CP Pathology and Surgeries Flashcards
Review: Define CP
An inclusive term to describe a group of nonprogressive disorders occurring in young children in which disease of the brain causes impairment of motor function.
- Secondary changes in the musculoskeletal system
may progress throughout growth
What can spasticity cause?
Spasticity ->
Inability to stretch muscles during normal play ->
Muscle contractures ->
Abnormal skeletal forces
What are some orthopedic problems for children with CP?
Spastic hip disease
Spinal deformity
Ankle/Foot deformities
What are the four priorities for CP patients?
- Communication
- ADL’s
- Mobility
- Walking
What are some oral interventions and what do they address?
Diazepam, Baclofen, Tizanidine
- Decreases tone
SE: Sedation, weakness, hypotonia
What are the secondary problems for patients with MS that can be changed/impacted?
Muscle contracture/Bony abnormalities ->
PT/Orthotics ->
Orthopedic surgery ->
Muscle lengthening, Muscle transfer, Osteotomy/Arthrodesis
What are some injectable interventions and what do they address?
Botulinim toxin A (botox)
- Irreversibly blocks acetylcholine release by nerves at motor end point (Reversible chemical denervation)
Phenol/Alcohol nerve block
- Similar to Botox but lasts longer
Who is a good candidate for botox and how long does it last?
Lasts ~4-6 months
Patient selection
- Dynamic muscle contracture
- Limited number of muscles involved (< 4)
Goals
- Delay surgical intervention
- Facilitate stretching
- Adjunct to PT, casting
- Simulates surgery
What is a surgical intervention and what does it address?
Dorsal Rhizotomy
Decreases stimulation from muscle spindles – section of sensory rootlets
- Weakens muscle
- Prevents need for
orthopaedic surgery ~ 50%
Who is a good candidate for Dorsal Rhizotomy surgery?
Patient selection is critical to success
- Pure spasticity
- No fixed contractures
- Good selective motor control
- 4-8 years old
- Adequate cognition to cooperate with rehab
Ideal SDR Candidate
- 3-8 y/o spastic diplegic
- Former preemie, LBW, with severe, pure spasticity
- Extensive postop rehab required
What is the result of Dorsal Rhizotomy surgery and what are some side effects?
Results
- Permanent decrease in spasticity
- Supraspinal effects
- Upper extremity function
- Bladder function
- Speech, swallowing
Complications
- Dysesthesias, weakness, neurogenic bladder, sensory loss
Effects on musculoskeletal system
- Effect the need for orthopaedic surgery?
- Spinal deformity
- Scoliosis, spondylolisthesis, hyperlordosis
- ? Hip subluxation
What is an Intrathecal Baclofen and why would one have that surgery?
Neurosurgical procedure
- Local delivery to spinal cord
- Intrathecal catheter
- Subcutaneous pump
- Complications in up to 25%
Indications
- Spasticity
- Interferes with function or ease of care
When does PT intervene for CP patients?
Children < 3 (early intervention)
Post-operative PT
Targeted interventions
“Primary care”
When would a serial cast be used and how often are they changed?
Mild spasticity/contractures
Dynamic deformities
Casts every 1-2 weeks for 6-8 weeks
Recurrence a problem
When would an orthotic be used and what can they help?
Prevent deformity
Stabilize joints
Substitute for weak muscles
Rarely go above knee
What are the primary problems in orthopedic treatment of CP?
Loss of selective motor control
Balance
Spasticity - leads to secondary problems
(permanent)
What are the secondary problems in orthopedic treatment of CP?
Soft tissue contracture
Bony deformities
(may be corrected)
What are the tertiary problems in orthopedic treatment of CP?
Compensation for primary and secondary problems
What is “Lever arm dysfunction”?
Alteration in the leverage relationships necessary for normal gait
Correction increases magnitude of moment acting on joint
What is included in a preoperative evaluation?
Collect data
- Functional level
- ROM, strength, selectivity
- Observational Gait Analysis
- Radiographs
Generate problem list
Instrumented motion analysis
What are the goals for a multiple LE procedure?
Correct lever arm problems
Lengthen muscles that are short
Transfer muscles that are out of phase or creating deformities
Adequate rehabilitation
Describe muscle-tendon lengthening and what are some issues that may occur?
For dynamic and static soft tissue contractures
- Multiple techniques
- Weakens muscle
- May decrease tone elsewhere
Describe tendon transfers and what are some issues that may occur?
Substitutes for weak muscles
- Changes pull of overactive muscles
- Weakens muscle
- Complete vs. Split transfers
Describe bony surgeries and what do they provide?
Osteotomies
- cutting and realigning bones
- corrects deformity
(Hip)
Fusions
- joining bones together
- decreases motion
- stabilizes
(Spine, Foot)
What are interventions for ambulatory (hemiplegia/diplegia) CP patients?
Both soft tissue and bony pathology may occur at hip, knee, and ankle
Address all components at once
- Lengthen muscles that are short
- Transfer muscles that are out of phase or creating deformities
- Correct lever arm problems
Have realistic goals
Adequate rehabilitation
Will still need orthotic support
Will still have problems with selectivity, balance, and spasticity!
What are some common gait deviations for the hip?
