Surgical Options for Treatment of Spastic CP

Spastic cerebral palsy can cause a wide array of symptoms that may negatively impact a person's life. A person with spastic cerebral palsy has excessively stiff muscles, which can be mild or severe. This muscle stiffness is caused by a defect in the brain which distorts movement signals to the muscles. Muscle stiffness can make it difficult or impossible to move certain parts of the body.

Spastic CP may affect the upper body, lower body, or both. It may also affect one or both sides of the body. Muscles that remain tight and strained can make it hard for a person to move certain parts of their body or they may not be able to walk at all. Other related conditions that are commonly found with spastic cerebral palsy include vision and hearing loss, trouble swallowing or digesting, and hydrocephalus.

Surgery for spastic cerebral palsy is one option available for the treatment of symptoms. Physical therapy and medication are first-line treatments for spastic cerebral palsy but in some, they cannot provide a permanent fix for mobility problems or muscle abnormalities. If you or a loved one suffer from complications of this condition, surgery can be extremely beneficial if other treatments do not address the underlying causes of certain symptoms.

Surgery mainly focuses on the legs, ankles, feet, hips, wrists, and arms. These operations are performed on the muscles, tendons, bones, and nerves. Surgery can improve a person's mobility, align their muscles, and correct posture. More importantly, surgery can increase a person's quality of life, especially for children that can have their complications fixed early on and therefore lead a more independent life. Without surgery, a person's condition has the possibility of getting worse over time if other medications are ineffective.

Each Spastic CP patient has different symptoms and levels of severity. The benefits of surgery should outweigh any risks associated with the procedure. The first step is to identify what conditions can be improved or fixed with surgery. Some complications of spastic cerebral palsy that surgery can help with include:

• Correcting scoliosis or curvations of the spine
• Reducing tremors and spastic muscles
• Lengthening shorted or stiff muscles
• Improving posture
• Improving walking ability and coordination
• Relieving pain associated with symptoms
• Correcting abnormal joints and tendons
• Fixing foot and toe deformities
• Preventing hip dislocation
• Improving vision or hearing
• Correcting hydrocephalus
• Relieving gastrointestinal problems
• Preventing further complications from developing in the future

To determine if surgery is a viable option, you should discuss with your doctor all of your present symptoms and the types of treatment you have previously used. Your doctor may weigh in other factors, such as a person's age, their functionality, and their access to treatments and rehabilitation.

Surgery tends to have better outcomes for those who can walk independently^[5]. For those who cannot walk, surgery can be less successful and an individual may want to pursue other available treatments. Children can also be good candidates for muscle and joint repair as they are still growing and physical therapy can help strengthen their muscles while they develop^[6].

Surgery can be a good consideration for those who have tried multiple treatments that have failed. Some therapies and medications are not strong enough to treat severe complications. If you have been struggling to find something to relieve your symptoms, surgery can be a good option to improve your condition.

Surgery should be considered if the benefits outweigh the risks. Even if the symptoms are severe, complications and side effects from surgery can be permanent and possibly exacerbate those symptoms^[1]. When thinking about benefits, consider the long-term goals of the surgery and how much improvement can be added to your life. Parents of children with spastic cerebral palsy should think about the development of their child's body and the way the surgery will affect it as they grow.

Some risks of surgery include:

• The surgery not being effective or providing minimal difference
• One surgery may end up requiring additional surgeries later
• The effects of surgery being temporary
• The surgery becoming the cause of another symptom
• The surgery may involve a long recovery process and intensive post-treatment
• A person may not be able to go to rehabilitation

Deciding whether or not to get surgery can be a serious and time-consuming process. To help make an informed decision, it could be a good idea to have your doctor reach out to other specialists and involve them in creating a unique plan for you.

There are several different types of surgery to address the symptoms caused by spastic cerebral palsy. Some surgeries are used to fix symptoms directly related to a person's brain injury, while others help with co-occurring conditions that are associated with it. Surgeries for spastic cerebral palsy include orthopedic surgery, ambulatory surgery, non-ambulatory surgery, and selective dorsal rhizotomy.

