Surgical Treatment

In the case of cerebral palsy, surgery may be performed for a number of reasons. Physical deformities, such as the hand in thumb deformity, may be correctable with the appropriate surgery. Motor coordination and range of movement may be facilitated by surgeries on bones, soft tissue and tendons. In addition, neurosurgery (surgery on the brain) may be performed to reduce spasticity, a common symptom of cerebral palsy. When successful, such surgeries can improve the cerebral palsied patient’s motor functioning, and in this way, improve their quality of life.

1. Kinematic and kinetic outcomes after identical multilevel soft tissue surgery in children with cerebral palsy

This study evaluates the outcomes of multilevel soft tissue surgery in 31 ambulatory children (n = 39 sides) with cerebral palsy. All children had undergone rectus femoris transfer, hamstring lengthening, and gastrosoleus lengthening for the purpose of correcting sagittal plane abnormalities. There were no simultaneous bony surgeries. Preoperative and postoperative evaluation consisted of clinical assessment and gait analysis, including 3-dimensional kinematics and kinetics. Results demonstrated improvements in knee and ankle function. At the knee, there was a decrease in mean flexion at initial contact (from 31 degrees [SD, +/-8 degrees] to 21 degrees [SD, +/-10 degrees]) and in stance (mean stance, 22 degrees [SD, +/-12 degrees] to 16 degrees [SD, +/-11 degrees]) associated with a decreased mean internal extensor moment in stance (from 0.09 Nm/kg [SD, +/-0.24 Nm/kg] to -0.03 [SD, +/-0.22 Nm/kg]). At the same time, knee flexion was preserved in swing and occurred earlier. At the ankle, mean dorsiflexion improved at the time of examination (from 8 degrees [SD, +/-9 degrees] to 14 degrees [SD, +/-11 degrees] with the knee in extension), in terminal stance (peak from 7 degrees [SD, +/-9 degrees] to 12 degrees [SD, +/-8 degrees]), and in swing. Peak ankle power generation in stance was preserved and shifted later in stance toward push-off, with no functional weakening of the ankle plantar flexors. A longer-term assessment of a subset of patients with a second postoperative gait analysis at a mean of 4 years after surgery showed that gains measured at 1 year were maintained during the longer term. A subgroup demonstrating a jump knee gait pattern (as defined by excessive knee flexion at initial contact followed by rapid knee extension to full knee extension in midstance) had a tendency to go into knee hyperextension in stance with resultant net knee flexor moment after surgery. This raises concern about the indications for hamstring lengthening in this patient group.

[Adolfsen, S. E. Ounpuu, S., Bell, K. J. & DeLuca, P. A. (2007). Kinematic and kinetic outcomes after identical multilevel soft tissue surgery in children with cerebral palsy. Journal of Pediatric Orthopedics, 27(6), 658-67.]

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2. Functional neurosurgery of cerebral palsy

In 1983, approximately 40 000 patients in France and 5 760 patients in Switzerland suffered from cerebral palsy, representing more than 0.1% of their respective populations. The functional disability of these patients is particularly impressive and emphasizes the medical, social and economic importance of this problem. The term cerebral palsy is restricted to non-progressive disorders of motor function, already observed at an early age and due to cerebral lesions. These motor disorders can be of paretic, dystonic and dyskinetic nature. Their epidemiology, classification, etiology, pathology, early diagnosis and evolution are extensively reviewed by Th. Deonna. The difficulty in evaluation of treatment is the absence of a generally accepted rating scale. G. Broggi has proposed one on the basis of a large experience which could serve in the future for more objective evaluation. This monograph is devoted to the functional neurosurgical treatment of cerebral palsy. Physiotherapy and rehabilitation are part of the basic treatment of cerebral palsy, and must be continued after any neurosurgical treatment. Various conservative methods of treatment and their neurophysiological rationale are mentioned by P. Claverie. Some technical devices which improve the neurological deficits and facilitate rehabilitation are presented. Radiculotomies and neurotomies are probably the oldest neurosurgical operations for the treatment of spasticity. The neurophysiological and neuroanatomical basis of this therapeutic approach are treated in the review of the material from the neurosurgical department of Montpellier. Sixty cases were collected and the results analysed according to the type of operation (posterior radiculotomy, anterior radiculotomy, mixed) performed. Stereotactic thalamotomies and subthalamotomies are believed to be the best neurosurgical method to treat the tremor and improve other dyskinesias and hyperkinesias. The technique and a personal review of 49 cases of cerebral palsy are presented. The long-term follow-up in this study demonstrates that this type of operation markedly improves the functional disability of patients with moderate hyperkinesias, moderately improves patients severely affected, but also demonstrates that possible side effects cannot be ignored. Review of the literature indicates the difficulty in interpretation of results due to a lack of objective evaluation. Nevertheless, stereotactic thalamotomy can still be recommended when tremor and rigidity are the most prominent symptoms. Stereotactic dentatotomies in the treatment of spasticity were very popular 20 years ago, but have been largely forgotten for nearly a decade.(ABSTRACT TRUNCATED AT 400 WORDS)

