Cerebral Palsy 2nd National Workshop 2011 Karachi Pakistan

CEREBRAL PALSY

RECONSTRUCTIVE LIMB SURGERY

“Goals, Role and Timing”

ANISUDDIN BHATTI

at

2nd National Workshop

19th March 2011

“Decision Making Process”

RECONSTRUCTIVE LIMB SURGERY

CEREBRAL PALSY

Objectives

Background Why I Choose this topic

Role What & Why?

Timing When & When Not to Do.

Preparations How

Rehabilitation & Few other aspects

CP RECONSTRUCTIVE SURGERY

Orthopaedic surgery have the permanent and important role in management of CP child.

Factors: Decision making process for surgery:

1. Age Grouping.

2. Clinical pattern.

3. Prognosis of Walking: (Ability to walk independently) .

4. Structural changes.

5. Cosmetic improvement in gait.


Decision Making Process

1. AGE GROUPING for surgical corrections:

i. Pre-school age

ii. School age

iii. Adolescent and adults

CP RECONSTRUCTIVE SURGERY Decision Making Process

2. CLINICAL PATTERN: • Hemiplegia / Monoplegia • Diplegia / Paraplegia • Total Body Involvement Athetoid Ataxic Spastic: most common & Maneable Dynamic Static

3. PROGNOSIS OF WALKING


3. PROGNOSIS OF WALKING- Sitting:

Ability to sit is the major indicator for the ability to walk independently.

• Under age 2 years, the ability to sit independently

is not a good predictor of walking

But

• After age 4 years, Inability to sit do predict non-ambulation

(Molnar-Gordon)


3. PROGNOSIS OF WALKING- Other Indicators:

• All Hemiplegics walks between 18-21 months. • Most Spastic Diplegics walks by 48 months. • Quadriplegic children (with TBI) have poorest

prognosis.

“Ambulatory ability reaches a plateau by the age 7 years”

(Accuracy for walking prediction 94.5%)


3. PROGNOSIS OF WALKING

Criteria to Qualify as a Walker: Assessment to Qualify as walker should be made after the age 7 years

• Walker: when child could walk a minimum of 15 meters without falling

• Functional Walker: when a child could walk only with crutches.

• Non-Walker: when child could walk with aid of mobility device or only in parallel bars


3. PROGNOSIS OF WALKING: Why to Predict ?

“Ability to make a reasonably accurate PREDICTION about walking allows the Orthopaedist to DELAY SURGERY,

merely to force the child to walk and reduces role of surgery in non-ambulatory patient

& preventing serious structural changes in the hips.”


• 3. PROGNOSIS OF WALKING:

“Prognostic testing for walking also benefits the various THERAPY & PROGRAMMES because it permits JUDGMENT to be made on efficiency of various treatment programmes that use ability to walk a criteria of success.

Good Results can be obtained in 75-95% Patients”

CP RECONSTRUCTIVE SURGERY 3. PROGNOSTIC INDICATORS: Beals Motor Quotient

Motor performance of spastic Diplegic children.

• From birth to about 3 years , the functions that were thought to be absent before this age may develop spontaneously with neuronal maturation.

• Motor gains reaches plateau or cease between 6-7 years.

• No change in motor performance, after age 7 years.

Motor performance of spastic Diplegic children


3.PROGNOSTIC INDICATORS: PREDICTION OF WALKING

Beals Severity Index & Goal to Achieve free Ambulation:

Severity Index (SI) shows Motor Age in Months at 3 yrs. The prediction for walking can be determined on SI as follows:

SI Ability to walk Surgery (Motor Age in months) Goal to achieve free ambulation

12-18 Free walking by age 7 yrs Surgery only to improve walking.

10-11 Lowest score consistent with Surgery may be performed

free walking is reasonably good to reach Goal.

9 Crutch walking No Surgery.

9-0 No walking No surgery.



4. STRUCTURAL CHANGES:




On long term followup progression of structural changes in joint are well evident despite

assiduous therapy and bracing. That may be a: 1. Painful degenerative arthritis as a result of hip

subluxation, that too jeopardize Spastic walking after 18 years.

2. A dislocated hip that become painful at late adolescent.




Orthopaedic surgery in late adolescent is more difficult, has more complication and causes on increased incidence of post operative psychological problems.

Therefore:

Orthopaedic surgery to prevent and

correct structural change ought to be performed before age of 15 (13) years.



