Surgery Options Overview
Surgery treats several conditions resulting from cerebral palsy. Various orthopedic procedures, for example, address muscle stiffness and spasticity – among the most common cerebral palsy symptoms. Easing spasticity with surgery improves range of motion and fine motor control, helping patients walk with or without assistive devices, and grasp small items.
In addition to improving mobility and coordination, surgical intervention may also correct or help prevent deformities and other cerebral palsy complications. Orthopedic surgery is widely used to treat movement limitations, some patients may also be candidates for procedures correcting co-occurring conditions, such as hearing loss and GI disorders.
Benefits of Surgery for Cerebral Palsy Patients
As part of a comprehensive therapy plan, surgery can help improve a cerebral palsy patient’s independent mobility and support healthy physical development. Orthopedic surgery on the legs, feet, ankles, arms and wrists leads to better posture and control for some patients, correcting alignment and enhancing motor functioning. Cochlear implant surgery and gastric procedures are also recommended in some cases, correcting co-existing conditions tied to CP.
Physical therapy, medication, and other forms of treatment have a positive impact, but surgical procedures may provide additional benefits for select cerebral palsy patients. In some cases, CP surgery:
- Improves – mobility, posture, physical alignment, range of motion
- Promotes – independence, healthy physical development
- Prevents – complications and deformity
Like other forms of CP treatment, surgery accounts for the needs of individual patients. When pain or discomfort is present, surgical intervention may furnish the most immediate relief. In other cases, specialists may try other forms of therapy, before recommending surgery.
When surgery is advised, various procedures alter muscles, bones, tendons and nerves – correcting and improving severe limitations. Surgery addresses these and other conditions:
- Spinal curvature (scoliosis)
- Muscle spasticity
- Hearing difficulty
- Gastrointestinal distress
- Joint problems
- Spinal deformities
- Hip dislocation
Surgical Considerations for Cerebral Palsy Patients
Surgery is recommended when the benefits of performing a particular procedure outweigh the risks. It is only one aspect of treatment, however, so surgical intervention is not the best alternative for every patient. Before settling on surgery, parents, pediatricians, surgeons and other specialists consult on each case, evaluating various forms of intervention.
Surgery performed under general anesthesia presents inherent risks. Though complications are rare, those considering surgery must account for every possibility. Bleeding, infection and the need for further surgeries are additional risks associated with CP surgery.
Types of Surgery
Effective cerebral palsy surgery improves quality of life for the patient. Orthopedic procedures, for instance, are widely used to enhance mobility and independence. Other types of CP surgery address co-occurring conditions, like hearing, vision and digestive difficulties.
Orthopedic surgery is recommended when movement is severely limited by cerebral palsy and/or pain is present. Various orthopedic procedures ease spasticity and increase range of motion, enhancing mobility and comfort.
Orthopedic surgery is also used to reduce complications and limitations resulting from bone and joint deformities. The following surgical procedures may improve conditions related to cerebral palsy.
When CP muscle contracture is severe, lengthening procedures may improve the patient’s ability to walk and move independently. The surgery may also remedy joint problems caused by contracture, reducing the possibility of deformity or dislocation.
The hamstring is among the most common muscles targeted for lengthening, as well as the heel cord. While recovery time was once a major concern, modern minimally invasive procedures enable patients to begin rehabilitation within days.
Like muscle lengthening, this procedure reduces spasticity associated with cerebral palsy. Tendon lengthening helps patients walk, but some research indicates muscle and tendon lengthening may have detrimental long-term effects. As a result, surgeons have become more selective when lengthening tendons and muscles.
Cerebral palsy commonly causes tendons to pull too hard in one direction, leading to deformity. Turned-in feet, for example, result when tibialis tendons exert irregular pull.
Surgeons correct the condition by transferring a portion of the tendon to balance its pull on the ankle joint. Another variation of the surgery transfers tendons around the knee, correcting spasticity in the thigh and making it easier for the patient to walk.
Cutting tendons (tenotomy) or muscles (myotomy) may be recommended when contracture is severe and other remedies fall short. Braces and casts are used following surgery, to support alignment and growth. The procedure is particularly beneficial for those at risk of hip fracture or displacement.