[Siegfried, J., Lazorthes, Y., Broggi, G., Claverie, P., Deonna, T., Frerebeau, P., Verdie, J. C., Alexandre, F., Angelini, L., Benezech, J., et al. (1985). Functional neurosurgery of cerebral palsy [French]. Neuro-Chirurgie, 31(Suppl. 1), 1-118.]

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3. Deformity of lumbar spine after selective dorsal rhizotomy for spastic cerebral palsy

To observe the effect of selective dorsal rhizotomy (SDR) on the deformity of the lumbar spine, a retrospective review was conducted from October 1992 to December 2002 on children who had undergone SDR in our department, and in whom preoperative and postoperative spine radiographs had been obtained. The angles of hyperlordolysis were measured. The study group comprised 219 patients, in which 61 cases were followed up and examined between May 2004 and February 2005. The mean age at surgery was 6.9 years (range 3-20 years), with a mean time to recent follow-up radiographs of 6.3 years (5-9 years). A total 219 children underwent laminectomy from L(2)-S(1). Scoliosis existed in one case, and two cases of L(5) spondylolysis were detected before surgery. One case presented lumbar hyperlordosis. After SDR, 10 cases showed distinctively abnormal walking posture of hyperlordolysis. Compared with the preoperative angle of hyperlordolysis, the angle was improved after the operation. Among them, four patients developed spondylolysis and spondylolisthesis (grade I). We also observed that one case developed lumbar kyphosis deformity. In conclusion, cerebral palsy patients may develop spinal deformity. Some cases showed distinctively abnormal walking posture of hyperlordolysis, and they developed spondylolysis and spondylolisthesis after surgery.

[Li, Z., Zhu, J. & Liu, X. (2008). Deformity of lumbar spine after selective dorsal rhizotomy for spastic cerebral palsy. Microsurgery, 28(1), 10-12.]

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4. Femoral head resection as a salvage procedure for the severely dysplastic hip in nonambulatory children with cerebral palsy

BACKGROUND: Proximal femoral head resection (FHR) has been used as a treatment option in patients with cerebral palsy (CP) who suffer from pain, contractures, and impaired personal hygiene. We analyzed the overall functional outcome following this surgery and associated patient satisfaction.

METHODS: This study was a retrospective case series with a follow-on questionnaire. A consecutive sample of 27 patients with CP who underwent proximal FHR between 1988 and 2004 were analyzed. Medical and radiographic records were used alongside a patient satisfaction questionnaire. Average follow-up time was 7.8 years (range, 2.3-16.5 years).

RESULTS: We found an improvement in hip pain, range of motion, activities of daily living, and quality of life after surgery. Age at surgery, type of immobilization, and presence of heterotopic ossification or femoral migration did not affect the long-term surgical outcome.

CONCLUSION: This study confirms the efficacy of proximal FHR for the treatment of chronic severe neuromuscular hip dysplasia in children with CP.

LEVEL OF EVIDENCE: Level IV.

[Muthusamy, K., Chu, H. Y., Friesen, R. M., Chou, P. C., Eilert, R. E. & Chang, F. M. (2008). Femoral head resection as a salvage procedure for the severely dysplastic hip in nonambulatory children with cerebral palsy. Journal of Pediatric Orthopedics, 28(8), 884-9.]

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5. The outcome of surgical intervention for early deformity in young ambulant children with bilateral spastic cerebral palsy

We reviewed the outcome in 24 children with bilateral spastic cerebral palsy aged seven years or younger for whom surgery was recommended between 1999 and 2005 following gait analysis. A total of 13 children (operative group) had surgery and the remaining 11 (control group) did not, for family or administrative reasons. The operative group had at least two post-operative gait analyses at yearly intervals, with eight children having a third and six children a fourth. The control group had a second analysis after a mean interval of 1.5 years (95% confidence interval 1.1 to 1.9). In the operative group, the Gillette gait index, the ranges of movement in the lower limb joint and knee extension in stance improved following surgery, and this was maintained overall at the second post-operative analysis. The minimum knee flexion in stance in the control group increased between analyses. These results suggest that surgical intervention in selected children can result in improvements in gait and function in the short to medium term compared with non-operative management.

