We are grateful to Dr Crilly for his comments. There are differing opinions on the place of selective dorsal rhizotomy (SDR) in the management of spasticity in children. In a recent debate in the House of Commons SDR was strongly advocated, a speaker saying “At this time, medical evidence shows that SDR is more robust than any other treatment for cerebral palsy.” Families have been going to the USA at considerable cost to access this treatment.
The guideline developers were acutely aware of the lack of high quality clinical evidence for SDR, particularly in relation to important functional benefits and long-term outcomes. Crilly cites a meta-analysis of three randomised controlled trials, each of which was included in the developers’ deliberations. A recent prospective study also failed to demonstrate improved Gross Motor Function Classification System (GMFCS) scores during a 10 year follow-up. However, the developers were aware of reports of children with spasticity experiencing sustained improvement in motor function following SDR. They believed that children whose walking was primarily impaired by spasticity rather than weakness, contractures or poor muscle control would have the potential to benefit. SDR is an irreversible procedure which could cause harm. The developers therefore recommended that teams offering this procedure should participate in a coordinated national agreed programme to collect information on short- and long-term outcomes on all patients assessed for SDR, whether or not performed. In addition they made a research recommendation for the urgent evaluation of long-term outcomes (including adverse effects) using a range of designs, including randomised controlled trials. A similar plea has been made by others. The NHS can provide an ideal environment in which to carry out such research, and determine which children with spasticity may benefit from SDR to achieve improved participation and quality of life.
We also thank Willoughby and Graham for their comments regarding the need for early detection of hip dislocation in children with spasticity. The guideline developers recognised that this was of crucial importance. The guideline does not advise that the diagnosis of dislocation should depend on symptoms and physical signs, but it was of course considered important to make a recommendation regarding the recognition of such clinical manifestations. Specific recommendations are provided with regard to radiological monitoring in those at increased risk of dislocation, but it is important to strike a balance between the risk of delayed diagnosis and the hazards associated with increased radiation exposure. As Willoughby and Graham indicate, the guideline recommends that hip X-ray be offered at 24 months for all with bilateral cerebral palsy, but it does go further than this. It recommends that consideration be given to repeating the X-ray annually in those at GMFCS level III, IV or V. Additionally, it is recommended that consideration be given to repeating the hip X-ray sooner (after 6 months) in children and young people where the initial hip migration is greater than 30%, and then to consider repeating the hip X-ray every 6 months after this if the hip migration is increasing by more than 10 percentage points per year.
 Selective Dorsal Rhizotomy, Daily Hansard, 18 Apr 2012: Columns 474-482, http://www.publications.parliament.uk/pa/cm201212/cmhansrd/cm120418/debt...
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