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Apr 4, 2013 - Correspondence to Eline Bolster at VU University Medical Center, Department of Rehabilitation Medicine, Boelelaan 1117, 1007 MB ... 2013 Mac Keith Press ... motor development curves for each of the five GMFCS levels.
DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY

ORIGINAL ARTICLE

Long-term effect of selective dorsal rhizotomy on gross motor function in ambulant children with spastic bilateral cerebral palsy, compared with reference centiles ELINE AM BOLSTER 1 | PETRA EM VAN SCHIE 1 ROB LM STRIJERS 4 | R JEROEN VERMEULEN 5

| JULES G BECHER 2 | WILLEM JR VAN OUWERKERK 3 |

1 Department of Rehabilitation Medicine, Physiotherapy Section, VU University Medical Center, Amsterdam; 2 Department of Rehabilitation Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam; 3 Department of Neurosurgery, VU University Medical Center, Amsterdam; 4 Department of Clinical Neurophysiology, VU University Medical Center, Amsterdam; 5 Department of Paediatric Neurology, VU University Medical Center, Neuroscience Campus Amsterdam, Amsterdam, the Netherlands. Correspondence to Eline Bolster at VU University Medical Center, Department of Rehabilitation Medicine, Boelelaan 1117, 1007 MB Amsterdam, the Netherlands. E-mail: [email protected] This article is commented on by Steinbok on page 586 of this issue.

PUBLICATION DATA

Accepted for publication 18th February 2013. Published online 4th April 2013. ABBREVIATION

SDR

Selective dorsal rhizotomy

AIM The aim of this study was to evaluate the long-term effect of selective dorsal rhizotomy (SDR) on the gross motor function of ambulant children with spastic bilateral cerebral palsy (CP), compared with reference centiles. METHOD The study used a prospective cohort design and participants comprised 29 children classified using the Gross Motor Function Classification System (GMFCS) in level I (n=7), II (n=4), or III (n=18; 18 males, 11 females; median age at time of surgery 6y 4mo; range 2y 10mo–12y 1mo), who were examined 5 years and 10 years after SDR. We used individual centiles based on Gross Motor Function Measure (GMFM-66) scores and age, corresponding to the GMFCS levels. Individual improvement or deterioration was defined as a change of more than 20 centiles. Side effects experienced and additional treatment received after SDR were also recorded. RESULTS Five years after SDR, 10 out of 28 children showed improvement, and 10 years after SDR 6 out of 20 children had improved. Spinal side effects were noted in two children and hip subluxation in three. Additional treatments included subtalar arthrodesis (n=13), endorotational osteotomy of the tibia (n=5), and botulinum toxin treatment (n=13). INTERPRETATION None of the children showed deterioration of gross motor function based on centile ranking. Five and 10 years after SDR, gross motor function in some children had improved more than would have been expected according to the reference centiles. This suggests, taking the limitations of this study into account, that the applied criteria for selection were adequate. However, the children still required additional treatment after SDR.

Spastic bilateral cerebral palsy (CP) is the most common subtype of CP in Europe, accounting for 54.9% of all children with CP.1 Selective dorsal rhizotomy (SDR) is an accepted treatment to reduce spasticity in the lower limbs of children with spastic bilateral CP.2 It is assumed that reducing spasticity will improve gross motor function in children with spastic bilateral CP classified in levels I to III on the Gross Motor Function Classification System (GMFCS). A previous meta-analysis of three randomized controlled trials found that SDR, combined with intensive physical therapy, had a greater beneficial effect on gross motor function 9 months to 1 year post surgery than intensive physical therapy alone.2 Various uncontrolled studies have reported that SDR also improves gross motor function 610 DOI: 10.1111/dmcn.12148

over a longer period.3–7 None of these long-term studies, however, looked at individual changes by using a comparison group or reference centiles. Recently, Lundkvist et al.8 described changes in gross motor function up to 10 years after SDR. They reported a mean increase in Gross Motor Function Measure (GMFM-66) score and they also plotted group curves based on GMFCS level and GMFM-66 scores. These curves were compared with the motor development curves corresponding to each of the five GMFCS levels of Rosenbaum et al.9, which were based on GMFM-66 scores and age.9 The aim of the present study was to compare motor function with motor development curves but also to assess improvement in individual children rather than the average progress of the group as a whole. One method to evaluate individual © 2013 Mac Keith Press

change would be to compare motor function following SDR, in each child individually, with his or her own reference centiles. In 2008, Hanna et al.10 created reference centiles for the motor development curves for each of the five GMFCS levels. Once a child is classified in a GMFCS level, the GMFM-66 score can be transformed to centiles. The centiles can be used to evaluate a child’s relative capability at a particular time point and they can be used to understand change in motor function over time.10 The aim of our study was to evaluate the long-term (5y and 10y) effect of SDR on the gross motor function of ambulant children with spastic bilateral CP, compared with reference centiles. The secondary aim was to investigate the long-term side effects and the need for additional treatments after SDR.

METHOD Participants Thirty-six ambulant children underwent SDR at the VU University Medical Center in Amsterdam between August 1998 and October 2007. The children were selected for SDR if they satisfied the following criteria: (1) they had spastic diplegia; (2) they were aged 2 years and 6 months or older; (3) they had spasticity (defined as velocity-dependent resistance to passive stretch) in at least six groups of muscles in both legs; (4) they had no contractures limiting function at the hip, knee, or ankle (