1. AGE GROUPING

for surgical corrections:

i. Pre-school age (< 5 years)

ii. School age (> 5 – 12 years)

iii. Adolescent and adults (> 13 Years & Above)

C P IN PRESCHOOL CHILD

PRE SCHOOL CHILD Delay the Surgery, till ?

• Better to defer surgery for functional and cosmetic improvement of gait until the child has learned to walk

and

• Walked independently for a year, at least

PRE SCHOOL CHILD Delay the Surgery, till ?

Because: A. If a child has a good prognosis of walking – surgery will

not hasten the development of ambulation. Infact: Surgery – particularly on feet, may even delay the walking (Bleck) Sometimes: Surgery is given a credit, that it may allow the child to

walk. It may be a dramatic therapeutic triumphs'.

However: That happen only when, The surgery timing coincide with

the development of onset of independent walking. “that may not always be true”

PRE-SCHOOL CHILD Delay the Surgery, till ?

B. When there is no structural changes (e.g. hip subluxation or Gastro-Solius and knee contracture) there is no harm to delay surgery until child can walk

Exception to this Rule: This rule may not applied in pre-school child when

prevention of sub-luxation and dislocation of hip is necessary.

Therefore: In all children with spastic muscle, radiograph of hip

should be made in infancy and every 6-8 months. If Subluxation is noticed – spastic muscle release

should be done.

PRE-SCHOOL CHILD: TYPE OF SURGERY

Loco-motor prognosis determines the type of surgery needed:

I. Poor prognosis of walking & child having subluxation of hips:

Myatomy of adductor Longus & Gracilis

Neuroctomy of anterior branch of obturetor

nerve

Iliopsoas tenotomy.

PRE-SCHOOL CHILD: TYPE OF SURGERY

Loco-motor prognosis determines the type of surgery needed:

II. Good prognosis for walking:

Don’t risk for the permanent weakness of hip flexor by Iliopsoas tenotomy.

lengthening or recession of Iliopsoas muscle is preferable.

“Never release

ankle & knee,

before the child

has walked

independently”.

C P IN

SCHOOL AGE CHILD

SCHOOL AGE CHILD TIMING OF SURGERY

A) The optimum time for lower limb surgery in ambulatory child is between ages of 5-7 years, as at this age the gait pattern can be analyzed easily.

B) Try to finish most treatment programmes by the age 7-8 years (Bleck)

B) Surgery should not be staged over period of a years, perform one stage surgery under single anesthesia.

SCHOOL AGE CHILD TIMING OF SURGERY

Repeated examination,

careful analysis of the gait problem and recognition of potential skeletal changes

lead to better judgment

to correct or prevent structural changes

reasonably early i.e before 15 (13) years. (Molnar-Gordon)

Gait Laboratory

Plays important

role in accurate

Judgment

Gait Laboratory: Pedogram:Cavovarus & Planovalgus

EMG: Indicating spastic, normal &

Weak Muscles

Visit to Gait Laboratory NED Biotechnology Campus

18th March 2011

C P IN

ADOLESCENT & ADDULT

ADOLESCENT & ADDULT

• Fixed contracture often present.

• Functional improvement is not as satisfying.

• In late adolescent (>15 years) correction of deformities often cause pain and discomfort in hip, knee ankle and foot.

In adult; mostly surgery for painful degenerative arthritis secondary to

subluxation and dislocation is required.

Cerebral Palsy

“Clinical Pattern”

Specific Problems

DO & DO’NT DO

UPPER LIMB


Upper Limbs

PROGNOSIS FOR UPPER LIMB FUNCTIONS is poor when there is

failure to develop:

• Limb Dominance.

• Lateralization.

• Ability to cross mid line.

Function will always be compromised, when Stereognostic sensation in hand is deficient.

Child will use his eyes (Visual feed back) to control his hands.

Intelligence always paralleled the upper limb severity index.


Upper Limbs

Beals Severity Index for upper limbs, with motor age in months

at 3 years

SEVERITY INDEX DISABILITY

0-6 Profound Disability

7-11 Moderate Disability

12-17 Mild disability

SPASTIC HEMIPLEGIA:

Upper limb

• The surgery should be deferred until motor pattern is established and child is old enough to cooperate.

• Generally agreed age is 4 years.

Exception to this general rule: severe pronater spasticity, leading to posterior subluxation of head of the radius.

• Several different surgical procedure can be done at one time.

