How We Use Rhizotomy to Treat Cerebral Palsy

Cerebral Palsy patients pose for photos at Main Campus., Patient is Hunter Watters

How We Use Rhizotomy to Treat Cerebral Palsy

Our specialists offer minimally invasive rhizotomy techniques to treat spasticity and dystonia, enhancing comfort, mobility, and quality of life for children.

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Team Approach to Care Enhances Cerebral Palsy Outcomes

Specialists at the Cincinnati Children’s Cerebral Palsy Center are practicing a team approach with delivering care for spasticity and dystonia in children with cerebral palsy by carefully selecting candidates for surgery, refining surgical techniques and optimizing intensive post-operative rehabilitation.

At our Surgical Spasticity Clinic, neurosurgery experts perform selective dorsal rhizotomy (SDR) to reduce lower extremity spasticity. This one-time procedure severs nerve rootlets that interrupt abnormal signals originating from the brain travelling down the spinal cord branching out to nerves that send and receive signals from muscles. This abnormal circuitry is responsible for muscle tightness known as spasticity. Spasticity improves immediately after surgery. After spasticity is eliminated, strength, mobility and function are improved with intensive physical therapy (PT).

SDR offers a safe, long-lasting treatment for spasticity, which reduces burden of care and long-term reliance on spasticity medications and injectables. Due to its significant benefit, rhizotomy indication has been expanded to treatment of moderate to severe dystonia, which is involuntary movement characterized by variable fluctuating high muscle tone that interferes with movement, positioning or care. A combined (ventral-dorsal) rhizotomy approach could be considered for children with moderate to severe dystonia if standing and walking is not a priority goal for the caregivers and child.

SDR reduces spasticity to allow lower extremity strengthening and gait training. Combined rhizotomy, on the other hand, eliminates both spasticity and dystonia, thereby easing comfort and care for non-ambulatory children.

“The goal is to maximize each patient’s potential,” says Smruti Patel, MD, neurosurgeon. “The biggest key is to ensure there is an intensive PT plan already set up before surgery.”

Coordinated, Team-Based Care

Illustrations depicting the procedure. A: After the conus medullaris is clearly identified, a single laminectomy is performed. B: An operating microscope is used to identify the L-1 and L-2 spinal roots at the corresponding intervertebral foramina. C: The L2–S2 dorsal roots are separated from the ventral roots. D: A 5-mm Silastic sheet is placed under the L2–S2 dorsal roots.

The cerebral palsy (CP) team may consider SDR or combined rhizotomy when stretching, bracing, physical therapy, antispasmodic medications and/or botulinum toxin no longer provide adequate or long-lasting effects or when intrathecal baclofen therapy is contraindicated or not feasible.

Patients with gait impacted by high muscle tone or joint contractures and bony malalignment may undergo a two-day mobility surgical evaluation to determine if they are good candidates for either surgical tone reduction and/or orthopaedic interventions. Specialists in motion analysis, neurosurgery, orthopaedics, pediatric rehabilitation medicine (PRM) and physical therapy evaluate each patient and discuss various treatment options tailored to the patient’s and caregivers’ goals.

“The collaborative spirit is really what makes our work so successful,” Patel says.

There is no age limit for SDR, but the best candidates are:

At least 2 years old
Cooperative and motivated to participate in intensive physical therapy
Having moderate predominant lower extremity spasticity that is impacting mobility and/or comfort, for which nonsurgical interventions are no longer adequate

Paola Maria Mendoza-Sengco, MD, a PRM specialist, says that SDR is ideally performed at an early age, prior to the onset of contractures, if the family and child are motivated and ready to participate in post-operative rehabilitation.

“If we wait too long, patients can develop irreversible joint or bone changes that may require a second orthopaedic intervention,” Mendoza-Sengco says.

The goal is to maximize each patient’s potential. The biggest key is to ensure there is an intensive PT plan already set up before surgery.

Smruti Patel, MD

We continually refine our post-operative therapy protocols to optimize functional outcomes. In a shared decision-making process, we pay attention to details and carefully discuss patient and parent goals.

Paola Maria Mendoza-Sengco, MD

Minimally Invasive Rhizotomy Technique

The comprehensive approach extends into the operating room. Using a minimally invasive technique called a single-level laminectomy, the neurosurgeon removes a small amount of bone from the spinal column to open a window to the nerves.

While more challenging than removing multiple pieces of bone, the single-level laminectomy provides a faster recovery and less pain. Cincinnati Children’s is one of a few centers offering this specific surgical technique.

Once the nerves are exposed, each is tested and evaluated. The neurosurgeon, a neurophysiologist and a physical therapist work together to determine which dorsal and/or ventral nerve rootlets should be cut.

Severing the abnormal nerves “disrupts the feedback loop from the spine to the muscles that causes the increased stretch reflexes and muscle tone,” Mendoza-Sengco says.

As the team performs more combined rhizotomies, they better understand the type of patients who could benefit most from the procedure, particularly those with mixed hypertonia or a predominance of dystonia.

“They are often not ambulatory, but it can be used to greatly improve their quality of life,” Patel says.

Post-Op Physical Therapy Protocols

After SDR, children complete two to three intensive physical therapy sessions a week for at least a year that focus on functional mobility and strengthening, gait training, power training and eventual re-entry into sports or recreational activities that are meaningful for the child.

“It’s truly gratifying to see these results,” Mendoza-Sengco says. “Patients reduce their risk of joint deformity and pain. We can wean off the medications and reliance on botulinum toxin injections.”

Combined rhizotomy patients also complete a physical rehabilitation plan, of lesser frequency than those undergoing SDR, designed for their individual condition and needs.

Mendoza-Sengco, Patel and the surgical spasticity team collect patient outcome measurements before surgery, and at six and 12 months after surgery. They track patients into young adulthood.

“We continually refine our post-operative therapy protocols, so we get optimized long-term outcomes,” Mendoza-Sengco says. “In a shared decision-making process, we pay attention to details and carefully discuss patient and parent goals.”

(Published April 2025)

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