DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY
Selective percutaneous muscle lengthening in cerebral palsy:
when there is little or no evidence
In many countries, new medications undergo rigorous test-
ing before market introduction, with clear indications and
mandates for monitoring of their long-term side effects.
There are no such protections for surgical, physical
therapy, unregulated supplements, or other interventions;
not even provisions for informing patients and families
about the experimental nature of some procedures. Occa-
sionally, animal studies and feasibility projects are per-
formed, but the norm (e.g. for surgeons) has been to come
up with an idea and ‘try it out’ on the patient.
Often, it is claimed that there is a time window for the
effectiveness of interventions, based on sound theoretical
considerations versus evidence that they alter natural his-
tory. For example, early use of umbilical stem cells, assum-
ing that there is any evidence that it alters the natural
history.1 It is also claimed that selective dorsal rhizotomy
should be performed early in the development of a child to
control spasticity, even when it cannot be clear what their
ultimate functional level is.2 Efficiency of intrathecal baclo-
fen has been demonstrated in spasticity and dystonia man-
agement, but the long-term effect of chronic exposure of
the spinal cord and brain is unclear.3 The use of cannabis
extracts to treat seizures and movement disorders is
promising, but there is little empiric evidence of short-
and long-term efficacy or complications.4
There are dozens of physical therapy approaches and
techniques which have very dedicated and convincing
adherents, yet little long-term outcome data and few
prospective randomized trials. I appreciate that many will
take umbrage that I am suggesting these are not state-of-
the-art treatments, as many dedicated providers feel that
they are doing the best for the child despite not having the
evidence.
Many surgical techniques that are currently utilized in
cerebral palsy were designed for polio and then exported
for an upper motor neuron disorder. Many of these tendon
transfers resulted in worse outcomes than doing nothing at
all and most are not reversible.
The newest trend in orthopedic surgery is the percuta-
neous lengthening of various tendons. This technique,
REFERENCES
1. Wagenaar N, Nijboer CH, van Bel F. Repair of neonatal
brain injury: bringing stem cell-based therapy into clinical
practice. Dev Med Child Neurol 2017; 59: 997–1003.
2. Grunt S, Fieggen AG, Vermeulen RJ, Becher JG, Lan-
gerak NG. Selection criteria for selective dorsal
rhizotomy in children with spastic cerebral palsy: a sys-
328
EDITORIAL
called selective percutaneous muscle lengthening (or
‘percs’), has been promoted as a better alternative to tradi-
tional open lengthening of the musculotendinous unit.
Providers of this surgery state online that patients have
better outcomes, faster recovery, little to no scarring, and
few complications. However, there is little evidence back-
ing these claims. In one of the few peer-reviewed papers, it
is claimed that over half of the patients who had percuta-
neous adductor and hamstring lengthening had an
improvement of one Gross Motor Function Classification
System (GMFCS) level and about 10 percent improved
two GMFCS levels.5 As in many of these relatively unex-
amined techniques, families are forced to make a decision
as to whether they should travel to the places which pro-
vide this treatment or trust their local surgeon who does
not perform this particular procedure.
It is easy to criticize these new techniques, to even
question the motivation behind the people who are tout-
ing them. But there is ample documentation describing
how all of us in medicine are utilizing medications, thera-
peutic techniques, and surgical procedures which do not
even have Level III evidence. Almost all the surgical tech-
niques have, at best, Level IV evidence with inherent
error and bias. We tend to do what our training suggests
works and we all have relatively short-term follow-up of
our patients.
Declining research budgets, loosening of regulatory
oversight, the rise of social media, advertising on the inter-
net, and peer pressure all contribute to the conundrum
which families face. It is our role as clinicians to stay
abreast of the current trends, to understand the science
behind the claims, to have an open but skeptical mind, and
to advocate for our patients with the best evidence avail-
able to provide sound advice and treatment.
HENRY G CHAMBERS
Associate Editor
doi: 10.1111/dmcn.13698
tematic review of the literature. Dev Med Child Neurol 4. Dan B. Cannabinoids in paediatric neurology. Dev Med
2014; 56: 302–12. Child Neurol 2015; 57: 984.
3. Albright AL, Gilmartin R, Swift D, Krach LE, Ivanhoe 5. Mitsiokapa EA, Mavrogenis AF, Skouteli H, et al. Selec-
CB, McLaughlin JF. Long-term intrathecal baclofen ther- tive percutaneous myofascial lengthening of the lower
apy for severe spasticity of cerebral origin. J Neurosurg extremities in children with spastic cerebral palsy. Clin
2003; 98: 291–5. Podiatr Med Surg 2010; 27: 335–43.
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