Take orthopedic surgeons, neurosurgeons, rehabilitation medicine specialists, physical and occupational therapists, and specially trained nurses and what do you have? A multidisciplinary team that makes Children’s of Alabama one of the few pediatric medical centers in the U.S. to offer state-of-the-art surgical and medical therapies for children with cerebral palsy and severe spasticity, whether that be selective dorsal rhizotomy or intrathecal Baclofen pump therapies.
“We all work together to determine the best option for the child,” said Children’s neurosurgeon Brandon Rocque, M.D. But the medical professionals aren’t the only ones who play a role in the decision. “The most important factor is the family’s goals for the child,” Rocque said, which typically focus on some improvement in walking.
The two main options are rhizotomy, in which the surgeon exposes, stimulates and then severs nerve roots in the spinal cord, or a Baclofen pump, which continuously releases the muscle relaxer through the implanted pump.
“There are an infinite number of ways to stimulate the nerves (for rhizotomy) and make decisions about what to cut and not cut,” Rocque said. “Every program is unique.” To bring a more objective approach to the procedure, Children’s participates in the Cerebral Palsy Research Network (CPRN), a group of 25 medical centers committed to planning and executing high quality clinical research and quality improvement protocols.
“The idea of CPRN is to pull clinical data from the electronic medical record from children with cerebral palsy into a single data repository to understand it better,” Rocque said. That includes identifying children most likely to benefit from rhizotomy as well as the most appropriate surgical approach based on their condition.
For children who don’t require the extensive rhizotomy surgery, orthopedic surgery to release tight hamstrings or Achilles tendons might be used to reduce spasticity. And for those with more severe spasticity or dystonia, there’s the Baclofen pump.
More recently, the team has been performing palliative rhizotomy for children who would typically be considered for a Baclofen pump. While the pump remains an option, Rocque said, it is an implanted device, has to be refilled and carries a risk of infection and mechanical complications. Palliative rhizotomy, while not restoring the ability to walk, improves muscle tone in the legs. “Families are thrilled with how much looser the kids are, how much more comfortable and easier to take care of.”
The program sees about 100 children a year, most referred through rehabilitation medicine specialists, and hopes to expand from a bimonthly to a monthly clinic.