Orthopedic surgery is one of the most common types of surgery used for treating spastic cerebral palsy and is usually considered after other treatments were proven unsuccessful. Orthopedic surgery is aimed at improving mobility, fine motor skills, gross motor skills, balance, and coordination.

Orthopedic surgery for cerebral palsy is most commonly seen for long bone torsion, knee flexion, contractures, foot deformities, and ankle equinus contractures.

The surgery is performed on bones, ligaments, joints, tendons, nerves, and muscles. The actual location for the surgery can focus on either upper or lower extremities but is usually more successful for upper extremities due to a lower risk of sensory damage. Orthopedic surgery is also popular because of the ability to greatly reduce pain in the affected areas^[1].

There are six different types of orthopedic surgery, and each one has its benefits.

• Muscle lengthening: Muscles are surgically lengthened to relieve contractures and improve fine motor skills. Surgery relieves tightness in extremities such as the hands and fingers, and arm muscles can be lengthened to allow better grasp on objects. Hamstrings and heel cords are also common locations for muscle lengthening. This type of surgery is beneficial for preventing other muscle complications that could develop in the future.
• Tendon lengthening: Similar to muscle lengthening, this surgery is performed to help contractures and can help a person walk or sit upright. While this surgery can be extremely beneficial, some doctors are becoming more cautious when recommending it as new evidence has indicated that there could be long-term side effects. Still, it remains popular for being minimally invasive and requiring little rehabilitation.
• Tendon transfer: One common symptom of spastic cerebral palsy is the muscle being constricted and pulled towards one direction. This is why some people with spastic cerebral palsy have feet that point inwards. Tendon transfer involves cutting and transferring a tendon to improve alignment and extension of muscles. This type of surgery can relieve pain or walking problems associated with deformed muscle tension.
• Tenotomy/Myotomy: Tenotomy is the cutting of a tendon and myotomy is the cutting of muscle. This can increase muscle function, fine motor skills, and help a person regain the ability to control their upper limbs. People who are at risk of hip problems, such as fractures, can be good candidates for this surgery.
• Osteotomy: Osteotomy refers to surgery on the bones, primarily used to align joints to help a person's mobility. During this procedure, the surface of the bone is cut and reshaped on areas like the hips, knees, and ankles. This surgery is common in children who have problems with hip dislocation.
• Arthrodesis: This surgery is used for those who experience severe muscle spasticity. Arthrodesis permanently fuses bones into a permanent rigid position after removing damaged cartilage and shaping the bone. Motion in the affected area will be lost, but ultimately improves a person's ability to walk and reduces pain.

Selective Dorsal Rhizotomy

Selective Dorsal Rhizotomy (SDR) is a type of surgery that is usually limited to individuals that suffer from the most severe muscle spasticity. This procedure is much more aggressive and invasive compared to other surgeries. But this approximately four-hour procedure is the only treatment that can permanently fix a spasticity^[5].

SDR involves cutting sensory nerve fibers attached to the spinal cord that are connected to the muscles. Surgeons can identify which specific nerve fibers are causing spasticity and then cut them to limit the number of chemical messages sent from the brain through them. Patients will come out of surgery with the ability to voluntarily control their movements.

The downside to SDR is that it requires long and intensive post-surgical physical therapy to learn and regain muscle movement^[7]. Individuals who decide to get this procedure should be prepared for an extensive rehabilitation process that requires a full-time commitment to fully recover. However, if completed, the benefits from this spasticity surgery can be life-changing and complications are generally rare^[4].

Is selective dorsal rhizotomy the right procedure for your child?  It depends.  If your child has some ability to walk but is impeded by spasticity, this spasticity surgery may be a good option.  It is also a viable option for any child that has spasticity impacting all four limbs and that spasticity makes ongoing care for the child a challenge.

