Three major treatments for cerebral palsy: rehabilitation training; surgical treatment; and brace help
There are two types of surgical treatment: orthopedic surgery; neurosurgery SPR (posterior spinal nerve rhizotomy) Xiaowei Wang, Department of Orthopedics, Xi’an Children’s Hospital
The purpose of using orthopedic surgery
Correction of static (staic) or dynamic (dynanic) deformities of cerebral palsy
Balance muscle strength
Stabilize joints that cannot be controlled autonomously
Orthopedic surgery classification
Static deformities: major tendon lengthening, capsulotomy, osteotomy (e.g. internal and external rotation of the appendages, tibia, femur, forearm ulnar radius or rotational syndesmosis).
Dynamic deformities can be corrected with at least partial tendon lengthening or cutting to weaken the muscle. Examples include partial muscle severance of the posterior tibialis, iliopsoas, gastrocnemius, adductor, and hallux valgus muscles. The same procedure is applied to the arm and hand.
Tendon transfers in different types of joints can also be done with satisfactory results, provided that the transferred muscles have self-control and casual movement, for example, the commonly used external tibialis anterior muscle.
Indications for surgery in pediatric cerebral palsy
1.Age 3 years old or above, not very poor in intelligence, able to understand simple words
2. Surgery is best for flexor spasticity, but is worse for tonicity or tachycardia, but is not an absolute anti-significance.
3. The purpose of surgery is mainly to improve limb function, create walking conditions and improve the quality of life.
Common surgical methods for cerebral palsy
Upper limb surgery
1.Rotary anterior circular muscle release with dorsal placement of ulnar flexor carpal muscle.
Conditions: the fingers have flexion and extension function, and the thumb has opposite palm function. After surgery, the wrist joint is corrected from the flexion position to the neutral position, which can improve the finger flexion function and increase the grip strength.
2.Other muscle release surgery
If the upper limb has abnormal posture and forced position, the corresponding muscles can be cut off (released) to balance muscle strength, improve posture and reduce pain.
Wrist fusion surgery: elderly people with wrist flexion deformity
Lower limb surgery.
Lower limb surgery should focus on hip adduction, knee flexion and clubfoot deformity
1.Laxation of the adductor muscle + severance of the anterior branch of the foramen ovale nerve. Surgery to cut off the key of the longus medialis, if necessary, part of the shortus medialis and the thin femoral muscle, and at the same time cut off the anterior branch of the foramen ovale nerve, so as to paralyze the longus medialis and the shortus medialis, and release part of the inward force, while retaining the large inward muscle (innervated by the posterior branch of the foramen ovale nerve), otherwise the hip abduction cannot be walked.
2.Half tendon and half membrane, thin femoral tendon severance (or lengthening), and additional biceps femoris tendon membrane lengthening. The knee flexion deformity can be removed, but it is not necessary to release the posterior knee tendon in cerebral palsy patients with knee flexion of 5-10° walking is stable, the knee flexion is more serious, the quadriceps muscle is very laborious, walking is easily fatigued, so surgery is needed.
3. Supracondylar osteotomy of the femur. In older cerebral palsy cases, in addition to posterior knee spasm and contracture, there are also contractures of the posterior wall of the knee capsule, contractures of the lateral collateral ligaments of the cruciate ligament, and even osteoarthrosis, so that the posterior knee tendon release alone cannot completely straighten the knee joint, and a supracondylar (subtrochanteric) osteotomy must be performed at the same time.
4, Achilles tendon lengthening plus posterior tibial muscle cut (or lengthening) surgery. Achilles tendon lengthening to correct the horseshoe deformity, posterior tibial muscle cut to correct the inversion of the foot, if necessary, the anterior tibial muscle can be externalized (Achilles tendon lengthening posterior tibial muscle lengthening or do not deal with the posterior tibial muscle, the anterior tibial muscle externalization, if the posterior tibial muscle cut and then add the anterior tibial muscle externalization, the lateral foot muscle force is too strong instead of becoming an exotropic foot deformity.
5. Heel talus fusion. Surgery to correct the severe flatfoot deformity of cerebral palsy.
6.Triple joint fixation (heel talus, talus navicular, and talus femoral joints are fixed by bony fusion) to correct severe osteoarthritic deformity in older patients or inability to stabilize the inward and outward movement of the subtalar joint.
Complications of surgery
Postoperative pain
Swelling of the limb
limb ischemia, ischemic contracture, limb necrosis
Plaster compression, skin necrosis, ulceration
Plaster allergy
Nerve injury: e.g. inferior femoral osteotomy to correct flexion deformity, common peroneal nerve pull, injury
Wound bleeding
Wound infection about 1 per 1,000
Muscle atrophy: surgical trauma congestion and disuse muscle atrophy
Osteoporosis: acute bone atrophy, severe pain after fracture cast
Fracture: limb in plaster fixation, easy to cause fracture of the limb part outside the plaster when fixation
Postoperative fixed limb.
Muscles, tendons, ligaments and joint capsule should be fixed for at least 4 weeks after surgery, so the postoperative cast is generally fixed for 4-6 weeks.
Subtrochanteric osteotomy should be fixed for 6-8 weeks after surgery, and the internal fixation pin or plate or screw should be removed after 3-6 months.
The cast should be removed 3 months after triple joint fixation.
Postoperative treatment
Postoperative rehabilitation training should be continued and walking training should be done in some cases with the help of braces.
Postoperative rehabilitation: there are two main types of postoperative rehabilitation, one is passive exercises to prevent soft tissue contracture and maintain the normal amplitude of joint activities, while also focusing on allowing the patient to stand, walk or learn to walk with support, through active exercise to improve the brain’s ability to control muscles, coordination and balance, while enhancing muscle strength, and through standing and walking activities also exercise the knee and trunk muscles.
Conclusion
In conclusion, rehabilitation, orthopedic surgery, and bracing are complementary and not contradictory, and only when all three are integrated can a more satisfactory outcome be achieved.