Cerebral palsy, also known as cerebral palsy and cerebral palsy. Cerebral palsy is a syndrome caused by damage or injury to the immature brain before birth, at birth, or within one month after birth, with motor and postural disorders as the main manifestations, and is often complicated by epilepsy, mental retardation, and speech disorders. It is basically synonymous with pediatric cerebral palsy. The lesions often damage the pyramidal tract and the extrapyramidal system. The disease is directly related to cerebral hypoxia, infection, trauma and hemorrhage. For example, rubella, herpes zoster or toxoplasmosis in early pregnancy, severe infection in middle and late pregnancy, severe gestational hypertensive syndrome and pathological obstructed labor can cause neonatal cerebral palsy. Wei Lin, Department of Neurosurgery, Shandong Qianfo Mountain Hospital
[Causes of cerebral palsy].
Causes include placental abnormalities, fetal malposition, intrauterine distress, prematurity, multiple births, asphyxia at birth, and neonatal hypoxic-ischemic encephalopathy, nuclear jaundice, infection, trauma, cerebral hemorrhage, brain malformation, etc.
1) Hypoxic asphyxia: including Fetal hypoxic asphyxia in the mother’s womb, neonatal hypoxic asphyxia during delivery, respiratory distress syndrome, peripheral circulatory failure, and erythrocytosis.
(2) Brain injury: such as infant brain injury during delivery, neonatal cranial injury or brain infection, cerebrovascular accident .
(3) Premature birth and fetal dysplasia: intrauterine infection, intrauterine growth retardation, congenital malformations. Newborn babies weighing less than 2500 grams are much more likely to have cerebral palsy (about 40% of children with cerebral palsy weigh less than 2500 grams)
4) Certain genetic diseases and neonatal nuclear jaundice.
5) Causes in pregnant women: including abdominal trauma in pregnant women, preterm abortion, prenatal hemorrhage in pregnant women, toxemia in pregnancy and placental causes (placental abruption, placenta praevia, placental necrosis or placental malfunction), and certain chronic diseases in pregnant women (hypertension, hepatitis, diabetes, drug addiction, drug overdose, etc.).
[Clinical typing of cerebral palsy].
Because the causes of cerebral palsy are diverse and the clinical manifestations vary with age, there is still no uniform classification. The first edition of the national seven-year “Neurology” planning textbook in February 2002 is divided into five types based on the nature and signs of movement disorders.
1. Spastic cerebral palsy is the most typical and common type. The main manifestation is spastic paraplegia mainly of both lower limbs. The child has difficulty walking and standing, and walks with a scissor gait on the toes. There is a marked increase in muscle tone, hyperactive tendon reflexes, and pathological reflexes may be present. It is often accompanied by speech and intelligence impairment.
2.Muscle tone incomplete cerebral palsy is mostly seen in young children, mainly manifesting as a marked decrease in muscle tone. They are unable to stand and walk, cannot lift their head and neck, have obvious movement disorders, have excessive joint movements, but have active tendon reflexes, and may have pathological reflexes. It is often accompanied by aphasia and low intelligence.
3, Hand and foot tardive cerebral palsy mostly develops from damage to the basal nucleus caused by nuclear jaundice and neonatal asphyxia. The child shows choreiform or tachycardia-like movements of the face, tongue, lips and trunk limbs. It is accompanied by motor disorders and increased muscle tone.
The main clinical manifestations are hypotonia, ataxia, intentional tremor, dysarthria and motor retardation.
The main clinical manifestations are hypotonia, ataxia, intentional tremor, dysarthria and motor retardation. 5.
Clinical manifestations of cerebral palsy
The manifestations of cerebral palsy can be divided into several types.
1. Spasticity (Spatic).
Spasticity is the second most common type of cerebral palsy in school children. Spasticity means that the muscles are stiff and inflexible. The main cause of this phenomenon is an incorrect transmission or message from the injured part of the brain to the muscles in the process of control. The normal phenomenon is that when we move, there will be two groups of muscles in mutual antagonism, a group of muscles contraction, the other group of muscles are relaxed, so as to produce the perfect action, if two groups, smooth muscle contraction at the same time, it will make the muscle becomes director tension, resulting in movement difficulties, stiffness.
2. Slow-motion type.
The most characteristic of this type is poor movement control, often exaggerated movements. In the early stage of tardive dyskinesia, the muscle tone is weak or hypotonic. As the patient grows older, without proper rehabilitation treatment, it often turns into a mixed type, such as hypertonic tardive dyskinesia.