Internal rotation gait
- Femoral torsion
- Muscular forces (Glut Min, TFL)
Flexion deformity
What are some surgical interventions for internal rotation gait hip?
Intramuscular Psoas lengthening
Derotational Osteotomy:
- Internal femoral torsion +/- coxa valga
What are some common gait deviations for the knee?
Excessive flexion in stance phase
- Hamstring contracture
- Torsional deformity
Impaired clearance in swing phase
- Spastic rectus femoris
What is a surgical interventions for knee gait deviations?
Fractional Hamstring lengthening: for “functional” HS contracture
Rectus femoris transfer: for spastic RF
Medial Hamstring Lengthening
Tibial derotational osteotomy: torsional deformity
What are some common gait deviations for the foot/ankle?
Loss of Stance phase stability
Impaired clearance in swing phase
Impaired prepositioning
What is a surgical interventions for equinus?
Preferably using a gastroc soleus recession technique
Avoid Z-lengthening if possible
- Soleus essential for stance phase support and power generation
What is Equinovalgus and what causes it?
Muscle imbalance of gastroc - make foot move into valves
Most common in diplegia
What is the surgical treatment for Equinovalgus ?
Treat equinus first
Lateral column lengthening
- Gastrocsoleus lengthening
- Calcaneal osteotomy
- Forefoot varus (bone block for lengthening)
OR
Triple Arthrodesis (fusion surgery)
What is the surgical treatment for FLEXIBLE Equinovalgus? (club foot)
Tibialis Posterior, Tibialis Anterior, both
Intramuscular Tibialis Posterior lengthening
Gastrocsoleus lengthening
Split tendon transfer
What is the surgical treatment for FIXED Equinovalgus? (club foot)
Hindfoot (Calcaneal osteotomy)
- Lateral closing wedge
- Sliding
Midfoot
- Dorsolateral closing wedge of cuboid
Forefoot
- Dorsiflexion osteotomy medial column
Triple arthrodesis
What results from a crouch gait?
Loss of PF/KE Couple. (Lever-arm dysfunction, Soleus insufficiency)
2 degree Contractures of hip & knee flexors
Contracture of posterior knee capsule
Quadriceps insufficiency/Patella alta
How can crouch gait be treated?
Serial casting
Hamstring lengthening
“Guided growth” with Plate or staples
Hamstring lengthening + posterior capsulotomy
Distal femoral extension osteotomy and patellar ligament advancement
What are the priorities for Quadriplegia/non-ambulatory CP patients?
Communication
Activities of daily living
Mobility
Only ~20% Ambulate
What are the goals for Quadriplegia/non-ambulatory CP patients?
Wheelchair to maximize function
Spine: straight enough to sit
Hips: located, mobile, painless
Knee: motion for sitting and transfers
Feet: plantigrade
What are some issues that result if a patient has hip displacement?
Pain
Sitting difficulty
Pelvic obliquity/scoliosis
Ease of care
What causes spastic hip disease?
Soft tissues
- Spasticity/muscle imbalance
- Adduction contracture
How do we screen for spastic hip disease?
Imaging, using Reimer’s Migration Index
CP Normal: < 30%
Subluxation: >30%
Dislocation: >90%
How to screen for dislocation potential?
Clinical = hip abduction
Baseline AP pelvis at 18 months
AP pelvis every 6 mos if “at risk”
What are the treatment options for hip subluxation in each phase?
Early = Soft tissue lengthening (preventative)
Bony changes = Reconstruction
End stage = Salvage
What are some surgical treatments for hip subluxation?
Soft tissue lengthening (early)
Femoral Osteotomy
Pelvic Osteotomy
Open reduction
Acetabuloplasty
What % of CP patients with spastic Quadriplegia will have scoliosis?
39-75%
Gets worse with skeletal maturity
What are treatment options for scoliosis?
Observation
- Small or nonprogressive curves
Nonoperative
- Wheelchair modifications (controls pelvis, trunk, head/neck)
- Bracing (does not prevent progression, improves function)
Operative
- Spinal arthrodesis (fusion)
What are the indications/considerations for surgical interventions for scoliosis?
Curve magnitude/progression > 40 - 50°
Sitting imbalance (loss of UE use)
Visceral problems or pain
Degree of intellectual disability?
What are the benefits for spinal fusion to address scoliosis?
Sitting balance/endurance
Use of upper extremities
Pulmonary function
Feeding/nutrition
Ease of care, transportation
Decreased pain
What are the complications for spinal fusion to address scoliosis?
Occurs in 48-81%
Respiratory (Atelectasis, Pneumonia)
Gastrointestinal (Reflux/aspiration, Ileus, SMA syndrome)
Skin/Wound
Infection (Superficial, Deep [5-8%])
Implant Related
Pseudarthrosis
What is athetoid CP?
Abnormal tone and
tension
Increases with activity
Squirming or writhing motion
Constant
Disappears during sleep
Complications and considerations for athetoid CP?
Kernicterus
Many are non ambulators
Soft tissue surgery unpredictable
Scoliosis
Cervical spine disease in adults
What is the orthopedic treatment process (summary)?
Define problem list
Address all components at once
Have realistic goals
Adequate rehabilitation
Pts will still need orthotic support and will have problems with selectivity, balance, and spasticity!
