SURGERIES IN CEREBRAL PALSY

 NEUROSURGICAL INTERVENTIONS
 ORTHOPEDIC SURGICAL INTERVENTIONS
Neurosurgical interventions

 Selective dorsal rhizotomy

 Intrathecal baclofen pump

Both these interventions are basically aimed at managing

spasticity
SELECTIVE DORSAL RHIZOTOMY

 Also known as selective posterior rhizotomy

 It focuses on the spinal reflex arc & its modulation at

the level of anterior horn cell by supraspinal &
segmental influences

 Selective division of posterior spinal nerve rootlets is

believed to balance the decrease of normal inhibitory
influences on the motor neurons
 Patient selection is critical to a good outcome as only
2 types of patients are appropriate candidates

 1st group includes patients who are functionally

limited by spasticity but who have sufficient
underlying voluntary power to maintain & eventually
improve their functional abilities

 2nd group includes patients who are non-ambulatory

whose spasticity hinders with functions
 Typically done across L2 to S2 segments & only a
selected number of dorsal rootlets are sacrificed

 Long term sequelae that can occur after SDR are lumbar
hyperlordosis, grade 1 spondylolisthesis & scoliosis

 Functional changes after SDR are inconclusive

SELECTIVE DORSAL RHIZOTOMY
INTRATHECAL BACLOFEN PUMP
 Baclofen has been used orally in the management of
spasticity

 It involves implanting a pump into abdomen of an

older CP child & inserting a catheter directly into
intrathecal space

 Concentrations of baclofen have been found to be 10

times higher in cerebrospinal fluid with intrathecal
pump than when used orally & have gradient from
lumbar to cervical region of 4 to 1
Criteria for patient selection:
 Moderately severe spasticity children are included

 Client must have sufficient body mass to maintain pump

 Patient must be free of infection & medically stable

 Initially, a trial of baclofen is injected into intrathecal

space during hospitalization prior to implanting pump.
Done with 50, 75 0r 100 μg of baclofen
3 most common goals for using this procedure are to
 To decrease pain/improve comfort
 Prevent worsening of deformity of function
 Improve ease of care

 Amount of baclofen can be altered according to

results obtained & pump should be refilled once every
1 to 3 months

 Postoperatively PT plays a key role in assessing

equipment needs, rehabilitation service needs,
strengthening & monitoring skin integrity
INTRATHECAL BACLOFEN PUMP
Orthopedic surgical interventions

 Most procedures are best done as possible to prevent

the need to repeat surgery once the child has grown
more

 Goals of surgical intervention are to improve function,

decrease discomfort & prevent structural changes that
may become disabling

 Treating one problem without consideration of others

will result in unnecessary additional hospitalizations
for subsequent operations
Common problems that need surgery in CP

 Spine deformities
 Hip subluxation/dislocation
 Adductor tightness
 Flexor tightness
 Internal rotation deformity
 Knee flexion deformity
 Equinus deformity
 Pes valgus
 Varus deformity
SPINE
 Management of spine is done more frequently in child
with severe functional limitations, who is confined to
wheelchair

 Indications for posterior spinal fusion with a unit rod

is for a curve approaching 90 degrees when the child
is sitting

 Anterior spinal release is done in conjunction with the

posterior spinal fusion with unit rod when the curve
exceeds 100 degrees or for severe kyphosis or lordosis
Posterior spinal fusion
HIP SUBLUXATION/DISLOCATION
 Hips migrate laterally or sublux as a result of pelvic
femoral alignment changes & femoral shape changes,
lack of LE weight bearing, & muscular imbalance
across hip joint

 Hips can migrate laterally with excessive pull of

adductors & unopposed action of abductors

 If left untreated, femoral head can migrate until

dislocation
 Other causes of hip dislocation are acetabular
dysplasia & flexion/adduction contractures

 Conservative treatment options include passive

stretching of adductors, flexors & splinting of hips in
abduction

 Dislocated hips are painful, can lead to difficulty in

sitting, decubitus ulcers with asymmetrical weight
bearing & fractures
SURGERIES DONE FOR HIP
SUBLUXATION/DISLOCATION
 Soft tissue transfer and/or releases of adductors, iliopsoas
and/or proximal hamstring

