Surgery may be used to ease, relieve, or treat various symptoms or limitations that cerebral palsy (CP) causes. It can make the condition more manageable, prevent future complications, and improve patients’ quality of life.
Children with CP usually have poor muscle and bone growth. Weak muscles that are unable to support the bones and joints sufficiently lead to symptoms such as curvatures of the spine (scoliosis), hip displacement, or joint deformities in the ankles, feet, hands, knees, and shoulders.
If other therapies fall short, surgery can help manage these symptoms, thereby improving mobility, posture, balance, and alignment. It also can correct damaged joints and deformities, reduce muscle spasticity, stiffness, and contractures, and relieve pain. Doctors also may use surgery to correct or improve co-existing conditions such as hearing loss and feeding difficulties.
Is surgery appropriate?
Surgery usually is not the first CP treatment choice. Doctors always try less invasive non-surgical treatments first, such as physical therapy, orthotic devices, oral medications, and muscle injections. Since surgery has many risks, doctors use it only when the potential benefits outweigh the risks.
Doctors make a decision about surgical interventions based on the patient’s age, physical limitations, level of discomfort, and severity of symptoms.
The timing of surgery also is very important. There may be cases in which performing surgery too early will not produce a tangible benefit because many problems associated with mobility emerge only when the child grows older. In other cases, surgery performed at a later stage may not be beneficial because the joint alignments and posture already are established.
Types of surgery
There are different types of surgery, depending on the type of problem. Orthopedic surgery procedures are used to improve mobility and independence. Other types of surgery address co-existing conditions, such as hearing loss and digestive difficulties.
This is the most common type of surgery that doctors perform, but only when other therapies do not help and the condition limits movement severely with or without pain. They use it to correct or improve mobility, reduce spasticity (or jerky movements), loosen stiff muscles, and correct bone and joint deformities.
Children with CP may experience severe muscle contracture, which is permanent tightness in muscles that causes difficult and painful movements. In such cases, surgical lengthening through small incisions and subsequent relaxing of muscles allow increased ability to stretch and may improve the patient’s ability to walk and move independently. Surgical muscle lengthening may relieve the tightness in the fingers, hands, and arms. This can make it easy for patients to grasp objects and improve their fine motor skills. Muscle lengthening also may address joint problems caused by contractures, reducing the possibility of deformity or dislocation.
Patients with CP may experience tightness in tendons (the connective tissue that attaches muscles to bones) that causes pain and restricts movement. Tendon lengthening and realigning bones (in the feet, legs or hips) can reduce CP-associated spasticity and painful contractures, and improve the patient’s ability to walk and sit upright. For example, tendon lengthening in the groin and hamstrings (a muscle that attaches the hip to the knee joint) can help a patient to sit, stand, and walk more comfortably. The procedure also can be performed in the calf or heel to improve mobility in the leg and foot.
Tendon transfer surgery
If tendons pull too hard in one direction, it can lead to deformity and joint complications. Surgical cutting the affected tendon and reattaching it ensures the muscles are aligned properly. It also reduces pain or walking problems and improves flexibility. For example, tendon transfer around the knee can help correct spasticity in the thigh. This may make it easier for the patient to walk.
Doctors use tenotomy (cutting tendons) or myotomy (cutting muscles) to relieve pain and tightness. These operations also can improve muscle function, reduce spasticity, increase control of the upper limbs, and enhance the ability to grasp objects. Doctors may recommend these procedures when contracture is severe and other remedies fall short. They are particularly beneficial for those at risk of hip fractures or displacements. Following tenotomy or myotomy, patients may need to use braces and casts to support growth and alignment.
Osteotomy involves cutting, reshaping and repositioning the bones in affected areas (using plates and screws) to point them at a better angle. It can be used to realign joints (hips, knees, and ankles) for better posture and mobility and treat bone deformities in the lower extremities. For example, osteotomy may help correct the angle of the leg bone (femoral osteotomy), or help create a better shape of the hip bone (pelvic osteotomy).
