The treatment of cerebral palsy is multifaceted. The main treatment lies in muscle training, speech training and psychotherapy. Orthopedic surgery can only be used as an adjunctive treatment, and various rehabilitation therapies are needed continuously before and after surgery.
I. Non-surgical treatment
1.Muscle training: The principle of muscle training is to educate the child to relax the spastic muscles, to promote the use of certain muscles and to improve ataxic movements. Repetitive and rhythmic motor training is important to train the child step by step to be able to dress, go to the toilet and walk.
2. Application of orthopedic splints: In order to overcome deformities caused by muscle spasms, splints or casts are frequently used as tools. The first step is to gradually stretch the shortened muscles to correct the deformity as much as possible. If necessary, orthopedic treatment can be carried out under anesthesia, with a cast to maintain the limb in the corrected position for about 3 months, after which a movable brace or splint can be applied for long-term coexistence to prevent the recurrence of deformity.
3.Language training.
4.Vocational training: When the child reaches the age of one year, the muscle spasm has been relaxed after physiotherapy, then vocational training will be started. This includes writing, typing and some simple manual work. So that the patient can become a self-reliant worker.
5.Medication: Medication does not work for cerebral palsy, but Menton may help to control tremor, and sedative drugs such as hibernation can be effective in suppressing excessive activity of patients, and also help to carry out physical therapy. Sometimes antiepileptic drugs can also reduce convulsions and other symptoms, but close attention should be paid to whether the medication will aggravate muscle imbalances. Closure of the neuromuscular junction with 1% procaine can block the gamma conduction of the nerve without affecting the alpha conduction of the nerve and reduce the muscle spasm. Sometimes intra-neural injection with 3% phenol, which makes the nerve suffer permanent damage, can make 1/3 of the patients’ spasticity relieved and easy to train.
II. Surgical treatment
Surgery is only one part of the comprehensive treatment for cerebral palsy, and patients must be selected strictly and planned carefully. Pre-operative and post-operative physical therapy is required. Generally speaking, children under 5 years of age should not be treated surgically because they are still uncooperative and difficult to examine, in addition to the extent of the paralysis and the resulting consequences may not yet be fully reflected.
There are several methods of surgery as follows.
(i) Surgery of the nervous system
1. For patients with tardive dyskinesia, anterior spinal nerve root amputation can be considered. The anterior root of the spinal nerve from cervical 3 to thoracic 1 can cause complete loss of all movements of the upper limbs. However, it does not affect the sensory function and may be beneficial for some patients.
2. Hemispherectomy for spastic hemiplegic patients with severe epilepsy can reduce the number of seizures as well as their severity and facilitate the patient’s training.
3.For severe hand and foot xerostomia type cerebral palsy, pallidum destruction can be done with certain efficacy. All the above three surgeries are destructive and must be strictly controlled indications and should not be performed easily.
4. Peripheral nerve dissection surgery. Commonly used to cut a part or the whole branch of the nerve innervating a muscle with excessive spasm, so that the muscle relaxation. This surgery is more often used in the lower extremities.
(B) muscle and tendon surgery
1.Tendon cut-off technique market or tendon lengthening: tendon cut-off technique market or lengthening is performed on spastic muscles to reduce their mechanical forceful contraction and improve their muscle balance.
2.Tendon transposition: In some parts, transferring the muscle stop of aggravated deformity to a new stop can change its function, that is, changing the force of aggravated deformity to the power of correcting deformity.
(C) Bone and joint surgery
①Bone lengthening or shortening surgery to correct the unequal length of the lower limb.
②Osteotomy, including wedge osteotomy and rotary osteotomy to correct deformity.
(3) Joint fixation to fix the joint in a functional position to increase stability and improve function.
C. Introduction of some common deformities and treatment methods
(A) Treatment of hand and wrist deformities
Since the function of hand and wrist joints is more complicated, only about 4% of people can improve the function through surgery.
1.If the thumb is flexed and spastic in the palm, but the patient can still make a fist and open the hand, the thumb metacarpophalangeal joint can be fixed and the abductor longus thumb can be shortened.
2.Wrist and fingers can not be dorsal extension, thumb spasm in the palm, flexor superficial muscle has moderate spasm, can be made thumb metacarpophalangeal joint fixation, flexor superficial muscle through the interosseous membrane to the extensor and extensor thumb longus, and then the ulnar flexor wrist muscle to the radial extensor carpi radialis shortus.
