Selective dorsal rhizotomy remains experimental in cerebral palsy

• Published in: BMJ (Online) 2012-10, Vol.345 (oct09 1), p.e6670; author reply e6679-e6670
• Main Author: Crilly, Michael A
• Format: Article
• Language: English
• Subjects: Brain Diseases - complications; Cerebral palsy; Humans; Muscle Relaxants, Central - therapeutic use; Muscle Spasticity - etiology; Muscle Spasticity - therapy; Occupational Therapy; Orthopedic Procedures; Paralysis; Physical Therapy Modalities
• ISSN: 0959-8138; 1756-1833; 1756-1833
• DOI: 10.1136/bmj.e6670

The recent guideline from the National Institute for Health and Clinical Excellence (NICE) on the clinical management of children with cerebral palsy advises clinicians to consider selective dorsal rhizotomy to improve walking. 1 The guideline, however, omits publications on the benefits and harms of the procedure. 2 3 4 Only three small randomised clinical trials have assessed its effectiveness (combined with post-operative physiotherapy) compared with physiotherapy alone in improving motor function. A meta-analysis of the individual patient trial data (83 children aged 3 to 7 years) reported that selective dorsal rhizotomy improved gross motor function measure by 4.5 points (95% confidence interval 1.7 to 7.4) after 9-12 months. 2 However, the clinical collaborators considered this only a "small positive effect" since they had agreed in advance to a "minimal clinically important benefit" of 5-10 points for the primary outcome of gross motor function measure. 2 The NICE review notably does not identify a minimal clinically important benefit for selective dorsal rhizotomy. 1 A systematic review of adverse longer term outcomes (five years or more) associated with the procedure found only one small study (21 children) with an appropriate comparison group. 3 4 Six studies reported on the occurrence of spinal abnormalities and chronic back pain afterwards, but whether these complications were attributable to selective dorsal rhizotomy is impossible to know without appropriate comparison groups. 3 Published work shows that selective dorsal rhizotomy remains an experimental surgical procedure requiring further evidence from a much larger randomised controlled trial to establish its effectiveness.