[Gough, M., Schneider, P. & Shortland, A. P. (2008). The outcome of surgical intervention for early deformity in young ambulant children with bilateral spastic cerebral palsy. The Journal of Bone and Joint Surgery. British Volume, 90(7), 946-51.]

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6. Short-term outcome of multilevel surgical intervention in spastic diplegic cerebral palsy compared with the natural history

Outcome in 24 ambulant children with spastic diplegic cerebral palsy, in whom multilevel surgical intervention was recommended following gait analysis, is reviewed. Twelve children had surgical intervention (treatment group; eight males, four females; mean age 9 years 10 months, SD 3 years 4 months) while the other 12 did not (control group; five males, seven females; mean age 10 years 1 month, SD 2 years 11 months). All children had interval three-dimensional gait analyses (mean time between analyses: control group, 14.1 months; treatment group, 17.9 months). At follow-up the control group (mean age 11 years 9 months) showed a significant increase in minimum hip and knee flexion in stance which was not related to age, the interval between analyses, changes in the passive joint range of motion, nor changes in anthropometric measurements. The treatment group (mean age at follow-up 11 years 3 months) showed a significant improvement in minimum knee flexion and in ankle dorsiflexion in stance. Parents of nine children said their child's walking distance had increased following intervention. Of five children using posterior walkers preoperatively, two continued to use them postoperatively; two were using crutches or sticks and the remaining child walked independently. Two children who walked independently preoperatively used sticks postoperatively for community ambulation. The deterioration seen in the kinematics of the control group suggests that previous outcome studies comparing postoperative gait with preoperative gait have underestimated the immediate effects of surgery. It also raises concerns about the long-term effects of surgical intervention.

[Gough, M., Eve, L. C., Robinson, R. O. & Shortland, A. P. (2004). Short-term outcome of multilevel surgical intervention in spastic diplegic cerebral palsy compared with the natural history. Developmental Medicine and Child Neurology, 46(2), 91-7.]

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7. Surgical management of the lower extremity in ambulatory children with cerebral palsy

Despite the increasing popularity of nonorthopaedic treatment alternatives for children with cerebral palsy, bony and soft-tissue surgery remains a common component in the management of ambulatory patients. Multisite simultaneous tendon surgery provides improvement in gait by addressing hip, knee, and ankle contractures together. Careful preoperative physical examination is required; computerized gait analysis can be useful in confirming a plan for multiple tendon surgeries. Rotational osteotomies can improve transverse-plane malalignment. Shorter periods of immobilization and aggressive postoperative gait training and strengthening may optimize improvements in gait.

[Karol, L. A. (2004). Surgical management of the lower extremity in ambulatory children with cerebral palsy. The Journal of the American Academy of Orthopaedic Surgeons, 12(3), 196-203.]

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8. Is surgery of the hip adductor muscles justified in children with cerebral palsy

INTRODUCTION: Restricted passive hip abduction in children with cerebral palsy (CP) may be caused by uninhibited resting contractions and/or retractions, i.e., shortened muscle body or tendons. Pathological short tendons require surgical intervention, but lack of muscle body elasticity responds to physiotherapy or a postural splinting. Clinical examination can distinguish between short tendons and short muscle body. The thigh is slowly and passively extended while palpating the tendon. Tension is detected in the tendon when the leg is at angle Ao. The elastic tension of the muscle body then increases until no further movement is possible, at angle Amax. The difference Amax-Ao is an index of the structural length of the muscle body. If this difference is reduced during passive straightening there is shortening of the muscle body; if it is displaced it indicates shortening of the tendon. The value Ao indicates the muscular or tendon origin of the retraction for a given passive limitation (Amax). This study defines the physiological values of Ao and the relative precisions of chemical and instrumental measurements.

MATERIALS AND METHODS: A total of 30 children aged 9-11 years, 10 CP patients (7 girls and 3 boys, mean age 10.3 years) and 20 controls (11 girls and 9 boys, mean age 10.5 years) were studied. All the CP children had lower limb spasticity and adopted an adduction posture. None had undergone hip muscle surgery. Ao and Amax were measured clinically with a goniometer and EMG to monitor muscle silence, and experimentally using a deformable parallelogram and force transducers.

