SURGERY FOR CHILDREN WITH CEREBRAL PALSY - WHEN AND HOW IT HELPS
Motor Problems with Cerebral Palsy
How Can Cerebral Palsy Surgery Help
Cerebral palsy is the most common motor disability seen in children. In the US, it affects around 1 in every 345 children as per reports by the CDC. Globally, the incidence ranges from 1.5 to as high as 4 per 1000 live births. In Germany, it is estimated that out of around 700,000 children born every year, 1400 of them have infantile cerebral palsy/spasticity i.e., an incidence of 1 in every 500 children.
Children with cerebral palsy have to deal with a variety of problems. Muscle spasticity, imbalance, gait problems, uncontrollable movements, and musculoskeletal pain can all be associated with cerebral palsy.
Surgery for cerebral palsy can often improve the quality of life of cerebral palsy patients. Orthopedic cerebral palsy surgery deals with tendons, joints, muscles, and bones. The goal is to improve posture, movement, pain, mobility, and comfort in a child with cerebral palsy.
Surgical treatment for cerebral palsy is usually indicated when medications and physical therapy fail to provide satisfactory results.
Keep reading to learn more about the orthopedic surgical options for cerebral palsy patients, the types of procedures, and the benefits they provide.
Motor Problems with Cerebral Palsy
The symptoms and disabilities caused by cerebral palsy vary widely from one child to another. The severity of symptoms and the limbs and body parts affected depend on the diseased region of the brain.
All children with cerebral palsy share specific symptoms in varying degrees:
- Spasticity: Having stiff muscles is a common feature of cerebral palsy in children. When the muscles are constantly contracted and stiff, movement can be limited. Long-term muscle spasticity can lead to deformities and developmental problems in the affected limbs and joints. cerebral palsy surgery aims to counteract this spasticity to improve movement and prevent long-term deformity.
- Dyskinesia: Inappropriate and uncontrolled muscle movements are another feature commonly observed with cerebral palsy. Involuntary tics, awkward muscle spasms, and uncontrollable muscle contraction can prevent a child from properly walking, talking, sitting, and performing fine motor tasks.
- Ataxia: Gait (walking) problems and imbalance are also commonly observed in cerebral palsy.
- Mixed: Children sometimes exhibit signs and symptoms of more than one form of Cerebral Palsy which is referred to as Mixed Cerebral Palsy.
In general, there are several broad types of cerebral palsy, classified based on the dominant symptom - Spastic Cerebral Palsy, Dyskinetic Cerebral Palsy, Ataxic Cerebral Palsy, and Mixed Cerebral Palsy.
How Can Cerebral Palsy Surgery Help?
Surgery can be an effective treatment option for cerebral palsy, especially if spasticity is involved.
There are several goals and benefits for cerebral palsy surgery:
- Improve mobility in ambulatory children (those who can already walk, with or without assistance)
- Improve posture
- Reduce pain associated with muscle spasticity
- Correcting uneven limb length
- Improving coordination and ability to perform fine movements
- Correcting spine problems (e.g., scoliosis)
- Lengthening short muscles and tendons
- Preventing developmental bone and joint deformities
- Preventing hip dislocation
- Re-aligning bones, tendons, and muscles
- Improve the quality of life of the child, helping them gain more autonomy, and bringing them a step closer to leading a less-limited lifestyle.
The success of cerebral palsy surgery and the improvements it provides depend on the type of surgery performed, the severity and type of cerebral palsy, the age of the child, and the expertise of the care team.
Types of Orthopedic Surgeries for Cerebral Palsy
Orthopedic surgery deals with bones, muscles, and tendons to improve cerebral palsy symptoms, prevent deformity, and improve mobility.
There’s a variety of orthopedic procedures performed to treat cerebral palsy symptoms. The choice of procedure(s) depends on the symptoms, limb affected, present deformities, and goal of surgery. In general, cerebral palsy orthopedic surgery includes:
Muscle Lengthening
Spastic muscles can be shorter in length compared to relaxed muscles. This can cause walking imbalance, movement limitations, posture problems, and unequal limb length.