3. If the finger has severe flexion spasm, the ulnar flexor carpal muscle can be moved to the extensor digitorum longus and the radial flexor carpal muscle to the extensor digitorum longus, and the metacarpophalangeal joint of the thumb can be fixed at the same time. If necessary, fix the wrist joint in the functional position.
4.For poor wrist flexion, use the brachioradialis muscle to flex the wrist muscle.
5, the hand can not be opened, severe flexion contracture, available to extend the tendon and fixed thumb metacarpophalangeal joint and wrist joint. This surgery is only for aesthetic purposes and has little effect on functional activities.
(B) Treatment of shoulder and elbow deformity
When the abduction of shoulder joint is less than 45° or external rotation is less than 15°, subscapularis tendon can be cut and pectoralis major muscle can be stripped. When the elbow flexion deformity is more than 40°, the elbow extensor muscle can be lengthened.
(C) Treatment of hip deformity
1.Correction of hip flexion-internal rotation deformity: If there is only mild or moderate deformity and it only occurs when walking, just move the semitendinosus muscle to the front of the femoral epicondyle, or make soft tissue release in front of the hip joint and fix it with external booth plaster. If the broad fascial tensor is the main spasticity factor, the starting point can be moved posteriorly to the iliac crest to allow external rotation of the hip joint. If the flexion deformity has become fixed and can no longer be passively corrected, it is then necessary to do subtrochanteric or supracondylar rotational osteotomy.
2, correction of hip flexion deformity: if the deformity is more than 45 °, between the ages of 8 to 11 years old, can do iliopsoas muscle cut. If the spasm of the rectus femoris muscle is caused, the starting point on the iliac bone can be loosened.
3.correction of hip inversion deformity: often use closed-hole neurectomy and inversion muscle cut. However, the muscle strength of the hip abductor muscle must be checked and estimated before surgery. Before surgery, make closed-hole nerve closure and observe and check the muscle strength of hip abductor muscle. Sometimes the thin femoral muscle causes hip adduction spasm, so the patient can be made to lie prone with the hip abducted as far as possible and the knee flexed. If the patient gradually straightens the knee joint, the hip joint will be inwardly contracted if the thin femoral muscle is contracted. As long as the muscle of the muscle and tendon junction transection, you can correct the deformity.
4, the treatment of hip dislocation: some people believe that the lower limb spastic paralysis of children with hip dislocation is very difficult to avoid. For patients with subluxation, the anterior branch of the closed nerve should be cut, and the contracted adductor or thin femoral muscle should be cut, and the hip joint should be fixed in the outer booth for 6 weeks, however, the training of abduction muscle strength should be started again. If more than 1/2 of the femoral head is outside the acetabulum and the age is 9 years or older. A subtrochanteric inversion osteotomy should be performed. For old dislocations, the patient often already has an external hip, an increased anterior femoral neck inclination, a shallow acetabulum and other deformities, and if the child is unable to walk, treatment is not necessary.
For children who can walk, the following can be used.
(1) hip joint fixation.
(2) Femoral osteotomy to correct angulation and rotation, and pelvic osteotomy to deepen the acetabulum.
(3) Abduction osteotomy under the femoral trochanter to use the pelvis as a weight-bearing support.
(D) Treatment of knee deformity
When deciding on a treatment plan, attention should be paid not only to the localization of the knee. Attention should also be paid to the deformity of the hip and condylar joints, especially to the muscles that can affect the movement of both joints: such as the rectus femoris, thin femoral muscle, biceps femoris, semitendinosus, semimembranosus and gastrocnemius. If the knee flexion deformity can no longer be passively corrected, surgery is required. The degree of active knee extension and the position of the patella should be examined first. It is often found that the patella is displaced superiorly and the quadriceps tendon is elongated. The supination of the patella will reduce the strength of the quadriceps to extend the knee and will cause contracture of the knee joint. A posterior knee capsulotomy with a “Z” lengthening of the cord can be performed. It has also been suggested that the patellar tendon stop be moved down. Others suggest using a release of the patellar support band and a “Z” lengthening of the cord. The stop of the cord muscle is moved to the distal femur to release the knee flexion deformity. However, attention must be paid to the strength of the gastrocnemius muscle, because after such a transplantation, the only muscle that flexes the knee is the gastrocnemius. If the Achilles tendon has been lengthened or if the gastrocnemius muscle is too weak, the knee will not be able to flex. Therefore, this procedure has been modified to loosen the thin femoral muscle, move the semitendinosus to the medial femoral ankle, and lengthen the semimembranosus, while leaving the biceps femoris in place. Knee flexion contracture and patellar upward displacement can produce chondromalacia patellae and make the knee joint painful, so some people also advocate patellar osteotomy.
