Lecture 9: Neurosurgical Management of Spasticity Flashcards
Define: cerebral palsy
results from brain damage before, during, or after birth.
group of conditions that affect movement and posture
State some consequences of cerebral palsy
CP affects movement and posture and produces lifelong disabilities.
CP is irreversible, and despite medical advances, 1/500 children are afflicted.
About 80% of children with CP have spasticity. Often develops overtime. Noted often during walking stage
What are the adverse effects of spasticity
- Interference with voluntary movements
- Inhibition of longitudinal muscle growth
- Limited stretching of muscles in daily activities * Development of muscle and joint deformities; these are not present at birth.
State some CP spasticity treatment
CP spasticity is treated (aggressively) with oral medications, Botox, baclofen infusion, braces, physical therapy, orthopedic surgery and/or selective dorsal rhizotomy surgery
What is selective dorsal rhizotomy
neurosurgery to cut specific dorsal roots in an attempt to reduce spasticity
only surgical procedure that can provide permanent reduction of spasticity in CP
attempts to restore proper balance of sensory information from sensory nerves and inhibitory signals from the brain by cutting some sensory nerves. thus, bringing person closer to normal muscle tone.
Describe the surgical procedure for selective dorsal rhizotomy
- performed under general anesthesia for about 4 hours
- A 5-10 cm incision is made along the center of the lower back just above the waist.
- Retract away paraspinal muscles
- Laminectomy performed in 1 or 2 vertebrae.
- The surgical team divides each of the dorsal roots into 3 to 5 rootlets.
- Each rootlet is electrically stimulated to identify which cause spasticity.
- measure EMG of extensor muscle. Large signal = muscle is responding vigorously to electrical stimulation of dorsal root.
- Abnormal nerve rootlets are selectively cut, other rootlets are left intact.
- Skin is closed with glue; no stitches are required.
- Surgery takes 3-4 hours, depending on the age of the patient.
Ultrasound and x ray are used to locate tip of spinal cord
Rubber pad is placed to separate motor from sensory nerves to avoid cutting ventral root.
Rootlets are ranked from 1 (mild) to 4 (severe) for spasticity. The severely abnormal rootlets are cut.
What are the essential criteria for selective dorsal rhizotomy for children? and factors to be considered?
Essential Criteria
* Diagnosis of spastic diplegia or spastic quadriplegia
* Premature birth or full-term birth with typical signs of spastic diplegia.
* Two years of age or more.
* Based on MRI examination, no significant damage to key brain areas involved in posture and coordination.
* At least 3 months since last Botox injection.
* Botox tones the spasticity down. You want to make sure the effect of botox is washed out
Factors to Be Considered (ideal candidates)
* Adequate muscle strength in the legs and trunk, demonstrated by ability to:
o support full weight on the feet
o hold a posture against gravity
o make appropriate movements to crawl or walk
o move quickly from one posture to another
- History of delayed motor development. Able to crawl, sit and pull to stand by age 2 but spasticity hampers the development of skills and/or causes gait deviations.
- At least 1 year since an orthopedic procedure, to allow muscle strength recovery.
- little to no fixed contractures in the lower limbs
- strong motivation and support
What are the essential criteria for selective dorsal rhizotomy for adults? and factors to be considered?
Criteria:
* diagnosis of spastic diplegia
* history of premature birth
* currently walks independently without an assistive device
* relatively mild fixed orthopedic deformities
* potential for functional gains after dorsal rhizotomy
* motivated to attend physical therapy and perform home
exercise program
In adults only a single level laminectomy is required.
Therapy will be the same as for children immediately following surgery, but the frequency may be reduced faster in the longer term.
What age is SDR recommended?
Early surgery (ages 2-5) is recommended before the child has developed leg deformities
Describe what parents of CP patients can expect post op SDR in the first few days
- Catheter in bladder and IV line
- Catheter will be removed before they leave ICU
- Legs less stiff than before surgery
- Children can move legs but not as well (weak). They don’t have sensory assisted drive as they did before surgery. Will resolve with physical therapy
- Medication to relieve pain and reduce muscle spasms
- As the patient was lying face down during surgery, face will appear swollen. Facial swelling will disappear in 24-48 hours
- Fluids can be taken by mouth by 2nd-3rd day
- Positioned on the back or in a side lying posture and will be turned from side to side every 4-6 hours
- patient can leave after 7 days post op
Describe what parents of CP patients can expect post op SDR in the following weeks and months
3-4 weeks of recovery at home before returning to school or work
- vigorous physical activity needed for rehabilitation. patient must remain supported and motivated during this time for maximal surgical benefits.
- patients who walk independently can resume walking independently after a few weeks. patients who walk with crutches can assume crutch walking after a few weeks. walker walking before and walker walking after.
patients who use a walker and assistance require much longer time to resume level of walking they were capable before SDR
after spasticity is reduced, it becomes easier to increase strength with therapy and exercise.
improvements are most noticeable in the first 6 months after SDR. thereafter, improvements are slow but steady. in children can continue up to 10 years of age. in adults up to 2 years
What are the possible complications of SDR?
- Paralysis of legs and bladder
- Loss of sensory in the legs and bladder
- Wound infection and meningitis
- Leakage of spinal fluid through the wound
- Abnormal sensitivity of skin of the feet and legs (usually resolves)
- Most common: spinal problems if there is a multilevel laminectomy
- To prevent: single level laminectomy
- low back pain
- scoliosis or kyphosis
For what kind of patients is SDR possible to fail?
spastic quadriplegia
Describe the difference in spasticity in SCI and CP patients
Spasticity is not useful for any activities for a CP patient
Spasticity can be helpful for those with SCI though. Can help them take steps or stand
Why can’t shortened muscles and tendons be released after SDR in patients with contractures that have been present for many years?
permanently shortened and requires surgical release