• Thumb and wrist deformities should be corrected simultaneously.

HEMIPLEGIA

SPASTIC HEMIPLEGIA:

Lower Limb a. There is no evidence that manual stretching exercises,

plaster casts or orthosis have ever effected a release of the contactures.

b. All the procedures are designed to reduce the stretch relax and to lengthen the muscle.

• All procedures weaken the muscles • Too much weakness causes over dorsiflexion. A calceneus deformity is functionally worse then the

equinous deformity. Results of Therapy in a patient with spastic Hemiplegia

are often better then in those in diplegia because there is a normal apposite limb.

SPASTIC HEMIPLEGIA Equinous Deformity:

Test:

If foot is capable of dorsi-flexion to neutral position when measured with planter surface of heel and foot in varus position (to lock the mid tarsal joint) surgery is not indicated in most patient.

SPASTIC HEMIPLEGIA Equinous Deformity:

Post operative functional results of Achilles tendon lengthening can be ascertained preoperatively by:

• If patient can voluntarily dorsiflex foot with the knee fully extended, the post operative gait may be almost normal.

• If However, foot can be dorsiflex only when the knee is flexed at 90 degrees and when hip flexion is resisted, then the postoperative gait will be improved, but a step page gait (hip and knee flexed) will persist so that toe can clear the foot during swing phase.

Surgery for Spastic Gastroc- Solius

SPASTIC HEMIPLEGIA Knee flexion deformity

• Hamstring lengthening is indicated when FFC is >15o during stance phase of gait.

• Patient who tolerate </=15o FFC of knee, are those who have good hip extension that locks the hips and brings trunk forward anterior to knee, in addition to that ankle planter flexors serves to over come flexed knee at mid-stance and beyond.

SPASTIC HEMIPLEGIA HIP, KNEE, ANKLE CONTRACTURE

TEST:

• If patient could stand erect with a A/K cylinder plaster only: - Hamstring are lengthened

• If he could stand erect with a short leg B/K walking plaster only: - Achilles tendon needs lengthening.

• If there is forward trunk lean with either cast:

- Iliopsoas recession is recommended.

SPASTIC HEMIPLEGIA HIP, KNEE, ANKLE CONTRACTURE

If there is structural deformity at hip & ankle these deformities should be corrected at the same time as knee flexion deformity.

If Hamstring lengthening is done and FFC hip persist over 15o, unacceptable lumber lordosis develop and trunk leans forward.

SPASTIC HEMIPLEGIA Hip flexion Contracture

Iliopsoas recession and derotation femoral subtrochanteric osteotomy corrects gait of practically all such hemiplegic children to almost normal in function and appearance.

• Most common PITFALL of femoral derotation osteotomy in

Hemiplegic child is failure to recognize and treat simultaneously the concomitant excessive external tibial fibular torsion (>30o).

• If Untreated… tibial torsional deformity of leg becomes glaringly evident after correction of femoral torsion.

• To prevent this unhappy result derotation osteotomy of proximal tibia and fibular must be done.

DIPLEGIA

Both are DIPLEGIA but with Different Pattern

DIPLEGIA & PARAPLEGIA • Surgical procedure, its timing & indications are nearly similar as in Hemiplegia, the only difference is, the surgery on both side has to be performed simultaneously under same anaesthesia.

Correction of

Structural

Deformities in

Diplegics

TOTAL BODY INVOLVEMENT

TOTAL BODY INVOLVEMENT Problems & Structural Changes

•Most common orthopaedic problem in these patient are contractures and dislocations of hip, scoliosis, knee flexion contractures and equinous deformity. •Structural changes are particularly

distressing in athetoids. Walking is usually

not possible

TOTAL BODY INVOLVEMENT Problems & Structural Changes

• If skeletal changes in hip and spine persist without correction, degenerative changes occur in the joint, causing added pain and disability.

T B I: Goal Setting

• The goal setting and problem solving for the individual patient with TBI, should be done according to the priorities established by adults with CP:

1. Communication

2. Activities of daily living

3. Mobility

4. Walking

T B I: STRUCTURAL DEFORMITIES:

Spine Scoliosis: 25 – 38 %

- Spinal curve of 42-50o may not respond to a orthosis if it is more than 50o surgical correction and fusion is indicated.

- TBI Scoliotic spines are often rigid, one stage surgical correction may fails.

T B I: STRUCTURAL DEFORMITIES: Hip

• Adduction contracture interfere with perineal hygiene, Sitting balance due to pelvic obliquity.