3. Ataxia is characterized by muscle weakness in the limbs, inability to maintain body balance, unstable gait, and inability to complete fine movements such as pointing the finger to the nose. Simple ataxia is less common. Ataxia can also be associated with tardive dyskinesia. The child is often unable to maintain a fixed posture, and when standing, has to make frequent adjustments in order to maintain the standing position. Walking is learned later than in normal children. When walking to obtain a more stable balance, the feet are widely spaced from side to side and the gait is wobbly and poorly oriented.
The following symptoms can help in the early diagnosis of cerebral palsy.
(1) The child often cries little, moves little, cries weakly, and is excessively quiet shortly after birth. Or they cry a lot, are easily agitated, startle easily or have recurrent flesh jumping.
(2) Difficulty in feeding after birth, such as weak sucking, difficulty in swallowing, and poor oral closure.
(3) Uncoordinated, asymmetrical movements and little casual movement.
(4) Frequent abnormal muscle tone, abnormal posture and movement patterns.
(5) Motor development is delayed. For example, the 3- to 4-month-old child cannot hold his head upright in the prone position; after 4 months, he still cannot support weight with his forearms; his hands often make fists, and he cannot put his hands in his mouth to suck; at 6 to 7 months, he still cannot roll over and sit alone for a moment; when he is supported to stand, he cannot bear weight with his toes on the ground or with his legs flexed, or his two lower limbs are too straight or crossed, etc.
Diagnosis of cerebral palsy
1.Inquire whether there is any history of upper motor neuron dysplasia or damage, such as premature birth, difficult birth, high fever, cerebral ischemia, cerebral hypoxia, cranial injury, cerebral infection, etc.
2. Check for spastic paralysis, muscle movement disorders, muscle tone enhancement, hyperreflexia, muscle atrophy, joint deformity, ataxia and mental retardation.
[Auxiliary examination of cerebral palsy
Children diagnosed with cerebral palsy based on clinical manifestations must also undergo the following auxiliary examinations: ① intelligence test; ② electroencephalography; ③ brainstem auditory evoked potential measurement; ④ imaging and other examinations to confirm the diagnosis.
Prevention of cerebral palsy
1. First of all, before the child is born.
(1) Pregnant women should actively conduct early prenatal checkups and do perinatal health care to prevent congenital diseases in the fetus.
(2) Bad habits, such as smoking, drinking alcohol, and not abusing drugs such as anesthetics and sedatives, should be eliminated.
(3) Prevent viral infections such as influenza and rubella, and do not come into contact with cats, dogs, etc.
(4) Avoid contact with harmful and toxic substances such as radiation and frequent ultrasound examinations.
2.Fetal birth, i.e. during delivery. Fetal asphyxia and intracranial hemorrhage caused by delivery is an important cause of pediatric cerebral palsy. Preterm delivery and obstructed labor should be prevented. Medical personnel should carefully and meticulously handle all aspects of delivery and do all the treatments for difficult fetuses.
3.The fetus should be given better care and reasonable feeding within one month after birth, and intracranial infection and traumatic brain injury should be prevented.
4.Pregnant women with the following conditions should have prenatal checkups as early as possible.
(1) Older pregnant women (over 35 years old) or men over 50 years old.
(2) Marriage between close relatives.
(3) History of unexplained miscarriage, premature birth, stillbirth and neonatal death.
(4) Pregnant women with mental retardation or both close relatives with a history of epilepsy, cerebral palsy and other genetic diseases. If fetal abnormalities are detected in early pregnancy, the pregnancy should be terminated as soon as possible.
Psychological care of cerebral palsy
(1) Establish a good nurse-patient relationship with the child and set a special person for nursing care. Only with mutual trust and respect can the child reflect his or her psychological problems in a true and detailed manner, actively cooperate with the treatment and improve the treatment effect.
(2) Nursing staff can use conversation, questions and answers, and specific and effective scales or questionnaires to conduct psychological tests on children and their relatives to understand the psychological and behavioral problems of children and their relatives, and take corresponding nursing measures according to the psychological problems of children.
(3) Nurses should make frequent visits to the ward, communicate with the child, encourage the child to interact with others, ignore the misunderstanding and discrimination against cerebral palsy patients in the society, eliminate the fear, exercise social skills, and educate the child that he or she can still feed himself or herself through exercise and grow up to be a person with a disability.
(4) Instruct parents to help the child overcome the dependency mentality, not to do everything for the child, but to let the child do as much as possible on his or her own, to cultivate his or her sense of independence, so that he or she can take care of himself or herself, and to reduce the parents’ burden.
(5) Communicate with the child patiently, carefully, softly, slowly, use simple and clear language, listen patiently and adequately, and try to answer the questions raised by the child.
(6) Comfort and encourage the child more, and criticize less. When the child makes some progress, the nurse should give praise and encouragement in time.
(7) Assist parents to properly educate and guide the child, try to overcome psychological barriers, so that the child’s body and mind will develop in a healthy direction.
