Cerebral Palsy: Surgery and Nonsurgical Orthopedic Treatments

What are the treatment goals for children with cerebral palsy?

Orthopedic surgeons, physiatrists and therapists who care for people with CP aim to optimize function in activities of daily living and improve overall quality of life. For individuals who can walk, maintenance and enhancement of that ability, and the independence it affords, is a primary goal. Treatment objectives for those who are not able to walk focus on preserving comfortable, balanced, and level sitting. This facilitates upright posture to observe surroundings, communicate with the world, and remain mobile in a wheelchair.

Treatments for ambulatory cerebral palsy patients (those able to walk)
 

Children birth to seven years

During the early years, from birth to about seven years of age, orthopedic issues are usually addressed without surgery.
When young children with spasticity are learning to walk, their muscles become tight, and their legs are unable to move into the right position at the right time. One of the most effective ways to decrease spasticity is with the use of focal tone management techniques.

Other techniques such as nerve surgery (rhizotomy) and direct delivery of medication to the central nervous system (intrathecal baclofen) will also manage tone abnormalities such as spasticity and dystonia (involuntary and sustained muscle contractions that affect posture).
 

Children eight years and older

A child’s gait evolves throughout early childhood and, in children with CP who have had delays in their motor development, it eventually stabilizes by seven to eight years of age. Once a steady pattern of gait is established, clinicians often consider surgical interventions in addition to non-operative modalities as part of their treatment armamentarium.

Consideration of the individual’s entire lower extremity structure is paramount to the success of surgery.
 

Pre-adolescence and beyond

During adolescence the natural history for children with CP who are able to walk is frequently to experience a decline in the appearance of the gait and in their endurance. The most common manifestation of this is bending down at the knees, called “crouch gait’. Sometimes crouch gait develops as a result of interventions a child has had earlier in life, but sometimes it is just the individuals natural history.
 

What surgeries are used to treat cerebral palsy?

In the past, the main procedures performed for children with CP to optimize their gait were tendon lengthenings, such as lengthenings of the Achilles and hamstring tendons. These were relatively minor surgeries that were simple to perform and from which children recovered quickly. Typically, children would show improvements in their walking ability in the first several years after these surgeries, leading parents and doctors to believe that they had made the right decisions. However, longer follow-up, with the assistance of gait analysis to capture objective data, has helped us to understand that the early benefits from the treatments frequently dissipate due to the muscle weakness that results from these procedures. In fact, the individuals gait will sometimes decline more severely in the long term.

The recognition of these consequences and the knowledge gained through gait analysis has led to a newer treatment paradigm focused on optimizing the forces and individual can generate to enhance their gait. This is done by preserving muscle power (“dosing” any muscle procedures carefully) and by correcting the alignment of the bones using the principle of “lever arms” to make decisions. The lever arm principle is one that everyone is familiar with, even if one is not an engineer. If a person has ever sat on a teeter-totter, lifted a wheel barrel, opened a door or thrown a ball, then they have used a lever. By aligning the bones of the lower extremities in the optimal position, we can help individuals with CP generate the maximum forces possible (known as moments) when walking.

The types of surgeries done to help correct the levers and optimize “moments” in individuals with CP include osteotomies to rotate twisted femurs and tibias, foot surgery to make the feet more rigid and stable and knee surgeries to make the knees straighter in in order to correct crouch gait.