We continue to offer dorsal rhizotomy for adult patients based on our accumulated experience with over 200 adult patients. To date, we have observed satisfactory functional gains in adult patients that are similar to those in children.

Essential Criteria for Adult Patients

  • Between 19 and 25 years of age
  • Diagnosis of spastic diplegia, spastic hemiplegia or simple hereditary spastic paraplegia
  • History of premature birth
  • Currently ambulates independently without assistive device in all environments
  • History of delayed motor development
  • Good strength in trunk, hips and legs
  • Relatively mild fixed orthopedic deformities
  • Patients exhibit potential for functional gains after dorsal rhizotomy
  • Patients exhibit motivation to attend intensive physical therapy and perform home exercise program
  • BMI in "Healthy" range
  • No significant medical problems

Postoperative inpatient care

Adults 25 years and younger will undergo selective dorsal rhizotomy (SDR) at St. Louis Children's Hospital and will follow the same protocol for younger patients.

Following surgery, for a period of 3 days the patient will have an epidural catheter used for pain control, an intravenous line in an arm and a catheter in the bladder. Upon waking from the anesthesia, the patient will be able to move their legs, but possibly not as well as before the operation. Their legs may feel heavy and weak to the patient but should feel less stiff.

While on the Neurology/Neurosurgery floor pain medications will be infused through the epidural catheter. Valium will be given for muscle spasms.

The patient may begin taking fluids or solid foods by mouth as tolerated. The patient will be positioned on the back or in a side-lying posture and will be turned from side to side every 4-6 hours.

The face may appear swollen due to positioning during surgery, but the swelling will disappear in 24-48 hours. While in the neurology/neurosurgery unit, the patient can be kept relatively pain-free through a continuous infusion of pain medications through the epidural catheter. This infusion will be stopped and the catheter removed on the morning of the third post-operative day. At this point, Tylenol with codeine and oral valium will be given as needed.

Occasionally, a patient will experience a headache several days after surgery. This can be medicated with an appropriate dose of Tylenol. Some patients experience flexor spasms which generally occur at night or while resting after a period of activity. These spasms are temporary and can be minimized with a small dose of Valium.

Bed rest is required until the third postoperative day.

Back care after surgery. There are no stitches to be removed from the skin. Patients are allowed activity as they can tolerate it. The main restrictions are related to trunk movement. No passive hyperextension or trunk rotation is permitted. Patients are allowed to sit as tolerated; however, it is best to change position frequently during long periods of sitting.

Physical therapy during hospitalization. The patient will be limited to strict bed rest until the third day after surgery. On the third postoperative day, patients are assisted into a wheelchair for a maximum of 1 hour; support to keep the trunk straight is essential.

Postoperative care at home 

The following gives an overview of what to expect during the patient's recuperation at home.

Fatigue: The patient will tire easily for the first few weeks during sitting or standing. Often, a 5- or 10-minute rest, lying on the side or flat on the back, will be all that is needed. The muscle weakness that was hidden by the spasticity is unmasked by the rhizotomy, and development of strength will take time. In addition, because of bed rest and limited activity for several days, it will take a while for normal strength and activity to return. For these reasons, the patient should not return to school or work for 3-4 weeks after surgery. Depending on the patient’s occupation they may not be able to return to work for up to 12 weeks.

Pain: Expect complaints of discomfort in the lower back for a couple of weeks, particularly when changing position. This can be alleviated by moving slowly and avoiding excessive trunk rotation, lateral flexion, and forward flexion. The inpatient physical therapist will demonstrate the correct way to move and transition between positions. The patient may also complain of pain if the feet dangle while sitting. Feet should be supported and not allowed to dangle. Patients will be given a prescription for Neurontin to prevent heightened sensitivities in the legs.

Activity: Most patients quickly resume sitting. However, it may take several weeks before independent walking is possible, due to weakness and poor muscle control. The patient will resume independent activities common before surgery but may tire easily and need assistance to change some positions. Consult with the physical therapist if the patient wishes to engage in an activity before it has been introduced as part of the physical therapy program.

Sleep: Some patients experience disrupted sleep patterns. Frequent waking during the night is common. This problem resolves once the patient becomes more comfortable moving in bed.