(8) Instruct parents to communicate with their children more often and tell them that the rehabilitation of children with cerebral palsy is a long-term or even lifelong process, and the training of the training staff alone is far from enough. The effect of half the effort is twice as great.
Myths about the treatment of cerebral palsy in children
Myth 1: Although some parents find that their children have unexplained crying, poor milk eating, too quiet, and body jerking when frightened before the age of half a year, they simply think that their children are young and weak, is it a cold? Is it bad digestion? Is it infected with other diseases?
Myth 2: When parents of premature babies see that their children lag behind other normal children of the same age in terms of rolling over, lying down, sitting, standing, walking and other motor development, they often simply think that it is caused by premature birth, and that the child will recover slowly with natural growth and development, and often take a “wait and see, wait” attitude.
Misconception 3: When parents find that their children have abnormal posture in sports, they often think that it is the child’s bones and muscles that have problems, and miss the time to seek medical advice.
Misconception 4: Once a child is diagnosed with cerebral palsy by a doctor, parents are often the first to blindly seek medical help, hoping that the child’s motor malfunction can be relieved through conventional “injections and medication”.
Principles of cerebral palsy treatment
1. There is no significant and effective treatment method for posterior brain cell injury lesions at the current Chinese and Western medical level.
2.Brain cell injury leads to central motor neuron disorder affecting limb flexibility, generally surgery and rehabilitation functional training are used to strengthen the amount of functional movement of limbs and enhance flexibility.
3, limbs such as the following symptoms: 1, the inner part of the femur (groin) tendon belt tight, 2, knee bending forward is not straight, 3, pawing the toe, heel does not reach the ground, 4, feet walking into scissor step, 5, bone deformation misalignment, 6, limb spasm and other symptoms must go to the regular medical unit surgery, so that the lower limb body straight, the sole of the foot flat; increase the support and balance of the lower limbs, walking activities to further The walking activity can be further improved.
Principles of surgical treatment for cerebral palsy
Surgical treatment of pediatric cerebral palsy occupies an important position in clinical treatment, especially when various non-surgical treatments are ineffective, surgical treatment becomes an important choice. However, children with cerebral palsy have a variety of clinical manifestations and different causes, which makes surgical treatment more difficult. Different treatment plans are available for each type of cerebral palsy in order to strictly distinguish the specific treatments for different types of patients.
1. Pediatric cerebral palsy: relationship between type and surgery
Spastic cerebral palsy is the most suitable surgical treatment.
2. Neurological status and intelligence
The child should have good intelligence, IQ above 70%, desire for treatment, and be able to cooperate with rehabilitation therapy after surgery.
3. The fixed deformity of limbs affects the rehabilitation training situation
If the deformity that is difficult to be corrected by manipulation affects the improvement of motor function, surgery is recommended to correct the deformity.
4. Principles of upper limb surgery
The motor function of the upper extremity is complex, and there are many fine movements, so the requirements for the treatment effect are higher, and it is hoped that the fine motor function of the hand can be restored. Therefore, it is more difficult to correct the deformity of the upper limb and restore the random motion function of the hand. It is required that the recipient of the upper limb should have good intelligence, strong desire for rehabilitation, and be able to actively train after surgery, and should have a certain degree of random motor function before surgery.
5. Principles of treatment of polyarticular deformity of lower limbs
For children with multiple joint deformities of the lower limbs, such as hip, knee and ankle, the joint deformities should not be corrected at the same time. For example, hip flexion contracture or horseshoe foot can be followed by knee flexion changes, and knee flexion changes can often be improved after the primary deformity is corrected. Therefore, it is advisable to judge the primary deformity carefully before surgery and to correct it surgically. After surgery, the adjacent joints should be closely observed for a period of time, and depending on the changes, the need for subsequent surgery should be carefully decided.
6. Accurate determination of spastic and antagonistic muscle strength
The muscle strength of the spastic deformity and its antagonist muscles should be measured before surgery, so as to make a correct judgment and design an accurate surgical plan.
7. Prevent complications of hip dislocation
If the child has strong hip inversion with a tendency of hip dislocation, it is advisable to perform early soft tissue release surgery on the inner hip to adjust the balance of muscle strength in order to prevent hip dislocation.
8. Solve the difficulties of living care for children with severe cerebral palsy
Children with severe cerebral palsy are unable to overcome limb deformities or postural abnormalities, which seriously affect their daily life. Those who have extreme difficulties in nursing care should be implemented surgical orthopedics to adapt to the needs of nursing care and life. For example, if both lower extremities are severely crossed and unable to care for urination and defecation, although there is no standing and walking after surgery, the severed hand of the adductor muscle should also be performed
9. Post-surgical rehabilitation
Cerebral palsy is very different from other orthopedic disorders, and the outcome after surgery is also very different. It is wrong to think that the surgery is completed successfully, and the recurrence of deformity in many children after surgery is a good illustration. In order to prevent recurrence and to improve the therapeutic effect, rehabilitation and orthotic devices are necessary after surgery.
