Selektiv Dorsal Rhizotomi (SDR) Norsk Barnenevrologisk Forening Vintermøte Lillehammer 15-17. mars 2015 Kjersti Ramstad, overlege PhD Barneavdeling for nevrofag Oslo universitetssykehus
En het potet nasjonalt og internasjonalt PubMed søk på SDR og CP per 28. jan. 2015: 198 artikler, hvorav 46 (23%) publisert siste 5 år Nytt søk 11 mars: 201 artikler Pasientforening: Tema i CP-bladet 2014 og på CP-konferansen 2015 To norske barn operert for vel 20 år siden, seks norske barn operert de siste 5-6 år (med lett forbehold) alle i utlandet (Sverige, Tyskland, USA, andre steder? Samarbeid mellom utenlandskontorene i RHF-ene etablert 2014
Prosedyren Formål : Redusere mengden av signaler fra muskelfiberen til ryggmargens motoriske forhornceller En passelig andel av nervefibrene som sender slike signaler brennes eller klippes av.
Konsensus om SDR Den største utfordringen er å velge ut de riktige pasientene
Barn med CP som har gjennomgått SDR. Langtidsoppfølging publisert 2014-2015 Brit. Columbia Stockholm Lund Antall totalt 44 18 24 Alder ved SDR (år) 4.5 Ca 5 4 år 1 mnd Oppfølgingstid (år) Minst 10 17 10 GMFCS I 0 3 1 GMFCS II 8 5 7 GMFCS III 16 3 4 GMFCS IV 17 6 11 GMFCS V 3 1 1
Litteratursammendrag* Spastisiteten forblir redusert Motoriske ferdigheter bedres de første 3-5 år Motoriske ferdigheter kan bedres / ikke reduseres så mye som forventet de neste 5-10 år men mest hos gående Rasjonalet for seleksjonskriteriene kan diskuteres *Uautorisert, v/kr
Commentary (Steinbok): DMCN Mars 2015 (Lund, Sweden) This report adds to the growing body of literature that suggests that SDR has a positive impact on patients with spastic cerebral palsy in the longer term and is a valid treatment option for such patients. With the good results in functional performance in the severely affected patients in GMFCS levels IV and V, it may be that SDR should be considered as an alternative to ITB in this population.
Oversiktsartikkel* Arch Dis Child. 2015 Feb 10. pii: archdischild-2014-306874. doi: 10.1136/archdischild-2014-306874. [Epub ahead of print] Selective dorsal rhizotomy: an old treatment re-emerging. Aquilina K1, Graham D2, Wimalasundera N3. *Anbefalt lesing Vurdering i tverrfaglig setting Avklare behandlingsmål
Table 1 General selection criteria for selective dorsal rhizotomy Type of CP Severity of CP MRI Musculoskeletal Previous interventions Child and family factors Spastic without significant ataxia or dystonia Classically spastic diplegic CP A degree of ambulation with or without assistive devices; currently most patients are GMFCS grade II or III No injury to basal ganglia, brainstem or cerebellum on MRI; typical periventricular leucomalacia Good trunk control, good lower extremity antigravity strength on clinical examination No significant femoral head subluxation on pelvic radiograph (Reimer s index up to, or less than, 40%) No significant scoliosis Preferably at least 6 months after the last botulinum toxin A injection Preferably at least 1 year after orthopaedic surgery Ability to cope with rehabilitation process (cognitive and emotional) Supporting environment with access to rehabilitation facilities
NICE clinical guideline 145 forts. 1.8.1 Consider selective dorsal rhizotomy to improve walking ability in children and young people with spasticity at GMFCS level II or III: Patient selection and treatment should be carried out by a multidisciplinary team with specialist training and expertise in the care of spasticity, and with access to the full range of treatment options. Discuss the irreversibility of the treatment, the known complications and the uncertainties over long-term outcomes with children and young people, and their parents and/or carers (see also Selective dorsal rhizotomy for spasticity in cerebral palsy, NICE interventional procedure guidance 373). Teams offering selective dorsal rhizotomy should participate in a coordinated national agreed programme to collect information on short- and long-term outcomes on all patients assessed for selective dorsal rhizotomy, whether or not selective dorsal rhizotomy is performed. These recorded outcomes should include measures of muscle tone, gross motor function, neurological impairment, spinal deformity, quality of life and need for additional operations, with nationally agreed consistent definitions.
Nasjonalt SDR bør ha en plass i vår algoritme for behandling av spastisitet hos barn med CP* Hva skal til for å få dette til på en god måte? * Diskutert innad på OUS, sagt på CPOP/CPRN fagdag 2014 og på CP foreningens konferanse januar 2015 (KR)
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