Arthrodesis is an aggressive type of surgery doctors use in case of severe spasticity and severely reduced mobility. It involves permanently fusing bones of a joint together. They remove the damaged cartilage (tissue covering the ends of bones), then shape the bones and fuse the joint in a rigid position. This helps reduce pain and ultimately may improve the patient’s ability to walk. For example, fusing the bones in the ankle and foot can make it easier for a child to walk.
Children with CP may develop scoliosis, making it difficult for them to sit or stand easily. Surgeons may recommend a procedure called spinal fusion if scoliosis causes persistent back or neck pain, or affects the child’s ability to walk. The procedure involves permanent fusion of two or more backbones (or vertebrae) into one solid bone. Doctors use metal plates, screws, rods or bone grafts (or small pieces of bones they take from the child’s lower spine) to keep the spine straight and stabilize and prevent vertebrae from getting too close to nerves.
Selective dorsal rhizotomy
Selective dorsal rhizotomy (SDR) is a permanent, but risky, neurosurgical procedure. It has the potential to improve mobility, reduce spasticity, and relieve pain. It involves examining, identifying, manipulating and cutting the appropriate sensory nerve fibers that are causing spastic muscle movements. This may help optimize the number of messages sent from the muscles to the brain, ultimately reducing spasticity and improving the patient’s ability to walk, sit, stand, self-care, and fulfill lifestyle activities.
Doctors typically use SDR only for children with severe spasms or muscle tightness because of risks that include cutting the wrong nerve. The patient may recover from the surgery within a few days or weeks, but follow-up rehabilitative therapy continues for months so the patient can relearn muscle coordination.
Surgery for co-existing conditions
CP causes symptoms that are a direct result of injury to the brain. Symptoms also may be caused due to secondary co-existing challenges resulting from the condition. Doctors can use surgery to correct or improve some of these associated conditions that CP patients experience.
A cochlear implant is a surgical procedure that helps restore or improve the ability to hear. Each cochlear implant comprises two pieces — one resting behind the ear and the other surgically implanted nearby. Cochlear implants use a complex set of transmitters, microphones, and processors to help patients perceive and interpret sounds by processing the input into meaningful sounds. The surgery takes a few hours, but recovery and follow-up therapy may take several weeks.
Patients with CP frequently experience difficulty chewing and swallowing due to low or irregular muscle tone. This also can result in severe acid reflux and aspiration (food or drink entering the lungs). Gastroenterology surgery is performed to improve sucking, chewing, swallowing, digestion, and food processing. There are different types of surgical interventions available for these situations. They include nasogastric tube, gastronomy tube, fundoplication, submandibular duct relocation, and bladder augmentation (or augmentation cystoplasty).
A nasogastric tube helps introduce food through the nose to the stomach. However, this is a short-term solution since it may interfere with swallowing and trigger vomiting reflexes if used for longer periods.
A gastronomy tube is a feeding tube that the surgeon inserts through the abdominal wall to the stomach. It allows uninterrupted feeding.
Fundoplication is a surgical procedure that places a valve at the top of the stomach. This helps prevent stomach acid from backing up into the esophagus and reduces recurrent vomiting and chest infections. It also can help minimize choking attacks, wheezing, anemia, nocturnal asthma, and reactive airway disease.
Submandibular duct relocation
Submandibular duct relocation helps reduce dribbling and drooling. Doctors perform this operation when other measures, such as adaptive devices or medications, fall short.
Bladder augmentation (augmentation cystoplasty)
Bladder surgery is used for CP patients who have trouble urinating, including urinary incontinence, urgency, frequency, urinary tract infections, and other bladder function difficulties. The surgery enlarges the bladder and increases control.
Hydrocephalus is a rare and serious condition caused by the accumulation of excess cerebrospinal fluid in the skull that causes swelling, pressure, and abnormal increase in the size of the head. The excess fluid can be drained off by the surgical implantation of valves in the skull.
Last updated: March 13, 2020
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