation physician, neurologist, or another doctor.
• If the patient and family or Dr. Park and the rhizotomy team feel that another appointment in one year would benefit the child, a return visitappointment will be made.
• During each of these appointments, the child and family will meet with Dr. Park to discuss postoperative progress. This is also an opportunity for the child and family to ask questions regarding the type and frequency of PT, integration into community sports and activities, bracing needs and changes in assistive devices.
At the post-op appointment, all patients/families will be asked to bringnew hip x-rays. At both post-op and follow-up appointments the patientwill see Dr. Park for examination, and will see a physical therapist for an evaluation, which will be videotaped. After each clinic appointment,Dr. Park's notes will be mailed to the child's primary care physician andphysical therapist. The physical therapy report will be mailed to thechild's physical therapist. The patient's physical therapist will also becalled to discuss the evaluation, progress, continued treatment, andrecommendations for devices, bracing and more.
Sending a videotape of the child's motor function is not considered an
adequate examination of the child and will not take the place of either
a post-op or follow-up appointment at the Rhizotomy Clinic.

Our Team Addresses
Your Concerns

Could there be a reoccurrence of spasticity
after surgery?

There has been no return of spasticity inchildren with spastic diplegia, a form ofcerebral palsy. A few children with spasticquadriplegia have had return of spasticity.
Contracture: The shortening
How long have you been doing dorsal
of a muscle, tendon or other structure so that the joint Dr. Park began performing the surgery in cannot be straightened or 1987 and has performed the surgery on readily flexed and extended.
more than 1,600 patients ranging in agefrom 2 to 39 years.
Diplegia: Involvement
primarily in the hips and
legs; trunk and arms may be
Will the surgery enable my child to walk?
involved to a lesser degree.
Not necessarily. Selective dorsal rhizotomy MRI: Magnetic Resonance
only relieves spasticity. Problems with Imaging uses the body's abnormal muscle coordination, weakness natural magnetism to and abnormal reflexes may continue to be produce a clear picture of the evident. But better range of motion, better structure being scanned.
sitting postures and improvements in gait patterns can be expected.
involving the brain, spinal cord or nerves.
What improvements could my child have
in speech?
involvement of all four arms Some children's speech improves, but this is not predictable. Improvements in trunk Spasticity: Stiffness in the
position when sitting, allowing improved muscles of the arms, legs breath support for better sound production, may be a contributing factor. Do contractures go away with surgery?
Contractures are the shortening of muscles, tendons and other structuresso they cannot be straightened or easily flexed and extended. Theunderlying cause of contracture is eliminated by the surgery, and socontractures may be reduced. However, if the contracture is severe anddoes not respond to a stretching/positioning program, serial casting orsurgical intervention may be necessary. Serial casting involves a series ofcasts, applied at weekly intervals, to increase muscle length using a slowgentle stretch over a long period of time – usually three to five weeks.
Are there improvements in my child's upper body function?
Some progress is evident that appears to be related to the improvementof trunk control and pelvic position.
Will my child need orthotics or splints?
Most children require an orthotic for the foot and ankle after surgery tomaintain proper alignment of the foot during weight-bearing activities.
Often existing orthotics can be modified after surgery. If your child is inneed of new orthotics around the time of surgery, we recommend theybe fitted after surgery.
For More Information
For more information and a video about selective dorsal rhizotomy
surgery, you or your physical therapist may call the Center for
Cerebral Palsy Spasticity at 314.454.2813 or 800.416.9956.
Additional information is also available at

St. Louis Children's HospitalCenter for Cerebral Palsy SpasticityDepartment of Neurosurgery - Suite 4S20One Children's PlaceSt. Louis, Missouri 63110-1077 St. Louis Children's HospitalCenter for Cerebral Palsy SpasticityDepartment of NeurosurgerySuite 4S20One Children's PlaceSt. Louis, Missouri 63110


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