Single-event multilevel surgery can improve walking ability in children with cerebral palsy, particularly when performed from the ages of 10 to 12, a new study shows.
The study, “Follow-up of walking quality after end of growth in 28 children with bilateral cerebral palsy,” was published in the Journal of Children’s Orthopaedics.
About 50% to 80% of children with cerebral palsy (CP) are able to walk, though they often experience abnormalities in gait which make walking more difficult. Medical interventions, such as single-event multilevel surgery (SEMLS), can help to correct gait deviations.
Conceptually, SEMLS involves making modifications (lengthening muscles, cutting bone to shorten or lengthen it or change its alignment, etc.) to multiple parts of the leg (hip, knee, ankle, or foot) to correct deformities in muscles and bones in the course of one surgery.
“The positive effects of SEMLS have been shown to persist five years or more after surgery,” the researchers wrote. “However, the long-term evolution of the gait (more than five years of follow-up) in young adults with bilateral CP remains not well known.”
In the new study, researchers presented data from 28 people (19 male, nine female) with bilateral CP, meaning both sides of their bodies were affected. The participants underwent clinical gait assessment at two points: once in childhood (average age of 9.0 years), and once in early adulthood (average age of 19.6 years).
The clinical gait assessment used for this study involved having a person walk in a laboratory setting, with their movement recorded by numerous specialized cameras filming them from different angles. Then, a computer algorithm analyzed patterns in their walking, and converted them into a numerical score, called the gait deviation index (GDI). This score ranges from 0 to 100, with 100 representing a gait with no abnormalities.
In the time between the two assessments (averaging 10.5 years), 18 of the children included in the study underwent SEMLS. In this group, the average GDI significantly increased, from 69.0 points at the first assessment to 77.8 points at the second.
Eight (45%) of the children who underwent SEMLS had a clinically significant improvement in GDI — an improvement that is likely to be noticeable to the individual, defined in this case as an increase in GDI of at least 10.8 points. The remaining 10 children had no clinically significant change in GDI. None of these children had a clinically significant decrease in GDI.
The 10 children who did not undergo SEMLS did not show any significant difference in average GDI at the first measurement (81.0 points) or later (87.7 points).
As evidenced by their GDI scores, children who did not undergo SEMLS “had better initial levels of functionality and mobility (GMFCS level I and high GDI scores) at baseline than patients who underwent SEMLS,” the researchers wrote. “Their gait quality remained steady but did not improve during the period of transition to young adulthood. This observation emphasizes the significance of the levels of function and mobility at baseline.”
Importantly, improvements in gait quality occurred around the period between childhood and young adulthood (10 to 12 years old), when “the skeleton, muscles and body attain maturity,” the researchers wrote.
This suggests that SEMLS can have long-term benefits for children with more severe gait abnormalities, whereas such surgical interventions likely are not fully warranted for children with more mild abnormalities, because gait doesn’t usually worsen over time.
The researchers highlighted a few individuals among the cases, including one who experienced a significant worsening in mobility, reflected by a GDI decrease of more than 20 points, a few years after the initial gait assessment. This patient then underwent SEMLS, and four years later, another gait assessment showed that GDI had recovered by 14 points.
“This specific case highlights the potential positive impacts of SEMLS in improving gait quality,” the researchers wrote, noting that the patient did not require a walker to traverse short distances, which had not been possible before SEMLS.
This study is limited primarily by its small sample size, making it difficult to generalize the results. Additionally, the researchers stressed that gait abnormalities constitute a small part of CP, and that patient care should be delivered holistically.
“Further long-term longitudinal studies based on larger cohorts would be needed to develop a better understanding of the implications of different treatment combinations on different CP gait quality profiles, and these should also consider environmental factors such as personal situation, social well-being and rehabilitation procedures,” the researchers wrote.
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