Diagnosis and treatment of cerebral palsy
Cerebral palsy, also known as spastic cerebral palsy (cerebral palsy), was first reported by Ljule in 1841 and is a non-progressive brain dysfunction in infants and children caused by the loss or lack of control of some or all of the spinal nerves due to lesions in the higher nerve centers, mainly in the upper neurons before birth and at birth or after birth before maturity. The disorders include motor impairment and sensory awareness impairment due to developmental disorders or trauma. Attention is generally focused on peripheral motor nerve manifestations such as spastic monoplegia, hemiplegia, paraplegia or quadriplegia, involuntary movements and twins. However, mental retardation, learning difficulties, silence and sensory disturbances caused by brain damage should not be ignored.
The disease is more complex, more severe, mentally retarded, severely disabled, and even unable to take care of itself, involving family, social, economic, emotional and educational aspects, and is not simply a medical problem. Surgical treatment is only suitable for a small percentage of patients, mainly the spastic type, but not for the tardive and tonic types. Even if the surgery can improve the appearance and function, long-term postoperative treatment and vocational training are required, otherwise the effect is minimal.
The incidence of cerebral palsy is estimated to be 0.05%-0.2% in some parts of China, but it is often unrecognized at birth and may be missed.
The causes of cerebral palsy are complex and can involve various factors that exist or appear before birth, during delivery and after birth, sometimes there is no obvious identifiable cause, but hypoxia is probably one of the most common factors.
1.Congenital factors
(1) malformation of brain development, cerebral cortex with cerebral mass deficiency and subsequent cone rest bundle hypoplasia.
(2) Fetal infection within the mother’s body.
(3) Intra-maternal oxidative disorders and metabolic disorders leading to hypoplasia and hydrocephalus.
(4) Gestational toxicity and trauma.
(5) Maternal hemorrhagic qualities and fetal cerebral hemorrhage.
(6) Long-term maternal gonadal exposure to radiation and cellular hypoplasia.
(7) Neonatal hemolytic disease causing cerebral hypoxia and ischemia, cerebral membrane or cerebral cortex sclerosis, cyst formation or atrophy causing paralysis.
(2) Severe ventricular rest, obstructed labor or prolonged labor during delivery
Inappropriate use of forceps can cause neurological damage, intracerebral or intracerebral hemorrhage; or fetal malposition, placental insufficiency of blood supply, etc., which can cause hypoxia causing paralysis. It is more common.
3.Acquired factors trauma and diseases such as trauma to the brain and its blood vessels
Encephalitis, meningitis, tumor, measles, pertussis, meningeal and intracerebral parenchymal hemorrhage, vaccine encephalitis, carbon monoxide, carbon disulfide or manganese poisoning can cause atrophy of the cone bundle and lateral bundle of the brain parenchyma, forming cysts or sclerosis, resulting in cerebral palsy, which is also more common.
Treatment principles
The treatment of the sequelae of cerebral palsy is difficult and complex, involving multiple disciplines and aspects, and there is no satisfactory treatment yet. Treatment for those who cannot be educated (determined by IQ) is often ineffective, and in some cases may require lifelong care. Motor age and intelligence should be routinely measured before treatment, and treatment is difficult for those with an IQ <70. Both visual, hearing and speech abilities affect treatment choice and outcome.
1. General treatment includes nursing care and health system, proper nutrition, elimination of irritants and other measures to improve the condition of the disease is of some significance. If the special treatment and rehabilitation center, improve the conditions, centralized treatment, the effect is better.
(1) Long-term strengthening of education, language training, improve intelligence and function.
(2) Improve the environment and reduce stimulation.
(3) Functional exercise, together with physical therapy, body therapy, acupuncture, and braces, patiently and meticulously strengthen training to promote muscle relaxation and self-control, in order to improve posture, gait and function, prevent deformity, and create conditions for surgical treatment.
Patients with spasticity can use passive exercises, warm water baths, massage, acupuncture and physical therapy. Sometimes abnormal reflexes and stimulation points can also be used to make reflexes occur and promote activity; in the tardive dyskinesia type, self-control of truly voluntary movements should be trained, which is more effective when applied in adults with sufficient intelligence; ataxia type requires improvement of muscle tone and arm synergy training. Unless there is a cone bundle lesion generally should not be treated surgically; ankylosing deformities and twins can be surgically corrected, but cannot improve function.
