Orthopedic surgery is often recommended when spasticity and stiffness are severe enough to make walking and moving about difficult or painful.
For many people with cerebral palsy, improving the appearance of how they walk - their gait - is also important. A more upright gait with smoother transitions and foot placements is the primary goal for many children and young adults.
In the operating room, surgeons can lengthen muscles and tendons that are proportionately too short. But first, they have to determine the specific muscles responsible for the gait abnormalities. Finding these muscles can be difficult. It takes more than 30 major muscles working at the right time using the right amount of force to walk two strides with a normal gait. A problem with any of those muscles can cause an abnormal gait.
In addition, because the body makes natural adjustments to compensate for muscle imbalances, these adjustments could appear to be the problem, instead of a compensation. In the past, doctors relied on clinical examination, observation of the gait, and the measurement of motion and spasticity to determine the muscles involved. Now, doctors have a diagnostic technique known as gait analysis.
Gait analysis uses cameras that record how an individual walks, force plates that detect when and where feet touch the ground, a special recording technique that detects muscle activity (known as electromyography), and a computer program that gathers and analyzes the data to identify the problem muscles. Using gait analysis, doctors can precisely locate which muscles would benefit from surgery and how much improvement in gait can be expected.
The timing of orthopedic surgery has also changed in recent years. Previously, orthopedic surgeons preferred to perform all of the necessary surgeries a child needed at the same time, usually between the ages of 7 and 10. Because of the length of time spent in recovery, which was generally several months, doing them all at once shortened the amount of time a child spent in bed. Now most of the surgical procedures can be done on an outpatient basis or with a short inpatient stay. Children usually return to their normal lifestyle within a week.
Consequently, doctors think it is much better to stagger surgeries and perform them at times appropriate to a child's age and level of motor development. For example, spasticity in the upper leg muscles (the adductor's), which causes a "scissor pattern" walk, is a major obstacle to normal gait. The optimal age to correct this spasticity with adduction release surgery is 2 to 4 years of age. On the other hand, the best time to perform surgery to lengthen the hamstrings or Achilles tendon is 7 to 8 years of age. If adduction release surgery is delayed so that it can be performed at the same time as hamstring lengthening, the child will have learned to compensate for spasticity in the adductor's. By the time the hamstring surgery is performed, the child's abnormal gait pattern could be so ingrained that it might not be easily corrected.
With shorter recovery times and new, less invasive surgical techniques, doctors can schedule surgeries at times that take advantage of a child's age and developmental abilities for the best possible result.
Selective dorsal rhizotomy (SDR) is a surgical procedure recommended only for cases of severe spasticity when all of the more conservative treatments - physical therapy, oral medications, and Intrathecal Baclofen - have failed to reduce spasticity or chronic pain. In the procedure, a surgeon locates and selectively severs over-activated nerves at the base of the spinal column.
Because it reduces the amount of stimulation that reaches muscles via the nerves, SDR is most commonly used to relax muscles and decrease chronic pain in one or both of the lower or upper limbs. It is also sometimes used to correct an over-active bladder. Potential side effects include sensory loss, numbness, or uncomfortable sensations in limb areas once supplied by the severed nerve.
Even though the use of microsurgery techniques has refined the practice of SDR surgery, there is still controversy about how selective SDR actually is. Some doctors have concerns since it is invasive and irreversible and may only achieve small improvements in function. Although recent research has shown that combining SDR with physical therapy reduces spasticity in some children, particularly those with spastic diplegia, whether or not it improves gait or function has still not been proven. Ongoing research continues to look at this surgery's effectiveness.
Spinal cord stimulation was developed in the 1980s to treat spinal cord injury and other neurological conditions involving motor neurons. An implanted electrode selectively stimulates nerves at the base of the spinal cord to inhibit and decrease nerve activity. The effectiveness of spinal cord stimulation for the treatment of cerebral palsy has yet to be proven in clinical studies. It is considered a treatment alternative only when other conservative or surgical treatments have been unsuccessful at relaxing muscles or relieving pain.