(E) Treatment of foot deformity
1, correction of horseshoe deformity
(1) tibial nerve myotomy: cutting off the muscle branch of gastrocnemius or flounder muscle or both is effective in correcting spastic horseshoe deformity, and can also reduce ankle clonus, which is also helpful for walking. Before surgery, it is important to find out whether the ankle clonus is due to the gastrocnemius or the hallux valgus muscle. If the ankle clonus disappears when the knee is flexed, it is due to the gastrocnemius muscle, otherwise it is due to the hallux valgus muscle. This can be used as a basis for choosing which tibial nerve branch to cut.
(2) Calf triceps release surgery. There are two conditions of spastic horseshoe.
(1) The horseshoe is present when the knee is straight and can be corrected when the knee is flexed at 90°.
② The horseshoe cannot be corrected in either flexion or extension of the knee. In the former case, the cause of the horseshoe is due to contracture of the gastrocnemius muscle, and the method of correction is to move the starting point of the gastrocnemius from the lower end of the femur to the upper end of the tibia; in the latter case, the cause of the horseshoe is contracture of both the gastrocnemius and the flounder muscle. The method of correction needs to be Achilles tendon lengthening.
(③) Achilles tendon stop point forward displacement: because after the Achilles tendon lengthening, the horseshoe deformity often recurs. Some people move the stop of the Achilles tendon to the dorsal side of the heel bone at the posterior edge of the heel talus joint. This reduces the leverage of the calf triceps. For those who have not yet fixed the horseshoe, the treatment effect is better.
2.Correction of inversion and valgus deformity of the foot.
For the fixed inversion and valgus deformity, it can be corrected by wedge osteotomy of the heel bone or fusion of the subtalar joint. Generally, the muscles that cause pronation deformity are contracture of tibialis anterior and tibialis posterior muscles, and the muscles that cause valgus deformity are contracture of fibular long and short muscles. Therefore, the two muscles are moved to the opposite position to correct the deformity. It is also advocated to split the anterior tibial or posterior tibial tendon in two, with half of the tendon remaining at its original stop and the other half sewn to the short fibularis muscle or dice bone to correct the valgus deformity. Before surgery, it must be determined which muscle plays a major role in the deformity and which one will be split. If the inversion deformity is caused solely by contracture of the posterior tibial muscle, a “Z” extension of the posterior tibial tendon or lengthening of the posterior tibial tendon or lengthening of the muscle can be done.
3, correction of supinated toe foot: rare, often due to excessive lengthening of the Achilles tendon or at the same time after the myotomy of the tibial nerve. The anterior tibial muscle, posterior tibial muscle and gastrocnemius muscle can be moved to the Achilles tendon. Others advocate removal of the talus.
4. Correction of claw toe: The motor branch of the lateral plantar nerve innervates all the interosseous muscles except the 4th and 5th intermetatarsal muscles and the 2, 3, 4 earth muscles and the retractor muscles. The first earthworm and flexor hallucis muscle are innervated by the medial plantar nerve. The nerve motor branch can be cut, metatarsophalangeal capsulotomy and flexor digitorum brevis cut to correct.
5, forefoot inversion correction: often due to contracture of the abductor muscle, the muscle can be cut off to correct.
6.The treatment of spinal deformity
Scoliosis (paralytic) can occur in 20-25% of patients if the scoliosis is less than 30° in the standing or sitting position, and is non-progressive aggravation, available brace. Surgery may be considered if
(1) Thoracic scoliosis exceeding 60° with cardiopulmonary complications.
(2) Imbalance due to thoracolumbar scoliosis in the sitting position, which affects the user of the upper extremity.
(3) Occasionally, surgery is performed for aesthetic reasons.
Prognosis
The clinical presentation of cerebral palsy varies, with the severity of the disease varying from severe cases with symptoms appearing a few days after birth to most cases detected months after birth when family members try to pick them up. The prognosis also varies widely, with most cases of severe bilirubin encephalopathy dying within days to 2 weeks if left untreated, and even if the child survives, mental retardation, deafness, and hypotonia are often left behind; children with paraventricular leukomalacia have an average survival age of 8.5 years; while most children with mild post-refractory brain syndrome can recover or survive with only minor sequelae for life.