• In crossed leg deformity, intrapelvic obturetor neuroctomy is indicated with adductor myotomy.

• But exclude presence of tension athetosis other wise it will lead to excessive abduction.

• FFC Hip need not be relieved in non ambulatory patient ; however if subluxation of hip -- Iliopsoas tenotomy is needed

T B I: STRUCTURAL DEFORMITIES: Hip Dislocation

Hip dislocation occur almost exclusively in

non- ambulatory total body involvement

• Prevention of dislocation by early surgical treatment appears to be a good policy.

Orthotics and physiotherapy

have not demonstrated efficacy

to prevent dislocation.

T B I: SURGICAL TREATMENT OF DISLOCATION

Whether all dislocation need surgery ??

as children aged 7-16 years have no pain with dislocated hip.

Often Yes:

because relocation in later years, become painful (47%) and

modified Girdlestone had a poor results.


Relocation of dislocated hip in children and adolescent is indicated:

1. To prevent a painful hip in adult life that may compromise patients limited mobility

2. To prevent and correct sever pelvic obliquity, that interfere with sitting balance.

3. To prevent and correct severe adduction of the femur, that makes perineal hygiene difficult

4. To prevent painful bursal formation over greater trocharter on the dislocated side and over the Ischeal tuberosity when pelvic obliquity become fixed


Surgery is limited solely to:

- Adductor release + obturetor neurectomy (optional)

- Iliopsoas tenotomy (essential preventive surgery)

- Iliopsoas tenotomy done before 7-8 years age has significantly good results. After this age skeletal reconstruction is also required.

Acetabuloplasty

has not been

consistently

successful.

T.B.I: KNEE FLEXION DEFORMITY

• Knee FD need be corrected only if such knee FD interfere with assistive transfer from the wheel chair or positioning in bed become uncomfortable

• F.F.C more 15-20 should not be allowed to develop before that hamstring lengthening should be done.

• In adult combined supracondylar osteotomy & hamstring lengthening is the safe procedure.

TBI: Equinous Deformity

Since Walking is usually not possible in TBI, foot deformity correction is often not required.

Your Opinion may differ in this case….

Rehabilitation

&

Other factors

Rehabilitation

•Physical

•Mental

•Social

•Psychological

•Occupational

Rehabilitation

Pre-Operative PREPRATION OF CHILD & PARENTS • The child and parent must feel secure with the

surgeon.

• Child and parent familiarity with physical therapies for the period of 3-4 months before surgery is mandatory (Ideal), to gain full cooperation of child in postoperative rehabilitation if child is inordinately fearful or anxious,

Pre-Operative PREPRATION OF CHILD & PARENTS

• Delay the surgery till he / she:

a) Gains confidence able to accept reality of hospitalization

b) Recognize the need to take medications for post-op discomfort.

c) Under stand the need of continuous post of rehab programme for a estimated period of time.

Pre-Operative PREPRATION OF CHILD & PARENTS

EXPECTATIONS FROM SURGEON & SURGERY

The parent and child must be made understand that:

a) Post-op period may be painful but will be made comfortable with medication.

b) 1st two post op days shall be more difficult

c) Multiple incision will be made, preferably absorbable sutures will be used, to avoid stitch removal pain.

d) POP cast, its extent and change.

e) Length of cost immobilization and after such time child may be allowed walk in plaster.

EXPECTATIONS FROM SURGEON & HOSPITAL

• Child and his parents should be told what to expect of Hospital organization, Hospital services and OT room.

• Admit 2-3 days before surgery to

– Get optimum psychological benefit

– Enhance a smooth recovery

– Able to integrate many radical changes in his life

– An atmosphere need to be created, where the child feels like having a best friend in the hospital.

Post operative Rehabilitation

Include:

• POP cost for a limited time

• Early mobilization

• Children do not require an unduly prolonged period of post operative rehabilitation.

• Usually a maximum of 6 months post operative physical therapy under supervision

HOSTILE PARENTS

• Parents (sometimes older children) are displacing their resentment that this disaster has occurred to them.

• Their hostility is often directed against one who confronts them with the painful realities, they would rather not face.

• Surgeon must have patience with seemingly hostile parents.

