Long-term benefits from selective dorsal rhizotomy in a young patient with cerebral palsy

Abstract Introduction Spasticity is considered to be one of the most important factors hampering functional abilities among patients with a cerebral palsy (CP). Aim The aim of the study was to present results of the selective dorsal rhizotomy (SDR) procedure combined with the physiotherapy process in a 3 year follow-up study, presented from a functional and structural perspective. Case study After the diagnosis of CP in the form of spastic diplegia, the 2-years-old patient (GMFCS 4) was directed for a comprehensive rehabilitation. After clinical examination and family consultation, spasticity was found to be important factor limiting patient functional abilities. Results and discussion The patient was directed to SDR operation. The patient was evaluated four times: before the SDR, and then 1, 2 and 3 years after the SDR surgery. The spasticity was assessed using the modified Tardieu scale. A functional assessment was done using the gross motor function measure (GMFM) scale, 6-min walk test and functional assessment questionnaire (FAQ-10). A muscle tension remained decreased throughout the 3 years of the follow up period. The achieved reduction in muscle tone was accompanied by a change in a range of motion, an improvement in GMFM total score result, an increased distance in 6-min walk test and in the FAQ-10 questionnaire. Conclusions SDR procedure combined with comprehensive rehabilitation programs leads to short- and long-term reduction in the spasticity of a 5-year-old boy with a spastic diplegia. Decreased level of spasticity was accompanied by an increased gross motor functioning and mobility.