17.3 Cerebral Palsy

Question 1

An 8-year-old child with severe cerebral palsy is scheduled for an elective femoral osteotomy.

a) Define cerebral palsy. (15%)

Answer 1

> > Permanent damage to the
developing brain in utero,
at birth or in very
early infancy.

> > Primarily affects motor function,
but may also impact on cognition,
sensation and communication.

> > Increased risk of epilepsy.

> > Very variable presentation.

Question 2

b) List the clinical effects of cerebral palsy on the central nervous
with their associated anaesthetic implications. (50%)

Answer 2

Central nervous system

1 Epilepsy.
Ensure medication is not missed when nil by mouth.
Ensure levels are checked if there is a recent change in seizure frequency.
Consider the impact of enzyme inducers and enzyme inhibitors.

2. Cognition or communication problems.
   May increase child’s anxiety.
   Involve carers, play specialist. Consider
   individual need for sedative/anxiolytic premedication but caution if child has respiratory compromise.

Question 3

List the clinical effects of cerebral palsy on the
gastrointestinal
systems with their associated anaesthetic implications.

Answer 3

Gastrointestinal
1. Swallowing difficulties, oesophageal dysmotility,
abnormal lower oesophageal sphincter tone.

Increased risk of reflux,
consider need for rapid sequence induction.

2. Swallowing difficulty.
   Poor nutrition, low weight,
   need to calculate based on weight not
   age,
   consider the possibility of anaemia,
   dehydration or electrolyte
   disturbance and treat preoperatively (may have PEG), difficulty with oral medications.
3. Risk of temporomandibular joint dislocation if
   affected by muscle spasticity.
   Possibility of difficult intubation –
   difficult airway equipment, asleep fibreoptic or video laryngoscopy may be indicated.
4. Poor dentition.
   May complicate airway management. Loose or decayed teeth should
   be managed in advance.

Question 4

List the clinical effects of cerebral palsy on the
respiratory
systems with their associated anaesthetic implications.

Answer 4

Respiratory
1. History of premature birth and gastro-oesophageal
reflux predispose to chronic lung disease.

Assess for acute infection.
Consider need for respiratory assessment,
physiotherapy.

May still require long-term oxygen therapy or CPAP.

2. Weak cough, respiratory muscle hypotonia,
   reduced immunity due to malnutrition.
   Increased propensity to lung infection –
   check for acute infection preoperatively.
3. Long term truncal spasticity
   results in scoliosis.
   Restrictive defect, pulmonary
   hypertension, cor pulmonale,
   respiratory and cardiac failure.

Question 5

List the clinical effects of cerebral palsy on the
musculoskeletal systems
systems with their associated anaesthetic implications.

Answer 5

Musculoskeletal

1. Spasticity causes fixed flexion deformities,
   joint
   dislocations.

Cannulation, monitoring and positioning problems.

2. Thin skin, little subcutaneous fat, atrophic
   musculature (large surface-area-to-weight ratio).

Prone to pressure sores,
poor heat conservation, poor wound
healing.

Need for careful padding and active warming at all times.

3. Immobility.
   Cannot assess cardiopulmonary reserve.

4.Non-weight-bearing long bones become
osteopenic.
Bone fragility, risk of fracture.

Question 6

c) What are the specific issues in managing postoperative pain in this patient? (35%)

Answer 6

> > Cognitive impairment or communication difficulties may make assessment of pain difficult.

> > Muscle weakness and cognitive impairment
may limit use of PCA.

> > Opioid analgesia may further
compromise lung function.

> > Painful muscle spasms precipitated by cold,
anxiety, pain. Consider epidural or regional nerve catheter to optimise pain relief.

Continue regular antispasmodic medications.
Epidural analgesia will necessitate
escalated level of care postoperatively.

> > NSAIDs may be contraindicated in the
presence of renal impairment due to chronic neuropathic bladder or nephroureteric reflux.