10. Purpose of surgery
The main purpose of surgical treatment is to release muscle spasm, balance muscle strength, correct deformity, adjust the negative gravity line of the limb and improve motor function.
At present, the main procedures frequently performed by the Department of Neurosurgery of Shandong Province Qianfo Mountain Hospital include: selective posterior rhizotomy (SPR), selective partial peripheral nerve dissection, and sympathetic net stripping of the common carotid artery, etc.
1. selective posterior rhizotomy (SPR)
The modern SPR (lumbosacral) was founded by Fasano in Italy in the late 1970s, and his innovation was the use of intraoperative electrical stimulation. Peacok in the United States in the late 1980s made further improvements by lowering the SPR plane to the level of the cauda equina. These two scholars made great contributions to the promotion of modern SPR.1,2 In 1990, the Journal of the American Medical Association published an article affirming the safety and effectiveness of SPR in the treatment of spastic cerebral palsy, and SPR was introduced into China in the same year. Clinical practice over the years has demonstrated the importance of this procedure in the treatment and rehabilitation of spastic cerebral palsy[1,2,4,5] . Currently, lumbosacral SPR has been performed in several medical units in China, and cervical SPR has been successfully performed in several large medical centers to treat upper limb spasticity states with satisfactory results.
Source :Medical Education Network
Lumbosacral SPR is indicated for patients with multiple spasticity of the lower extremity joints such as hip, knee and talofibular (ankle) at the same time. The procedure should be performed under general anesthesia and without intraoperative muscle relaxants. The width of the laminectomy is as small as possible, preserving the small articular processes on both sides, and this osteotomy does not have a major impact on the stability of the spine. The surgery is performed under a microscope after cutting the dura, and the posterior root of the spinal nerve is partially severed after applying a neuromuscular electrophysiological stimulator for strict selection. If the neuroendoscope is applied to lumbosacral SPR, the anterior and posterior roots of the spinal nerve can be more accurately identified, variants such as nerve coaptation and exit abnormalities can be detected, and the strain on the nerve can be reduced, and the extent of laminectomy can be further reduced, which can further improve the safety and effectiveness of the operation and is worthy of further study and promotion. This technique has not been reported at home and abroad.
The efficacy of cervical SPR is not inferior to that of lumbosacral SPR, but because the operation in the lower cervical segment has the risk of damaging the cervical medulla leading to paraplegia, and the laminectomy range is larger in order to fully reveal and reduce the strain, which increases the possibility of postoperative cervical instability, it is recommended that the indications for the operation should be more strictly controlled, and that the operation should only be performed by senior physicians with rich experience in microscopic neurosurgery in units with better medical conditions. It should not be promoted blindly.
2. Selective partial peripheral nerve dissection
Selective Partial Neurotomy, also known as selective microdiscectomy according to Japanese custom, was formerly known as peripheral neurotomy. Although the complete severance of the peripheral nerve can greatly relieve spasticity, there are serious disadvantages such as low muscle strength, sensory impairment, and establishment of antagonistic deformity. One of the improvements of microdiscectomy is the intraoperative application of the neuromuscular electrophysiological stimulator, and the second is the selective partial severance of the peripheral nerve instead of total severance. This procedure has been carried out more widely in Europe and the United States, with definite efficacy in long-term follow-up [1,2,6], but it has not been promoted in China, and there is a lack of accumulation of large number of cases and experience. The surgery is performed on the tibial nerve (for ankle spasm), sciatic nerve (for knee spasm), musculocutaneous nerve (for elbow spasm), median nerve (for wrist and finger spasm), closed nerve (for thigh adductor spasm), and brachial plexus nerve (for shoulder adductor spasm) for selective microscopic reduction of spasm in different parts of the extremities, which has the advantages of small incision, less bleeding, precise efficacy, and fewer complications, especially It is especially suitable for children with single and limited symptoms and signs, and is in line with the principle of early treatment of cerebral palsy. Although this procedure is simpler and easier to perform than SPR and is more suitable for dissemination at the primary level, it is emphasized that the procedure must be performed under a microscope and carefully selected using a neuromyographic stimulator to achieve optimal results.
3. Bilateral sympathetic network stripping of the common carotid artery sheath
Bilateral sympathetic net stripping of the common carotid sheath (i.e., cervical desympathectomy) can be effective for tardive and partial torsion spastic cerebral palsy, and may improve symptoms such as salivation, strabismus, slurred speech, and ataxia in some patients with minimal surgical trauma and risk.