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 walking to the exclusion of overall development the child’s interest will not be served in the long term.

  Surgery for cerebral palsy in the lower limb

  Toe walking

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.