 Femoral osteotomy

 Pelvic osteotomy

 Combined femoral & pelvic osteotomy with & without STR

 Resection of femoral head & neck

 Arthrodesis & arthroplasty

 Postoperative physical therapy begins with 1st or 2nd
POD in the form of
 Range of motion exercises
 weight bearing to tolerance
 strengthening of muscles around hips
 proper positioning to prevent recurrence of mal-alignment
ADDUCTOR TIGHTNESS
 Indications for management of hip adductors are
Prevention of hip subluxation, Improvement in a
scissored gait & Improved care of perineum

 When femoral head migratory percentage is 25% to

60% in hip & child is between 2 to 8 years, it is
necessary to perform lengthening

 Adductors can be lengthened in isolation or with

iliopsoas
ADDUCTOR RELEASE
 There is no period of immobilization postoperatively
& ROM exercises can be started immediately

 Physical therapy must include stretching,

strengthening of muscles around hips in order to
achieve improved muscular balance between hip
adductors & abductors & functional training &
returning to ambulation
FLEXOR TIGHTNESS
 Hip flexion contractures interfere with function in
standing position because full hip extension becomes
impossible

 Compensation occurs with excessive extension at

thoracolumbar region & knees remain flexed so that
body orientation remains vertical

 Surgical intervention involves lengthening of the

iliopsoas muscle
 Physical therapy after surgery includes prone lying to
maximize the lengthening into hip extension &
strengthening of hip extensors & abductors &
facilitation of functional skills
INTERNAL ROTATION DEFORMITY
 Femoral anteversion is a consistent deformity
associated with exaggerated internal rotation during
gait

 Anteversion interferes with functional ambulation by

tripping the child when the toe of one shoe gets
caught behind the heel of the opposite side

 Femoral derotation osteotomy, which may include

medial hamstring release is a standard surgery
 Postsurgical
management does not include any cast
immobilization & PT begins passive ROM on day 1 or 2

 Wheelchair sitting by 2nd day

 Fullweight bearing & assisted ambulation is expected by

discharge which occurs between day 4 & 7

 Rehabis aimed at improving ROM & strengthening

muscles around hips for improvement in muscle balance

 Functional training as possible

KNEE FLEXION DEFORMITY
 Often related to spastic shortened hamstrings & may
be secondary to hip flexion contracture

 Persistent flexion of knee can lead to a contracture of

the knee joint capsule & shortening of sciatic nerve

 Botulinum toxin A injection, soft knee immobilizers

& standing regime are part of conservative approach
Indications for lengthening of hamstring include

 Kyphotic sitting due to shortened hamstrings

 Fixed knee flexion contractures

 Popliteal angle > 40 to 45 degrees or SLR < 45 degrees

 Knee flexion of 20 to 30 degrees at heel strike of gait

 Knee flexion during midstance of 20 to 30 degrees

 Surgeries include medial transfer of distal rectus
femoris to sartorius or gracilis

 In extreme cases, selective neurotomies have been

performed on the hamstring branches of the sciatic
trunk

 Posterior capsulotomy is indicated when there is a

fixed knee flexion contracture with hamstring
lengthening
 Goals of distal hamstring lengthening include
 Eliminate or diminish inefficient crouched gait
pattern
 Improve stride length
 Decrease compensatory ankle equinus & hip flexion
 Minimize internal rotation in gait
 Improve sitting balance & posture
 Decrease abnormal pull that can cause hip
dislocation
 Postoperative management includes use of knee
immobilizers for 8 to 12 hours per day & at night time

 ROM & strengthening of knee extensors & flexors to

improve balance across knee joint

 As hamstring crosses both hip & knee joints, therapist

must emphasize ROM & strengthening exercises for
hip musculature

 Functional training in new ways that emphasizes knee

extension
ANKLE & FOOT
EQUINUS DEFORMITY
 It is manifested as toe walking in ambulatory child
with premature heel rise during gait