RESULTS: The minimum physiological value of Ao was 8 degrees with the knee flexed and 0 degree with the knee extended. Smaller values of this angle indicated tendon retraction. The difference between Ao and Amax in the controls and CP children was < or = 10 degrees; the reproducibilities of the clinical measurement of Ao and Amax were very similar.

DISCUSSION: Clinical examination provides an acceptably accurate method of distinguishing between tendon and muscle body retraction of adductor muscles in CP children. The conditions required for successful measurement are: careful examination with strict positional reference and sufficiently relaxed pelvic muscles. A hip extension angle Ao of less than 8 degrees with the knee flexed or 0 degree with the knee straight indicates tendon retraction requiring tendon surgery, otherwise, the retraction involves only the muscle body. This reduced elasticity can be overcome by prolonged extension (at least 6 hours/24). Effective muscle extension may be hindered by non-suppressed adductor contractions. This must be overcome prior to physiotherapy by surgery of the ramus ant. n. obturatorii.

CONCLUSION: Clinical measurement of Ao of adductor muscles is a reliable way of distinguishing between tendon retractions requiring surgery and muscle body retractions resulting from staying too long in a position with the muscle shortened. This muscle body shortening can be due to lack of physiotherapy or a stretching apparatus treatment, pathological contractions, or compensation for disorders of the controlateral limb.

[Renaudin, E., Khouri, N., Robert, M. & Lespargot, A. (1994). Is surgery of the hip adductor muscles justified in children with cerebral palsy [French]? Revue de Chirurgie Orthopedique et Reparatrice de l’Appareil Moteur, 80(2), 108-12.]

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9. Soft tissue surgery for equinus deformity in spastic hemiplegic cerebral palsy: Effects on kinematic and kinetic parameters

The purpose of this study was to evaluate how soft tissue surgery for correcting equinus deformity affects the kinematic and kinetic parameters of the ankle and proximal joints. Sixteen children with spastic hemiplegic cerebral palsy and equinus deformities (age range 3-16 years) were included. Soft tissue surgeries were performed exclusively on the ankle joint area in all subjects. Using computerized gait analysis (Vicon 370 Motion Analysis System), the kinematic and kinetic parameters during barefoot ambulation were collected preoperatively and postoperatively. In all 16 children, the abnormally increased ankle plantar flexion and pelvis anterior tilting on the sagittal plane were significantly improved without a weakening of push-off (p < 0.05). In a group of 8 subjects with a recurvatum knee gait pattern before operation, the postoperative kinematic and kinetic parameters of the knee joint were significantly improved (p < 0.05). In a group of 8 subjects with ipsilateral pelvic external rotation before operation, the postoperative pelvic deviations on the transverse plane were significantly decreased (p < 0.05). These findings suggest that the soft tissue surgery for correcting equinus deformity improves not only the abnormal gait pattern of the ankle, but also that of the knee and pelvis.

[Park, C. I., Park, E. S., Kim, H. W. & Rha, D. W. (2006). Soft tissue surgery for equinus deformity in spastic hemiplegic cerebral palsy: Effects on kinematic and kinetic parameters. Yonsei Medical Journal , 47(5), 657-66.]

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10. Pre- and postsurgical evaluation of hand function in hemiplegic cerebral palsy: Exemplar cases

Evaluation of hand function for treatment planning and outcome documentation in individuals with cerebral palsy (CP) proves challenging. Because of the complexity of multisystem involvement and time constraints during physician clinic visits, we developed a comprehensive evaluation protocol to assist with team surgical decision making in CP. We report findings from three adolescents with hemiplegic CP who were evaluated pre-/post-intervention using measures of impairment (clinical examination procedures), activity (Pediatric Evaluation of Disability Inventory and Jebsen-Taylor Test of Hand Function), and participation (goal attainment scaling). An intervention to improve hand function consisted of single-event multilevel orthopedic surgery and postsurgical therapy. Wrist/finger biomechanics and active range of motion improved after the intervention. The targeted surgical intervention and undefined therapy intervention, however, seemed to have little influence on activity and participation. The descriptive results of these exemplar cases suggest that, instead of assisting only with surgical decision making, the evaluation protocol should focus on specific postsurgical therapy plans in addition to surgical/therapy decision making.

[Wesdock, K. A., Kott, K. & Sharps, C. (2008). Pre- and postsurgical evaluation of hand function in hemiplegic cerebral palsy: Exemplar cases. Journal of Hand Therapy, 21(4), 386-97.]

