Medical/Surgical Management of Children with CP

Principles of medical/surgical management of children with CP

problem-oriented, needs evolve as child grows up, consider pt priorities, dynamic vs. static contractures, soft tissue vs. bony deformity, set realistic goals

The approach to NM disorders is _____

multidisciplinary

priorities children with CP had

communication, ADL’s, mobility, walking

primary problems associated w/ CP

loss of selective motor control (spasticity, balance)

secondary problems associated w/ CP

muscle contracture, bony changes

What oral medications can be used to decrease tone in children with CP? what is the downside to these?

Diazepam, Baclofen, Tizanidine→ cause sedation, weakness, hypotonia

patient selection criterial for botulinum toxin type A injections

dynamic muscle contractures, limited muscles involved (<4), may be to delay surgical intervention/simulate surgery, or to facilitate stretching as an adjunct to PT/casting

how do botulinum toxin type A injections work to decrease spasticity (tone)

irreversibly block ach release by nerves at motor end points, by reversible chemical denervation

similar to botulinum toxin type A injections but last longer

Phenol/alcohol nerve block

Decreases stimulation from muscle spindles – section of sensory rootlets, also weakens muscle, prevents need for future orthopedic surgery by about 50%

Selective dorsal rhizotomy

patient selection criteria for selective dorsal rhizotomy

pure spasticity, no fixed contractures, good selective motor control, 4-8 y/o, adequate cognition to cooperate w/ rehab

Neurosurgical procedure, provides local delivery to spinal cord through intrathecal catheter and subcutaneous pump

Intrathecal Baclofen

Indications for Intrathecal Baclofen

spasticity that interferes with function or ease of care

indications for PT intervention

early intervention >3, post-op, targeted interventions, MSK primary care

Indications for serial casting

mild spasticity/contractures, dynamic deformities

typical serial casting course

casts every 1-2 weeks for 6-8 weeks, recurrence is common during growth

goals for orthopedic surgery intervention

restore anatomy, maximize biomechanical function, ROM, alignment

primary problems are _____ while secondary problems ______

Permanent, may be corrected

principles of CP intervention

problem is in the brain, multidisciplinary care, focus on function, address all components at once, realistic goals, plan for additional interventions

compensation for primary and secondary problems

tertiary problems

for dynamic and static soft contractures, multiple techniques, weakens muscle

muscle-tendon lengthening

substitutes for weak muscles, changes pull of

overactive muscles, weakens muscle, can be complete or split

tendon transfers

Cutting and realigning bones to corrects deformity (ex: hip)

osteotomy

joining bones together to decreases motion and stabilize (ex: spine, foot)

fusion

components of pre-operative evaluation

Collect date, generate problem list, instrumented problem analysis

what migration percentage is considered hip displacement?

>30%

pathophysiology of hip displacement

muscle imbalance and spasticity, abnormal bony anatomy, abnormal forces on acetabulum (higher GMFS level increases risk)

possible options for hip dislocation management

botox/soft tissue lengthening, proximal femur guided growth + soft tissue release, a la carte reconstruction, salvage osteotomy

does adductor botox in isolation decrease hip displacement?

no

when would hip reconstruction be considered as a treatment for hip displacemednt?

near maturity, high migration percentage >50%, and failed prior containment

standard of care for lower extremity intervention

Single Event Multi-Level Surgery (SEMLS)→ addresses all bone and soft tissue issues at once to reduce repeated hospitalizations/rehab periods

Surgical indications

Age 6-10 (except hip displacement), 6 month plateau in function, non-operative interventions are inadequate, patient/family committed to rehab

what is associated w/ knee flexion contracture?

crouch and jump gait patterns→ crouch gait has poor natural history

When to consider hip adductor lengthening

static and dynamic adduction contracture; <20 degrees abduction with hip extended

Indications of hamstring contracture

KFC < 10 deg, Popliteal angle >40-60 deg, Lack of knee extension in terminal swing, Increased knee flexion in early stance, Posterior pelvic tilt

Indications for distal femur guided growth

Crouch, Mild-moderate knee flexion contracture (15-25 deg, but varies), ≥2y growth remaining

Indications for distal femoral extension osteotomy

Crouch with KFC >20 deg, Insufficient growth remaining for guided growth

are heel cords better a little tight or a little loose

tight

possible surgical interventions for flexible equinovarus

Intramuscular Tibialis Posterior lengthening, Gastrocsoleus lengthening, Split tendon transfer

possible surgical interventions for fixed equinovarus

Hindfoot (Calcaneal osteotomy), midfoot dorsolateral closing wedge of cuboid, forefoot dorsiflexion osteotomy medial column, Triple arthrodesis

indications for intervention for foot/ankle valgus

Painful or non-braceable foot, lever arm dysfunction

a congenital deformity where a newborn's foot is twisted inward and downward due to shortened tendons

equinovarus

a foot deformity characterized by a foot pointing downwards and outwards

equinovalgus

potential surgical treatment for equinovalgus

lateral column lengthening, (gastroc, calcaneal osteotomy)

goals for spastic quadriplegia (non-ambulatory)

wheelchair to maximize function, spine straight enough to sit, hips located/mobile/painless, knee motion for sitting and transfers, feet plantigrade

incidence of scoliosis in CP

39% -75%

difference with scoliosis progression in children with CP

continues to progress after skeletal maturity

treatment options for scoliosis

Nonoperative (Observation for small or non-progressive curves, Wheelchair modifications, Bracing), Operative (spinal arthrodesis)

surgical indications for scoliosis

curve magnitude/progression (>40-50 degrees), curve rigidity, symptoms

benefits of spinal fusion

Sitting balance/endurance, Use of upper extremities, Pulmonary function, Feeding/nutrition, Ease of care, transportation, Decreased pain\

characteristics of athetoid CP

Abnormal tone and tension, Increases with activity, Squirming or writhing motion, Constant, Disappears during sleep, Kernicterus, Many are non-ambulators, Soft tissue surgery unpredictable, Scoliosis, Cervical spine disease in adults