 Lengthening of gastronemius is indicated if there is DF

to neutral when knee is flexed & less than neutral when
knee is extended

 Soleus is noted to be shortened as well when there is >

-10 degree DF when knee is flexed
 Achilles tendon lengthening (both gastrocnemius &
soleus) is most common surgical intervention

 Overlengthening is most common complication of

surgery & results in calcaneal gait or an increase in
DF during stance & gait is crouched in nature with
subsequent shortening of muscles in hips & knees
PES VALGUS
 It is a deformity which includes eversion, PF &
inclination of the calcaneus with abduction of forefoot

 These positions cause medial prominence of talus,

which is accompanied by callous formation on the
skin

 Usually corrected by reducing subtalar joint with

forefoot to neutral position with ankle PF
3 situations contribute to pes valgus

 Spastic peroneal muscles that change the axis of

rotation of the subtalar joint to a more horizontal
alignment & abduct the midfoot & forefoot

 Gastrocnemius/soleus contracture causing PF of the

calcaneus

 Persistent fetal medial deviation of the neck of talus

 Conservative measures include stretching &
strengthening foot & ankle & positioning in a splint
for partial-day or night time use

 Surgeries include extra-articular subtalar arthrodesis,

triple arthrodesis for rigid deformities & Grice-Schede
procedure

 Postoperative immobilization with a short leg cast

should last about 4 weeks with weight bearing to
tolerance
 Orthosis will be sometimes be used depending on the
results of surgery & whether joints require further
stability
VARUS DEFORMITY
 Less common

 Seen mostly in hemiplegics & diplegics

 Results from weak peroneals & spastic TA & TP

 Indication for surgery is a foot that is varus in stance

phase or swing phase of gait

 Surgeries include lengthening or splitting & transferring

either TA or TP muscles
 Post op PT should include muscle re-education for
muscle transfer, ROM exercises, strengthening &
facilitation of functional activities in standing & gait
EVIDENCES
Title: Recovery of muscle strength following multilevel
orthopaedic surgery in diplegic cerebral palsy

Type of study Prospective RCT

Year of publication 2006
Level of evidence 1b
Authors Seniorou et al
Citation Gait & posture, 2007, vol.26(4): 475-481
Aim To quantify lower limb muscle strength changes in children with spastic diplegia
after multi-level surgery & to compare efficacy of progressive resistance
strengthening versus active exercise
Method 21 children with spastic diplegia participated in the study. All of them underwent
multi-level surgery. At 6 months post-op they were randomly assigned to resistance
training or active exercise group for 6 weeks. Gait, motor function & isometric
strength
Results Resistance training showed some improvement over active exercise group

conclusion Study demonstrated significant improvement in muscle strength, gait & motor
function
 PICO
P: post surgery spastic cerebral palsy children

I: resistance training for lower limbs

C: controls with active exercise

O: muscle strength, gait & motor function

Title: combined effect of lower limb multilevel
botulinum toxin type A & comprehensive
rehabilitation on mobility in children with cerebral
palsy: a randomized clinical trial
Type of study RCT
Year of 2006
publication
Level of 1b
evidence
Authors Scholtes A Vanessa et al
Citation Arch Phys Rehabil
Aim To evaluate combined effect of lower limb multilevel botulinum toxin type A &
comprehensive rehabilitation on mobility in children with cerebral palsy

Method 46 children with spastic CP, experimental group: BTX-A plus rehab, control group:
only rehab for 18 to 30 weeks & then also received multi-level BTX-A & rehab.
GMFM-66 & problem score & energy cost were outcome measures

Results Treatment effect during the 1st 24 weeks of follow up in intervention group was
compared with effect of usual PT in control group
conclusion Treatment with BTX-A & rehab significantly improves mobility as measured by
GMFM & problem score in children with CP
PICO
P: Spastic CP Children

I: BTX-A & rehabilitation

C: controls with only physiotherapy

O: GMFM, problem score