Overview of Neurosurgical Interventions for Global Tone Management

Common neurosurgical procedures that are done for patients with cerebral palsy include:

• Shunt surgery to treat hydrocephalus
• Intrathecal baclofen pump surgery for tone control
• Selective dorsal rhizotomy for global tone management 
• Deep brain stimulation for treatment of dystonia
• Ventral dorsal rhizototomy for treatment of hypertonia in terms of both spasticity and dystonia.

Selective dorsal rhizotomy, or SDR, is a neurosurgical operation that can permanently reduce muscle tone and eliminate spasticity in the lower extremities in select patients with cerebral palsy.

Ideal candidates are typically:

• Individuals who are born early.
• Have certain findings on their MRIs of the brain, such as periventricular leukomalacia, which represents a little bit of volume loss in certain areas of the brain.
• Have multi-level lower extremity spasticity, meaning spasticity or high muscle tone in multiple muscle groups in their lower extremities that's affecting their gait.
• Have underlying strength.
• Ideal candidate is someone who is between the ages of four and eight.

After a rhizotomy, we want them to be moving in a different pattern from where they were before surgery. There's a lot of post-operative therapy and rehab that goes in after selective dorsal rhizotomy, so they have to be able to cooperate with the therapies because it is a very intensive process.

Intrathecal baclofen pump is a device that delivers baclofen, which is a medication that can be used to treat spasticity into the spinal sac directly and continuously.

It is most commonly used for: 

• Patients with cerebral palsy that have hypertonia or high muscle tone in both their arms and their legs, so have some element of quadriplegic cerebral palsy.
• Usually they're not ambulatory and they can have both spasticity and dystonia.

One of the advantages is that it's a fairly straightforward procedure. Surgery itself takes about an hour to do. The pump can be turned up and it can be turned down. It can even be turned off. If the effects of the pump are not ideal, then the pump can even be removed in certain circumstances.

Selective dorsal rhizotomy and intrathecal baclofen are two tools used to effectively treat global tone.