Osteotomies treat bone deformities in the lower extremities. Bone problems can interfere with gait and comfort – leading to dislocation, in some cases. Osteotomy cuts and reshapes the surfaces of bones in affected areas, realigning hips, knees and ankles. To reduce hip complications, osteotomy may be used to correct the angle and “twist” of the femur.
In cases of severe joint limitation, permanently fusing bones may present the best surgical alternative. Arthrodesis removes damaged cartilage, before shaping bones and fusing the joint in a rigid position. Although motion is lost in the affected joint, arthrodesis addresses pain and may ultimately improve the patient’s ability to walk.
Orthopedic surgeons strive to maximize the abilities of each patient. In order to have the greatest impact, specialists set surgical goals, based upon patients’ movement capabilities.
Ambulatory children with cerebral palsy undergo surgery to improve their walking ability. Poor stride, toe-walking, scissoring and walking with bent knees are common CP conditions, which may be mitigated by orthopedic surgery.
Non-ambulatory children require surgery to reduce CP contracture and manage other aspects of the disorder. Surgery can reduce cerebral palsy complications, like scoliosis and hip problems, and facilitate ease of care.
Selective Dorsal Rhizotomy
This permanent surgical procedure improves mobility outcomes for select cerebral palsy patients, particularly those suffering from spastic CP. Selective dorsal rhizotomy (SDR) involves cutting sensory nerve fibers that extend from muscles to the spinal cord.
To perform SDR, surgeons examine and manipulate nerve fibers responsible for muscle movement. By dividing the dorsal roots and stimulating them electronically, it is possible for neurosurgeons to identify particular nerve fibers responsible for spasticity. Cutting the appropriate nerves moderates the number of messages sent from muscles to the brain, ultimately reducing spasticity.
Cerebral palsy patients with spastic diplegia are the best candidates for SDR, reducing high muscle tone in the lower extremities. Successful SDR surgery leads to improvements in these areas:
- Lifestyle activities
- Voluntary motor control
Serious complications are rare, though some candidates for SDR may be at greater risk of developing spinal deformities, such as scoliosis or twisting. Immediate recovery from the surgery spans a few days to weeks, but therapy continues for months, as patients rehabilitate, relearn muscle coordination, and explore post-op possibilities.
Surgical Solutions for Co-Occurring Conditions
Cerebral palsy causes symptoms directly related to the brain injury behind the disorder. Unfortunately, many CP patients also face challenges resulting from the condition, which develop as co-occurring medical problems. Surgery can be used to treat some secondary conditions experienced by cerebral palsy sufferers.
This surgical procedure helps restore the ability to hear sounds. Each cochlear implant is comprised of two-pieces – one resting behind the ear and the other surgically implanted nearby. The device uses a complex set of transmitters, microphones and processors to help users perceive sounds. Implants are most effective among those with marked hearing loss.
Cochlear implants are more than hearing aids. Rather than amplifying sounds, as would a traditional aid, cochlear implants actually help process the input into meaningful sounds for users to interpret. Implant surgery typically completes in 2-3 hours, with several weeks of recovery time and follow-up therapy.
Cerebral palsy patients frequently experience difficulty eating and drinking. Muscle tone irregularities associated with the disorder can result in reflux, swallowing challenges and aspiration (food entering the lungs). Gastrostomy uses a surgically implanted feeding tube to ensure nutrition and feeding are not compromised by the effects of cerebral palsy.
This rare but serious condition may require surgical intervention. Hydrocephalus occurs when excess cerebrospinal fluid accumulates in the skull, causing pressure and swelling. Though few CP patients are impacted by the condition, some require surgery to implant drainage valves.
When is Surgery Appropriate?
Each cerebral palsy case is unique, so doctors and parents work together, determining when surgical intervention is in order. A patient’s age, physical limitations, level of discomfort and personal goals are all considered before surgery is recommended. Some important questions to ask when cerebral palsy surgery is contemplated:
- How will the child benefit from the procedure?
- What are the specific goals of the surgery?
- What can be expected during rehabilitation?
- Are there unique risks associated with a particular type of surgery?
- Are there other options?
- Will the enhancements outweigh the risk of surgery?
- Is the patient the correct age for this surgery?
- What are the full details for the surgery?
- What is the success rate for the recommended surgery?