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11. Surgical management of wrist and finger deformity

The surgical results of upper extremity intervention have been shown to improve hand function from paperweight/passive assist function to active assist function. Although children with cerebral palsy commonly have a sensibility deficiency in conjunction with their motor deficiency, several recent studies have disproved the previous doctrine that hand surgery should not be performed on children with sensibility deficiencies. The author's report of 134 children treated surgically showed that preoperatively 50% had impaired two-point discrimination and 75% had impaired stereognosis: impaired sensibility had no adverse effect on surgical results. Eliasson et al reported on 32 children treated surgically with tendon transfers and muscle releases. Impaired sensibility before the surgery did not influence the outcome. In fact, Dahlin et al reported 36 patients treated operatively and followed for 18 months, finding an improvement in stereognosis function associated with the improvement in their motor function, presumably because of improved functional use. Children with cerebral palsy can improve their motor function and perhaps also their sensibility function with appropriately planned and executed tendon release and transfer surgery. Balance of the wrist and fingers is the key clement in improvement of upper limb function.

[Van Heest, A. E. (2003). Surgical management of wrist and finger deformity. Hand Clinics, 19(4), 657-65.]

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12. Surgery for cerebral palsy: Part 1. Classification and operative procedures for pronation deformity

32 patients with cerebral palsy underwent operations for pronation deformity. The deformity is classified into four groups. Patients in group 1 are capable of supination beyond neutral. No surgery is necessary. Those in group 2 are able to supinate to the neutral position. A pronator quadratus release is advised and may be combined with a flexor aponeurotic release. In group 3, patients have no active supination. However a full range of passive supination is readily achieved. A pronator teres transfer is advised. Patients in group 4 have no active supination. Full passive supination may be present, but is tight. A flexor aponeurotic release and a pronator quadratus release may unmask active supinator activity. An active transfer for supination is possible as a secondary procedure.

[Gschwind, C. & Tonkin, M. (1992). Surgery for cerebral palsy: Part 1. Classification and operative procedures for pronation deformity. Journal of Hand Surgery [British], 17(4), 391-5.]

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13. Effectiveness of selective dorsal rhizotomy in 2 patients with progressive spasticity due to neurodegenerative disease

Selective dorsal rhizotomy at the lumbar level is a neurosurgical procedure, which reduces spasticity in the legs. Its effect has mainly been studied in children with spastic cerebral palsy. Little is known about the outcome of selective dorsal rhizotomy in patients with neurodegenerative disorders. We report the clinical course after selective dorsal rhizotomy in 2 patients with progressive spasticity. Leg spasticity was effectively and persistently reduced in both patients, facilitating care and improving sitting comfort. However, spasticity of the arms and other motor disturbances, such as spontaneous extension spasms and the ataxia, increased gradually in time. Selective dorsal rhizotomy leads to a disappearance of leg spasticity in patients with a neurodegenerative disease. Other motor signs are not influenced and may increase due to the progressive nature of the underlying disease.

[Grunt, S., van der Knaap, M. S., van Ouwerkerk, W. J., Strijers, R. L., Becher, J. G. & Vermeulen, R. J. (2008). Effectiveness of selective dorsal rhizotomy in 2 patients with progressive spasticity due to neurodegenerative disease. Journal of Child Neurology, 23(7), 818-22.]

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14. Thumb deformity in the spastic hand: Classification and surgical techniques

Surgery based on an accurate determination of deforming forces, muscle weakness, and joint instability achieves reasonably predictable results in patients with cerebral palsy. Thumb deformities can be classified into those of mainly intrinsic nature, extrinsic nature, and those of a combined nature. This allows identification of which muscles are released most appropriately and which muscle function requires augmentation. Joint instability needs to be taken into consideration because tendon transfers across unstable joints will be ineffective. The various surgical procedures are outlined in the text. In 32 patients, application of these principles and techniques allowed removal of the thumb from the palm in 29 patients during fist formation. Lateral pinch was established in 26 thumbs, and functional assessment revealed improvement in one functional grade. Functional benefit may be determined by other factors beyond the control of the surgeon. Therefore, the decision to proceed to surgery may be undertaken only after detailed and repeated clinical examinations are conducted that are coordinated with the assessments of parents, caregivers, physicians, occupational and physical therapists, and social counselors.

[Tonkin, M. A. (2003). Thumb deformity in the spastic hand: Classification and surgical techniques. Techniques in Hand & Upper Extremity Surgery, 7(1), 18-25.]

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Cerebral Palsy Treatment