Muscle lengthening for cerebral palsy is, as the name implies, surgery to make muscles longer. Muscles are made of millions of fibers. When some of these are cut and released, the muscle becomes longer and more relaxed.
Surgery to release spastic muscles can help a child with cerebral palsy, for example, walk better and grab objects more effectively.
Tendon Lengthening
Tendons are the fibrous bands that connect our muscles to the bones and joints. The muscles pull the tendons to move your arm, leg, fingers, etc.
Lengthening tendons of spastic muscles can reduce tension on the affected joints and improve mobility in cerebral palsy. It can also reduce pain from constant contracture and prevent long-term deformity of the joints and bones due to abnormal tension.
Tendon Transfer
If a muscle imbalance leads to a deformity (e.g. in neurgenic clubfoot), an even muscle tension can be restored by a tendon transfer to correct the deformity.
Tenotomy or Myotomy
Tenotomy and myotomy for cerebral palsy mean severing the tendon and muscle respectively. If the tendons or muscles cannot be lengthened, then cutting them completely can sometimes help.
It can release the tension, allowing for opposing movements to be better performed. This is more plausible around joints with multiple muscles and tendons pulling at them (e.g., wrist joint).
Osteotomy
Osteotomy in cerebral palsy is commonly used to treat hip dislocation. Osteotomy means cutting and removing a piece of bone. This allows better re-alignment and joint function in some cases.
Patients with cerebral palsy often have hip dislocation due to abnormal contractures affecting the hip joint. Proximal femoral osteotomy (PFO) is one of the most commonly performed procedures to fix hip problems associated with cerebral palsy. It is often combined with an osteotomy of the pelvis and an open reduction of the hip joint.
Osteotomy of the thigh and lower leg can improve the alignment of the legs so that the children can walk better and more easily.
Arthrodesis
Arthrodesis is another surgical option for cerebral palsy patients. It involves fusing two bones together to stabilize a specific joint.
It can reduce pain and improve walking ability in some children (e.g., fusing the subtalar joint).
When Should Surgery for Cerebral Palsy Be Done?
Orthopedic surgery for cerebral palsy is preferentially done at a younger age. By improving mobility and reducing excessive tension on joints and bones, surgery can prevent long-term complications and developmental problems.
Therefore, when indicated, surgery for cerebral palsy should never be delayed. It can be critical for the motor, sensory, and mental development of a child.
Dr. med. Michael Wachowsky is the Head of the Department of Pediatric, Adolescent, and Neuro Orthopedics at Sana Hospital, Rummelsberg - one of the oldest and most traditional departments in Germany. Under his guidance, a comprehensive range of therapy and treatment is on offer at the hospital: Conservative and surgical treatment of children, adolescents and adults with neurological disorders (e.g. cerebral palsy, spina bifida). A gait laboratory is available for the diagnosis and therapy of gait disorders, including botulinum toxin therapy, interdisciplinary center for the treatment of people with multiple disabilities, CT-guided thermocoagulation of osteoid osteoma, in-house orthopedic and shoe technology. In the course of his medical career, Dr. Wachowsky has gained decades of experience in pediatric orthopedics and is considered a renowned specialist in Germany in the treatment of children and adolescents with congenital or acquired diseases of the musculoskeletal system, as well as people of all ages with orthopedic problems related to nerve and muscle disorders.
Sources:
- https://www.cdc.gov/ncbddd/cp/facts.html
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5439309/
- https://books.google.de/books?hl=en&lr=&id=kbffCgAAQBAJ&oi=fnd&pg=PR5&ots=WZoI-IH5SM&sig=ezhyC9wYh-VW0_WJx15V3IFJN3E&redir_esc=y#v=onepage&q&f=false
- https://pubmed.ncbi.nlm.nih.gov/17370477/
- https://www.cdc.gov/ncbddd/cp/data.html
- https://www.birthinjuryhelpcenter.org/cerebral-palsy-statistics.html
- https://kinderneurochirurgie.charite.de/en/patients/conditions/spasticity/
- https://www.sana.de/rummelsberg/medizin-pflege/kinder-jugend-und-neuroorthopaedie
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