UK’s first pioneering operation at Frenchay offers hope to children with cerebral palsy

Tuesday, 24 May 2011

Frenchay Hospital in Bristol has become the first hospital in the UK to carry out a pioneering neurosurgical procedure that could enable children with cerebral palsy to walk.

The technique involves division of some of the nerves as they enter the spinal cord to free up constricting muscles caused by lower limb spasticity (or increased muscle tone).

If performed early enough, problems related to lower limb spasticity, such as muscle shortening, contractures and abnormal bone growth can be reduced or even eliminated.

The method called Selective Dorsal Rhizotomy (SDR) is already an established treatment in cerebral palsy but, up until now, its availability in the UK has been limited.

Now, Frenchay Hospital is offering a new version of SDR which concentrates on the lower part of the spinal cord – increasing its effectiveness and reducing risk. 

Kristian Aquilina, Consultant Neurosurgeon, carried out the first operation at Frenchay Hospital in early May 2011.

He said: “Up to now SDR, in its traditional form only, has been available at one hospital in the country and this year alone forty families from the UK have gone to the United States for SDR at their own expense.

“We have now set up a multidisciplinary team at Frenchay Hospital to evaluate and select children for SDR.

“This team consists of paediatric physiotherapists with special expertise in cerebral palsy, a paediatric neurosurgeon, a paediatric orthopaedic surgeon and a paediatric neurologist.

“Our first micro-neurosurgical SDR, also the first in the UK, was performed in Frenchay on May 3.

“The patient went on to have two weeks of intensive in-patient physiotherapy and is now at home where he will undergo more months of physiotherapy before he and his family start to see the real benefits.

One of the common causes of cerebral palsy is premature birth, and there is now extensive evidence, recently recognised by NICE, demonstrating the value of SDR in these children.

Mr Aquilina said: “Children over four years of age, with a diagnosis of spastic diplegia following premature birth, should be considered for SDR.

“Children with typical spastic diplegia, whether born prematurely or at term, should also be considered. These children tend to have delayed motor development, and spasticity interferes with their progress.”

Patient case study – Beau Britton (7) from Kelly Bray, Cornwall

Since having the SDR operation three weeks ago, 7-year-old Beau Britton’s life has already changed dramatically.

He has already undergone a two-week period of intensive physiotherapy at Frenchay and he will have to take part in a long-term programme of daily physiotherapy for at least two years. He will also have to have a lot of hydrotherapy.

His mum Tracy is already amazed at some of the instant effects the operation has had on him.

She said: “We know this is a long-term thing and we are fully prepared for that. My ultimate aim is for Beau to walk without his wheelchair or walking frame but that is a long time off and it is difficult to think that far ahead at the moment.

“What has amazed me are some of the instant effects. As far as we can tell he is not waking up with cramps at night due to spasticity anymore – something which has caused major sleep deprivation for all of us over the last seven years.

“Also his cerebral palsy meant that his legs were crossed and his feet were planted on top of each other. They are now straight and getting him dressed is so much easier because his overall balance has improved so much.

“He was sitting on the sofa the other day and started dangling his legs over the edge – this may sound like a really small thing but he has never been able to do this before. He can also wriggle his toes.”

If they had not received the operation on the NHS Tracy says the family would have had to fundraise for the £40,000 to take Beau to America for the operation.

Tracy said: “We would have had no option other than to fundraise and we feel incredibly fortunate that Beau has been able to have this procedure on the NHS in Bristol. The care he received from Kristian and all the staff at Frenchay was just wonderful. I cannot thank them and Cornwall and the Isles of Scilly PCT enough.

“Beau’s seven years old now and has already undergone extensive orthopaedic surgery on both legs and hips and without SDR this would be ongoing his whole life.

“We would love Beau to do some of things other children take for granted – to wear wellies and splash in the puddles and to go to the beach and wear flip flops.

“It would be wonderful to take him skiing and we would love him to be able to experience the freedom of independent movement and if ever possible, to dance.

“Kristian has been so dedicated and we feel we have been so lucky to be in the right place at the right time. He has given Beau a second chance, a chance of a more normal life – which is priceless.”

Beau’s story will be featured as part of a special BBC Inside Out West documentary on SDR which will be shown on BBC1 in the West of England at 7.30pm on Monday, June 20.

SDR interrupts the hyperactive reflex arcs in the lower end of the spinal cord, reducing spasticity permanently. In this way the necessity for multiple orthopaedic procedures later on in life is reduced and children’s ability to walk and move without a wheelchair or walking aid is improved.

SDR has evolved over the last thirty years. It involves selective division of the sensory nerves in the lumbar spine as they enter the lower end of the spinal cord.

The selection is guided by intra-operative nerve monitoring. Specific sensory nerves are sequentially identified and divided into small rootlets. Each rootlet is then stimulated and those that contribute most to the spasticity are divided. The objective is to divide approximately 70 percent of the sensory roots at these levels.

The traditional SDR technique involves exposure of the entire lumbar spine, with removal and replacement of the back part of all the lumbar vertebrae; traditionally it is considered necessary to expose the individual nerve roots as they leave the spinal canal.

This approach has raised concerns on spinal instability and progressive spinal curvature, particularly as these procedures are performed in children with cerebral palsy who already have a tendency to develop severe scoliosis.

Paediatric neurosurgeons in St Louis, Missouri, in the United States have, over the last twenty years, developed a new technique in which the spinal opening is limited to the upper end of the lumbar spine, and the nerves are identified and divided as they enter the lower end of the spinal cord. It is this technique which is now available at Frenchay Hospital.

This microneurosurgical procedure reduces the risk of spinal problems in later life, eliminates manipulation of the motor components of the spinal nerves and allows quicker post-operative recovery with early resumption of full physiotherapy.

Kristian Aquilina graduated from the University of Malta in 1995 and completed most of his neurosurgical training in Bristol.

During his training he was involved in original research on intraventricular haemorrhage in premature babies and on neuroprotection of the newborn brain. 

He completed a one-year clinical fellowship in paediatric neurosurgery at Le Bonheur Children’s Medical Center and St Jude’s Children’s Research Hospital in Memphis, Tennessee, in 2009.

During his fellowship he had the opportunity to learn the surgical techniques related to selective dorsal rhizotomy. He then visited the Center for Cerebral Palsy in St Louis and spent time learning the various modifications of the technique that were developed there.