(4) Although braces cannot correct the sigmoid, they can help control purposeless movements and muscle tone, improve posture, and prevent deformity.
(5) Once the muscles can be relaxed after training, occupational therapy should be started. The aim is to train control of the fingers for life-related movements such as eating, dressing and writing, without necessarily requiring special movements such as drawing and charting.
(6) General medications are not effective for the sequelae of cerebral palsy. Some drugs can be treated symptomatically, but have no long term effect.
Surgery is only used with limited caution to supplement or enhance the benefits of non-surgical treatment. If applied appropriately, the deformity and the function of the limbs and trunk can be improved to varying degrees, while the mobility depends mainly on the patient’s intelligence and the residual muscle activity that can be controlled autonomously. In general, children before the age of one year are not easy to cooperate and cooperate with postoperative rehabilitation and should not be operated.
(1) Indications:
In general, older children, those with good intellectual and psychological development, those who can improve function, correct sigmoid shape or stabilize joints are suitable for surgery, and those with hemiplegia have better results. The upper extremity should be reconstructed to improve the function and correct the deformity, without choosing destructive surgery such as nerve branch amputation; the lower extremity should be stabilized.
If spasticity and deformity are serious, surgery cannot relieve them; ankylosis surgery cannot improve function, and tachycardia is not suitable for surgery; mental retardation, quadriplegia, severe sensory impairment or combined with severe epilepsy, the effect is poor, and also not suitable for surgery.
(2) Purpose of surgery
(1) To prevent and correct deformity, improve posture, gait, negative gravity line and reduce the application of braces.
(2) To reduce hyperfunctional muscle activity and improve muscle balance.
(3) Release spasticity and twinning to create conditions for functional recovery.
(4) Stabilize the joint.
(3) Surgical methods
(1) Neurological surgery: sympathectomy (Royle) and posterior root cut of spinal nerve (Foerster) are no longer used. The anterior root cut (cervical, ~thoracic:) is only used for tardive dyskinesia, cerebral hemisphere cut can be used for spastic hemiplegia, which is not beneficial for functional recovery. Pale bulb dissection is used for chorea spasticity. The commonly used neurological surgery is motor nerve branch severing (stoeffel), which can improve the symptoms of the spastic muscle it is supplied to, commonly used for the anterior branch of the foramen ovale or the gastrocnemius or flounder muscle branch severing, respectively, for the correction of hip adduction, horseshoe foot or ankle clonus. In the upper extremity, cutting the anterior round muscle nerve branch can correct the anterior rotator contracture.
The posterior spinal nerve root dissection has recently been improved by cutting only the motor bundle (Fasono), i.e., cutting the 1a. class of fibers from the musculoskeletal afferents, blocking the loop in the spinal cord reflexes, and reducing peripheral excitatory afferents. A new relative balance of excitation and inhibition is achieved in the presence of pre-existing brain cell damage, thereby reducing abnormally high muscle tone, relieving limb spasticity, and improving the ability to care for oneself and receive care. At the same time, the sensory bundle is preserved and is adapted to the lower extremity spasticity type. For the upper limb spasticity type there is the use of carotid artery epicranial stripping, postoperative cerebral blood flow improved, symptoms have improved, but the mechanism has yet to be further explored.
(2) Tendon surgery: including tendon severing, lengthening and transposition surgery, which is helpful to correct deformity, obtain new balance and improve function. However, tendon transfer is not easy to achieve precise muscle balance in cerebral palsy, and to a large extent, it only plays the role of tendon fixation.
(3) Bone and joint surgery: If the deformity is still progressing under non-surgical treatment, soft tissue surgery alone cannot achieve satisfactory results and needs to be combined with bone and joint surgery to correct and avoid deformity and obtain stability. Such surgery includes bone lengthening or shortening, osteotomy and joint fusion, Guigui deformity also adapt to bone worry surgery weaving. They are usually performed after the age of 10-12 years.