ORIGINAL ARTICLE - FUNCTIONAL Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children Daniel D’Aquino 1 & Ahmad A. Moussa 1,2 & Amr Ammar 1 & Harshal Ingale 1 & Michael Vloeberghs 1 Received: 30 May 2017 /Accepted: 29 September 2017 # Springer-Verlag GmbH Austria 2017 Abstract Background Selective dorsal rhizotomy (SDR) has been established as an effective surgical treatment for spastic diple- gia. The applicability of SDR to the full spectrum of spastic cerebral palsy and the durability of its therapeutic effects re- main under investigation. There are currently limited data in the literature regarding efficacy and outcomes following SDR in Gross Motor Function Classification System (GMFCS) IV and V patients. Intrathecal baclofen has traditionally been the surgical treatment of choice for these patients. When utilised primarily as a treatment for the relief of spasticity, it is pro- posed that SDR represents a rational and effective treatment option for this patient group. We report our outcomes of SDR performed on children with severe cerebral palsy (GMFCS grade IV and V). The commensurate improvement in upper as well as lower limb spasticity is highlighted. Apparent ben- efit to urological function following SDR in this patient group is also discussed. Method A retrospective review of prospectively collected da- ta for 54 paediatric patients with severe cerebral palsy (GMFCS IV-V) who received SDR plus specialised physio- therapy. Mean age was 10.2 years (range, 3.0–19.5). SDR guided by electrophysiological monitoring was performed by a single experienced neurosurgeon. All subjects received equivalent physiotherapy. The primary outcome measure was change to the degree of spasticity following SDR. Spasticity of upper and lower limb muscle groups were quantified and standardised using the Ashworth score. Measures were col- lected at baseline and at 2-, 8- and 14-month postoperative intervals. In addition, baseline and 6-month postoperative uro- logical function was also evaluated as a secondary outcome measure. Results The mean lower limb Ashworth score at baseline was 3.2 (range, 0–4). Following SDR, significant reduction in low- er limb spasticity scores was observed at 2 months and main- tained at 8 and 14 months postoperatively (Wilcoxon rank, p < 0.001). The mean reduction at 2, 8 and 14 months was 3.0, 3.2 and 3.2 points respectively (range, 1–4), confirming a sustained improvement of spasticity over a 1-year period of follow-up. Significant reduction in upper limb spasticity scores following SDR was also observed (mean, 2.9; Wilcoxon rank, p < 0.001). Overall, the improvement to upper and lower limb tone following SDR—generally to post- treatment Ashworth scores of 0—was clinically and statisti- cally significant in GMFCS IV and V patients. Urological assessment identified pre-existing bladder dysfunction in 70% and 90% of GMFCS IV and V patients respectively. Following SDR, improvement in urinary continence was ob- served in 71% of affected GMFCS IVand 42.8% of GMFCS V patients. No serious postoperative complications were identified. Conclusions We conclude that SDR is safe and—in combina- tion with physiotherapy—effectively reduces spasticity in GMFCS grade IV and V patients. Our series suggests that spastic quadriplegia is effectively managed with significant improvements in upper limb spasticity that are commensurate with those observed in lower limb muscle groups. These gains are furthermore sustained more than a year postoperatively. In light of these findings, we propose that SDR constitutes an effective treatment option for GMFCS IVand V patients and a rational alternative to intrathecal baclofen. * Daniel D’Aquino ddaquino@gmail.com 1 Department of Neurosurgery, Queen’ s Medical Centre, Nottingham NG7 2UH, UK 2 Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK Acta Neurochir https://doi.org/10.1007/s00701-017-3349-z