Cerebral
palsy
Children with cerebral palsy are usually floppy babies at birth. It is
some months before the spasticity starts to develop. Even if the cerebral
palsy is severe, intelligence is usually normal. It is a grave mistake to
underestimate the intelligence or comprehension of these children.
Nonoperative
treatment
These children will need assessment of their special needs in terms of
walking aids, wheelchairs, etc. They will also need intensive physiotherapy to
avoid deformity during growth. The imbalance of muscles across joints and growth
plates during the growing period can lead to abnormal growth of bone which can
then be v&y difficult to correct later in life. This is especially true of
the spine where a particularly vicious form of scoliosis may develop which is
very resistant to treatment. Although every effort should be made to help the
child walk, this goal should not become the only goal to the exclusion of
everything else. If a child with severe cerebral palsy of the lower limbs does
succeed in walking, this is likely to be a temporary triumph. As they get older
they are likely to go off their feet again and return to a wheelchair. If all of
the parents’ and the child’s efforts are devoted to
Children with cerebral palsy frequently walk on their toes and appear
unable to bring the heel to the floor. There can be several reasons for this. If
they have a fixed flexion deformity to the hip and a flexion deformity at the
knee, the only way in which the foot can get to the ground is by toe walking.
Under these circumstances attention should be directed to the hip and/or the
knee. If however, correction of the flexion deformity of the hip will not get
the foot plantigrade because the tendo achilles is tight, then there may be a
place for releasing the tendo achilles at the same time. The old cerebral palsy
philosophy was to release one joint at a time, and to review the situation. This
was because the release of one muscle group appears to have profound effects on
the others. The problem with this was that the child was subject to multiple
admissions to hospital before any correction was obtained. A newer approach is
to do a global approach to the whole limb releasing hip flexors and adductors as
necessary, lengthening the hamstrings behind the knee and lengthening the tendo
achilles at the heel. The problem with this one-stage global correction is that
the muscles affected by cerebral palsy may already be weak. They will be
further weakened by surgery and there may not be adequate strength to hold the
leg straight when walking. Some deformities actually help other deformities. For
example, if the child is walking with bent knees and weak quadriceps, a fixed
plantar flexion of the foot may bring the centre of gravity forwards and provide
sufficient power to help the quadriceps to extend the knee and allow the child
to walk. Release of the tendo achilles may improve cosmesis but remove the
support to the quadriceps so that the child can no longer walk.
In
the upper limb spasticity tends to flex the wrist, claw the fingers and draw the
thumb into the palm, making the hand functionless and cosmetically unattractive.
Fusion of the wrist in slight extension with release of the finger and thumb
extensors may improve cosmesis but is unlikely to improve function unless some
active flexion of the thumb and fingers is maintained. On the whole tendon
transfers in the upper limb for cerebral palsy do not work as muscles lose power
when transferred and lose range of movement.
Release
of tendo achilles
The tendo achilles can be released with a triple cut through three
percutaneous stab incisions. Each incision enters the tendo-achilles vertically.
This scalpel blade is then turned to the right angle and half of the tendon is
cut through. The superior cut and inferior cut are medial, the middle cut is
lateral. Stretch applied to the tendo achilles then results in a sliding release
of the tendo achilles which will heal quickly in the lengthened position. The
child is put in a plaster with the foot fully dorsiflexed and mobilisation
started as soon as possible.
Release
of the hamstrings
Hamstring release should allow the knee to come straight but in the
older patient it may be necessary to release the posterior capsule of the knee
as well. This is a very major undertaking and risks damage to the neurovascular
bundle behind the knee. It is particularly difficult if the flexion deformity is
very severe because access to the back of the knee becomes very difficult.
Adductor
tenotomy of hip
The adductors of the hip can be released through a subcutaneous
incision. If the femur is held firmly by the assistant applying steady pressure
into abduction, the tendons can be felt tight as bow strings and divided as they
insert into the ischial tuberosity. Adductor tenotomy dramatically improves the
ability of a child to sit in a chair and makes perineal toilet much easier.
Scoliosis
This can be severe and aggressive in a child with cerebral palsy.
Surgery will prevent any further growth of the spine but correction may have
to be undertaken early because pulmonary function is being compromised by the
deformity of the spine.