Case Study: Selective Dorsal Rhizotomy (SDR) for Spastic Hemiparesis in a Toddler with a History of Prematurity and Intraventricular Hemorrhage

Case at a Glance

A 2-year-old male with a history of extreme prematurity, Grade IV intraventricular hemorrhage (IVH), and a VP shunt presents with significant right-sided spastic hemiparesis. His family and medical team are considering a Selective Dorsal Rhizotomy (SDR) to manage spasticity and improve his long-term functional potential.

Patient's Story

The patient is a 2-year, 11-month-old male, born extremely premature at 25 weeks gestation. His neonatal intensive care unit (NICU) course was complicated by a Grade IV intraventricular hemorrhage in the left ventricle and a Grade I hemorrhage in the right. This led to post-hemorrhagic hydrocephalus, which was managed with the placement of a ventriculoperitoneal (VP) shunt. The patient has also experienced significant feeding difficulties and remains dependent on G-tube feedings for nutrition. His parents report that while he is generally healthy and interactive, he has notable developmental delays. He exhibits a strong preference for his left side, using his left hand exclusively for exploration and mobility. He primarily moves by scooting on the floor. He can move his right arm and uses it for postural support, but does not engage it for functional tasks, a condition his parents describe as him 'not recognizing' his right hand. He is currently enrolled in intensive physical therapy, using orthotics and a walker to practice standing.

Initial Assessment

On presentation to the pediatric neurosurgery clinic in Japan, the patient weighed 11 kg and was 84 cm in height. The physical examination revealed a well-nourished toddler who was alert and engaging. Neurological examination was significant for right spastic hemiparesis. Increased tone was noted in the right upper and lower extremities, more pronounced in the legs. He demonstrated minimal functional use of his right hand. He was unable to stand or walk independently but could pull to a stand with support. His primary mode of mobility was scooting, propelled by his left arm and leg. The VP shunt site was clean, with no signs of malfunction.

The Diagnostic Journey

The patient's history of prematurity and IVH provided a clear etiology for his neurological deficits. He was diagnosed with spastic right hemiplegic cerebral palsy. Given the severity of the spasticity in his right leg, his physiatrist and neurosurgeon raised the possibility of a Selective Dorsal Rhizotomy (SDR). The rationale presented to the family was that SDR could permanently reduce the spasticity, thereby preventing the future development of fixed muscle contractures which might necessitate more invasive orthopedic surgeries later in life. Alternative treatments, including botulinum toxin injections and ongoing physical therapy, were discussed as management options, but SDR was proposed as a definitive intervention to eliminate the root cause of the spasticity. The family sought to understand the risks of this major spinal surgery, especially in a child with a VP shunt, and questioned the likelihood of the procedure improving his right-hand function.

Final Diagnosis

1. Spastic Right Hemiplegic Cerebral Palsy.
2. Status post Grade IV (left) and Grade I (right) Intraventricular Hemorrhage secondary to extreme prematurity.
3. Status post Ventriculoperitoneal (VP) Shunt for post-hemorrhagic hydrocephalus.
4. Oromotor dysfunction with feeding difficulty requiring gastrostomy tube dependency.

Treatment Plan

After extensive multidisciplinary consultation and discussion with the family, a Selective Dorsal Rhizotomy was recommended. The neurosurgical team addressed the family's concerns, noting that a history of IVH and the presence of a VP shunt are common comorbidities in candidates for SDR and do not preclude a successful procedure. Regarding upper extremity function, the team counseled the family that while SDR is performed to reduce lower limb spasticity, some patients experience a secondary, modest improvement in arm spasticity. However, it was emphasized that this is not a guaranteed outcome and should not be the primary expectation. The core treatment plan consists of:

1. Selective Dorsal Rhizotomy (SDR): To section specific sensory nerve rootlets in the lumbar spine to reduce spasticity in the lower extremities.
2. Intensive Post-Operative Rehabilitation: A critical component, involving immediate and prolonged physical and occupational therapy to retrain muscles, build strength, and maximize functional gains in mobility and motor skills.

Outcome and Follow-up

This case represents a pre-operative consultation. The primary goal of the proposed SDR is to achieve a significant and permanent reduction in lower limb spasticity. The expected outcome is an improved potential for ambulation (likely with assistive devices), prevention of painful contractures, and easier daily care (e.g., diapering, dressing). Any improvement in right-hand use would be considered a secondary benefit. The long-term follow-up plan involves a coordinated effort from a multidisciplinary team including pediatric neurosurgery, physiatry, physical therapy, and occupational therapy to monitor his progress, adjust therapies, and manage his overall development for years following the procedure.