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.
CP RECONSTRUCTIVE SURGERY
Decision Making Process
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
CP RECONSTRUCTIVE SURGERY
Decision Making Process
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 nonambulation
(Molnar-Gordon)
CP RECONSTRUCTIVE SURGERY
Decision Making Process
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%)
CP RECONSTRUCTIVE SURGERY
Decision Making Process
3. PROGNOSIS OF WALKING
CP RECONSTRUCTIVE SURGERY
Decision Making Process
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.
CP RECONSTRUCTIVE SURGERY
Decision Making Process 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
CP RECONSTRUCTIVE SURGERY
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
Free walking by age 7 yrs Lowest score consistent with free walking is reasonably good
Crutch walking
No walking
No surgery.
CP RECONSTRUCTIVE SURGERY
Decision Making Process
4. STRUCTURAL CHANGES:
CP RECONSTRUCTIVE SURGERY
Decision Making Process
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.
CP RECONSTRUCTIVE SURGERY
Decision Making Process
4. STRUCTURAL CHANGES: 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.
CP RECONSTRUCTIVE SURGERY
Decision Making Process
C P IN PRESCHOOL CHILD
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
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: Dont 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.
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.
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:
Pedogram:
Cavovarus & Planovalgus
EMG:
Weak Muscles
Cerebral Palsy
Clinical Pattern
Specific Problems
DO & DONT DO
UPPER LIMB
CP RECONSTRUCTIVE SURGERY
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.
CP RECONSTRUCTIVE SURGERY
Upper Limbs
Beals Severity Index for upper limbs, with motor age in months at 3 years
SEVERITY INDEX 0-6 7-11 12-17 DISABILITY Profound Disability Moderate Disability Mild disability
HEMIPLEGIA
DIPLEGIA
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
Rehabilitation
Physical Mental Social Psychological Occupational
Rehabilitation
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.
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
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
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 Role : side effects - Facilitates physiotherapy and mobilization Most patients still require - Delays surgical management lengthening for permanent - Trial to determine effects of specific proposed surgical correction 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 patients 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.
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.
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