SPASTICITY CONTROL

Rhizotomy

Drug Therapy

Muscle Relaxants

Spasticity Control

• When reduced patients may :

- perform integrated muscle movement

- develop muscle strength

- function at a higher level

• Approaches :

Selective dorsal rhizotomy

Intrathecal baclofen

Botulinum-A toxin

Selective Dorsal Rhizotomy

• 30 – 50 % of abnormal dorsal rootlets L2 - S1

• Followed by intensive physiotherapy

• Results encouraging

• May cause hyperlordosis / hip subluxation

• Best for : spastic diplegia, 4-8 yrs, no previous surgery, no contractures, no extra pyramidal signs

• ? Not enough alone

• Orthopedic procedures obtain similar results

Baclofen

• Oral : mixed reports/ side effects/ not selective

• GABA agonist – inhibits release of excitatory neurotransmitter at level of spinal cord

• Continuous intrathecal – implantable pump

• Good results in releasing spasticity, and improving function

• Complications of pump and catheter

• Needs specialized centers

Botulinum-A Toxin

• Acts at myo-neural junctions

inhibits exocytosis of Acetylcholine

• Inject selected muscles at multiple sites

• Spasticity reduction may last up to 6 months

• Reversible , painless , minimal side effects

• Most patients still require lengthening for permanent correction

Role : - Facilitates physiotherapy and mobilization - Delays surgical management - Trial to determine effects of specific proposed surgical treatment

DRUG THERAPY

• Alcohol has been the best available muscle relaxant but it is not really a practical and nor in the interest of a patient’s general health.

• Diazepam is presumed to control spasticity and athetosis

– Acting on CNS it lessens anxiety and startle reaction.

– Since it interfere with ability of concentration, ambulatory patients do not respond well.

– Works better in younger then 10 years age and total body involvement.

DANTROLENE SODIUM (DANTRIUM)

• Ambulatory children with spastic hemiplegia or diplegia show some objective improvement in gait and balance but it produce.

– Mental dullness

– Abnormal liver functions

This drug works better in children under 10 years age and with total body involvement.

TIZANIDINE

Centrally acting muscle relaxant that inhibit polysynaptic signal transmission at spinal interneuron level that is responsible for excessive muscle tone, and thus muscle tone is reduce. In addition its muscle-relaxant properties, tizanidine also exerts a moderate central analgesic effect.

Tizanidine is effective in both acute painful muscle spasm and chronic spasticity of spinal and cerebral origin it reduces resistance to passive movements, altercates spasm and clonus and may improve voluntary strength.

Summary

Summary

All the prediction scores to assess results of treatment are used after the age 03 years

Because of the Biological factor that:

“With growth of nervous system from birth to about 3 years , the functions that were

thought to be absent before this age may develop spontaneously with neuronal

maturation”. ‘Beals’

Summary

• Better to defer surgery for functional and cosmetic improvement of gait until the child has learned to walk

• And Child has been walking independently for a year, at least

• But there are certain exception to this rule:

- Prevent eminent subluxation

- Prevent expected contracture

Summary

• Surgery should not be regarded as a last resort or as something that can always be done when all other methods have failed.

• Neither should it be unduly staged so that with each birthday the gift is another hospitalization and another period of immobilization.

• The goal of treatment is a healthy functionally independent person, not a permanent patient.

Summary

• Optimum timing for surgery is between 4-8 years

• Surgery in a CP child to prevent and correct structural changes ought to be performed before the age of 15 (13) years.

• Pre-operative admission for few days, repeated evaluation & physical – occupational therapy, during that period helps to gain confidence of child & child understand the need for continuous rehabilitation (pos-op) for a estimated time i.e not more than 6 months.

Summary

In Upper limb the Surgery in Palsied child is duly useful when:

• He himself has the full knowledge of fundamentals of this complex entity

• Lack of knowledge of basics of this complex entity and improper selection of cases for surgery lead to no faith in surgery for CP cases.

Summary

• Assessment for Motivational status of patient & his parents is very important before planning for surgery.

• Before planning surgery, Patient & Parents understanding for OCCUPATIONAL THERAPY, PHYSIOTHERAPY & BRACING is required, as Intensive treatment by these modalities in postoperative rehabilitation is direly needed for long time.

“Mental retardation has little if

any effect on ability to walk”

God has created me …. special child

It is not my fault

Take care of His creatures

He will take care for U

Thankyou

Cerebral Palsy 2nd National Workshop 2011 Karachi Pakistan

Documents

Transcript of Cerebral Palsy 2nd National Workshop 2011 Karachi Pakistan