Toilet use: Some patients' toilet habits change. This may be due to normal swelling or healing in the area of nerves that go to the bladder. The patient may frequently feel the need to use the toilet and then find it is not necessary. Be patient. This resolves but can be frustrating to the patient.

Sensory changes: Most patients will have hypersensitivity on the bottoms of their feet. The patient may complain of tingling, itching, or funny sensations. This can be alleviated by wearing shoes and socks while standing. Place your hands firmly on the feet when dressing or bathing. Do not touch lightly or move your hands lightly over the skin. This problem usually resolves in the first several weeks.

Home program: At least for the first months, the patient's agenda will revolve around the physical therapy program. Home programs are provided at the time of discharge from the hospital. Programs vary for each patient, but all include positioning, range of motion to gain muscle length, strengthening, and developing reciprocal movement. A hospital therapist will give you specific activities and methods. Most of this program is learned during the preoperative physical therapy program and during the hospital stay. It is expected that the patient will perform a daily home exercise program in addition to receiving regular physical therapy.

Recovery and progress: The patient should be encouraged to be active, but may tire easily. Daily progress is not always evident. This is the normal recovery process. The nerves and muscles are learning new ways to move without spasticity. It takes time and repetition to produce consistent new movements.

The patient may be frustrated because movement is not the way it used to be and new ways to control muscles and movements have not yet been learned. An internalized image of a body without spasticity must be developed, and that takes time. Every patient progresses at an individual pace, and learning new skills is followed by a plateau while those skills are practiced. The rewards are tremendous but the work is intense.

Various factors may cause setbacks or a leveling off of progress. Being tired or under stress will affect the patient's muscle coordination and movement patterns. Expect this; don't be overly concerned. However, if the patient plateaus or regresses then does not improve in a week or two, discuss this with the home therapist. It may require a change of program frequency or a review of other activities in the program. If you have any concerns about the postoperative progress, please contact our office.

Outpatient physical therapy. The St. Louis Children's Hospital treatment team works to achieve an outpatient-based physical therapy program for patients who have undergone SDR. This program emphasizes discharge of the patient from the hospital as soon as acute postoperative care is complete and includes an intensive outpatient therapy program in coordination with the patient's primary home therapist. The goals for the physical therapy program are:

  • Developing alignment of pelvis, trunk, and head 
  • Increasing range of motion of the hips, legs, ankles, and feet 
  • Increasing strength in the trunk, pelvis, and legs 
  • Improving isolated movements of the legs as well as reciprocal movements 
  • Improving balance and alignment 
  • Improving the ability to move in and out of position 
  • Improving walking 
  • Incorporating new patterns of moving into functional skills 
  • Developing smooth coordinated movement 

Follow-up appointments

Post-op appointment at 4 months after surgery

  • Dr. Roland and the rhizotomy team will examine the patient 4 months after discharge. This appointment is mandatory for patients residing in the United States and patients are expected to return for that appointment. Patients may be asked to bring updated hip x-rays.
  • If the patient doesn’t agree to or is unable to return for this post-op visit, the rhizotomy surgery will not be considered for the patient.
  • Prescriptions may be provided for patients up to one year following the last appointment at the Rhizotomy Clinic.

Follow up appointment one year after post-op appointment

  • It may be beneficial to meet with Dr. Roland and the team one year or more after the 4 month post-op appointment.
  • If the patient and Dr. Roland and the rhizotomy team agree that that another visit in a year is not necessary, the patient will be counseled regarding follow-up by an orthopedist, rehabilitation physician, neurologist, or another doctor.

During each of these appointments, the patient will meet with Dr. Roland to discuss postoperative progress. This is also an opportunity for the patient to ask questions regarding the type and frequency of PT, integration into community sports and activities, bracing and changes in assistive devices.

After each clinic appointment, medical records will be faxed to the patient’s primary care physician. The physical therapy report will be sent to the patient’s physical therapist.

Sending a videotape of the patient’s motor function is not considered an adequate examination of the patient and will not take the place of either a post-op or follow-up appointment at the Rhizotomy Clinic.

For more information on selective dorsal rhizotomy and cerebral palsy treatment, please call us at 314.454.5437 or 800.678.5437 or email us.