When considering surgery, doctors may also suggest repairing co-occurring conditions while they fix a direct symptom. These secondary conditions do not stem directly from the brain injury but come about due to complications of the condition. Fixing these problems in addition to the primary surgery can further improve a person's quality of life by having one less condition to suffer from.

• Cochlear implants: Hearing problems are common in people with cerebral palsy with up to 15% of individuals having some kind of impairment. A cochlear implant is a device that can be surgically implanted inside the ear to restore the ability to hear. The device is made up of two separate parts, one that remains inside the ear and one that rests outside of it. A cochlear implant is different than a regular hearing aid, instead of simply amplifying sounds it helps a person interpret what they are hearing.  If cochlear implant surgery was not an option for your child in the past, you might want to check in with your doctor again.  The technology is moving forward quite quickly.
  
• Gastrostomy: Constricted and abnormal muscle tone can affect a person's ability to swallow and digest food properly. This can cause a person with spastic cerebral palsy to lack the necessary nutrition and cause a great deal of inconvenience. Gastrostomy is essentially a feeding tube that is permanently installed inside the body to ensure nutrition is being processed the right way. It is painful to see your child with a feeding tube. But it is not necessarily permanent and it can be a path to a smoother feeding process. 
  
• Hydrocephalus: Hydrocephalus is one of the rare complications that can happen with spastic cerebral palsy. Cerebrospinal fluid accumulates in the skull, making the head appear large or bulging. This complication requires surgery to fix and could be fatal if left untreated. The procedure involves installing valves inside the skull to drain excess fluid.

Timing can be important when it comes to getting surgery to fix a condition. Doctors have differing opinions^[1] on whether it is better to get surgery as a child or an adult. Children generally respond better to treatment and can have a better prognosis if mobility issues are fixed before they develop^[3].

If a child does not get surgery while they are young, their disability may become more present or get worse as they age. On the other hand, adults have a better understanding of their conditions and can independently decide what is right for them. They may be more committed to rehabilitation and other post-surgery treatments.

It's best to have an in-depth discussion with your doctor to determine what kind of surgeries are available, which one is most beneficial, and when is the right time to do it. Deciding to go under anesthesia and have a procedure done can sometimes be intimidating, so reaching out to friends and family for support can help ease stress. With proper care and consideration, surgery for spastic cerebral palsy gives an individual a chance to change their life.

^[1] Deepak Sharan. (2017). Orthopedic surgery in cerebral palsy: Instructional course lecture. Indian Journal of Orthopaedics, (3), 240.

^[2] Rana, M., Upadhyay, J., Rana, A., Durgapal, S., & Jantwal, A. (2017). A Systematic Review on Etiology, Epidemiology, and Treatment of Cerebral Palsy. International Journal of Nutrition, Pharmacology, Neurological Diseases, 7(4), 76-83.

^[3] Agarwal, A., & Verma, I. (2012). Cerebral palsy: An overview. Journal of Clinical Orthopaedics and Trauma, 3(2), 77-81.

^[4] Tilton, A. (2009). Management of Spasticity in Children With Cerebral Palsy. Seminars in Pediatric Neurology, 16(2), 82-89.

^[5] Understanding Cerebral Palsy: A Guide for Parents and Professionals. Marion Stanton. Jessica Kingsley Publishers. London and Philadelphia. 2012.

^[6] Cerebral Palsy: A Complete Guide for Caregiving 2nd ed. Freeman Miller, M.D. and Steven J. Bachrach, M.D. The Johns Hopkins University Press. Baltimore, MD. 2006.

^[7] Kainz, H., Hoang, H., Pitto, L., Wesseling, M., Van Rossom, S., Van Campenhout, A., … Jonkers, I. (2019). Selective dorsal rhizotomy improves muscle forces during walking in children with spastic cerebral palsy. Clinical Biomechanics, 65, 26-33.

^[8] A. A. Andreev, D. V. Ryzhikov, & E. V. Gubina. (2016). Surgical Treatment of Stiffness and Motion Disorders of Upper Limb in Children with Spastic Cerebral Palsy (Review) (3), 135.