What Types of Surgeries May be Required to Manage Cerebral Palsy?
There are times when surgery may be considered to improve ambulation, correct or prevent debilitating deformities, improve functioning levels, control pain, enhance appearance, or improve caregiver functions.
For those with cerebral palsy, orthopedic surgeries are common. When surgery is warranted physicians want to minimize physical impairments and movement barriers as much as possible. The goal of orthopedic surgery is to create the ideal functional use of extremities while improving the individual’s ambulation with or without adaptive equipment. Some goals of orthopedic surgery include:
- Loosen tight or stiff muscles
- Correct curvatures
- Compensate uneven growth
- Sever nerve roots
- Correct limb positioning
- Facilitate sitting, walking, and hand use
- Reduce spasticity
- Minimize tremors
While orthopedic reasons for surgery can be numerous, some opt for surgery to improve functionality and use it to address feeding difficulties, bowel and bladder challenges, ensure joint stability, correct spinal curvatures, or minimize drooling, for example. Some may wish to decrease chronic pain levels. Others may elect surgery for appearance, hygiene or caregiver reasons. This may involve improvements in gait, standing, bracing, aligning bite, or improving the appearance of a smile.
For general information on surgery, Surgery for Cerebral Palsy
Surgeries most common to those with cerebral palsy usually fall under the following categories:
- Gastroenterology Surgery
- Hearing Correction Surgery
- Medicine Related Surgery
- Orthopedic Surgery
- Vision Correction Surgery
These are briefly detailed below. The surgeries are listed to provide a general idea of common surgeries considered in managing cerebral palsy, but are not meant to be all-inclusive, nor fully comprehensive.
Gastroenterology surgery for children with cerebral palsy aims to improve the process of feeding, digestion, and bladder or bowel functioning. The intake of liquids and solids requires a sophisticated process. There are two major ways to swallow food, both may present problems to a child with a movement impairment.
One way to initiate swallowing is through sucking food through the mouth. The second is by collecting the food on the tongue, then moving the food to the back of the throat to initiate swallowing. This may be difficult to some children with cerebral palsy, particularly when they have impairment to the facial muscles that control these movements.
If the child has difficulty closing his or her lips and also has swallowing problems, excessive drooling can occur, leading to skin conditions and secondary bacterial infections. Drooling can also erode tooth enamel.
When the food travels down the throat, the larynx – which is responsible for allowing air into the lungs – closes to allow liquids and solids to travel through the esophagus into the stomach. A child with cerebral palsy can aspirate when their larynx does not close properly. This can lead to food and germs entering the lungs, making the lungs susceptible to infection.
Some food, when having traveled to the stomach, is regurgitated back up the esophagus. The stomach acids that are also regurgitated in this process may cause the esophagus to become sore or swallowing to become painful. A child experiencing frequent regurgitation is prone to malnutrition. When this happens, dietary specialists may recommend dietary measures like texturized foods, thicker liquids, proper positioning for food intake, or dietary supplements. If ineffective, a child may eat less, lose weight, or gain too much weight.
Children with cerebral palsy are at higher risk of bowel and bladder motility problems. Sometimes a change in diet, more frequent intake of fluids and fibers, or suppository assistance may address the concerns.
In cases of severe cerebral palsy or when a child is unable to communicate, caretakers may not be aware that a child has a very full bowel, bladder infection, constipation, or incontinence. If the bowels or bladder are not completely emptying, infections can set in. These conditions may warrant gastroenterology surgery.
Gastroenterology surgery is primarily performed to improve sucking, chewing, swallowing, digestion, and food processing. Some common surgical interventions considered for these situations, include:
- Nasogastric tube – a nasogastric tube can be placed through the nose to introduce food to the stomach. This is usually considered a short-term option as the tube may interfere with swallowing and vomiting reflexes in the long-term.
- Gastrostomy tube – this tube is inserted through the abdominal wall to the stomach allowing for uninterrupted oral feeding while supplementing nutrients.
- Fundoplication – is a surgical procedure that places a valve at the top of the stomach to reduce recurrent vomiting and chest infections, called gastro-oesophageal-reflux disease (GERD). This procedure can assist with minimizing reactive airway disease, nocturnal asthma, choking attacks, anemia or wheezing.
- Submandibular duct relocation – this surgical procedure addresses drooling once other measures such as adaptive devices, medications, and therapy are exhausted and proven ineffective.
- Bladder augmentation (augmentation cystoplasty – AC) – bladder surgery provides urinary continence for those that lack bladder capacity or have abnormal compliance that results in urinary tract infections, urgency, frequency, incontinence and other bladder function difficulties.
Hearing impairment can delay a child’s speech, language, communication, and social development. Children with cerebral palsy as a course of normal growth and development can experience conductive loss. Common ear blockages or infections are referred to as conductive loss, a condition that normally responds well to drug therapy. Children with cerebral palsy are also prone to nerve or sensorineural hearing loss due to a defect in the nerve fiber within the inner ear or in the nerve pathway of the brain that can affect hearing higher, rather than lower, tones.
Hearing devices or communication aides can be helpful when hearing impairment is diagnosed.
- Hearing aids – amplify sounds without distortion.
- Radio aides – the use of microphone and transmitters
Visual cues, lip reading, gesturing, and sign language are also recommended non-surgical options. The goal is to provide the best opportunity for the child to learn, function, communicate, and develop.
Children experiencing chronic pain, or in need of constant and consistent doses of medication, may benefit greatly by the insertion of a pump that continuously disperses medication through the spinal column.
- Baclofen pump – this is a device – about the size of a hockey puck – implanted in the abdomen. It is connected to the spinal cord with a thin tube that threads under the skin.
- Lumbar puncture – before implanting the pump, neurosurgeons may perform a lumbar puncture to inject a dose of baclofen into the child’s spinal canal as a test measure.
The pump must be refilled periodically, usually every six months. Failure to refill the pump in a timely manner can harm the child. Ask your doctor how long the pump is expected to last, as it may need to be removed and replaced in another surgical procedure, down the road.
Even though cerebral palsy is a neurological condition, there is no neurosurgery that can cure the condition. There are, however, a variety of neurosurgical interventions that may assist in the management of cerebral palsy. Controversy exists over whether the measures have been proven clinically successful, and experts typically suggest other alternative measures be considered and exhausted before considering a neurosurgical approach. Two common surgeries include:
- Baclofen pump – a pump is implanted in the child’s abdomen to continuously deliver muscle relaxant into the fluid surrounding the spine in an effort to reduce spasticity.
- Selective dorsal rhizotomy (SDR) – a procedure where 30%-50% of sensory nerves are cut to decrease spasticity.
Cerebral palsy is a neurological condition that results in orthopedic challenges, whether paresis (weakened) or plegia (paralyzed). The damage to the brain affects muscles and a person’s ability to control them. The primary orthopedic conditions prevalent in cerebral palsy are:
- Abnormal muscle tone
- Movement coordination and control
- Reflex irregularity
- Fine motor function
- Gross motor function
- Oral motor function
Orthopedic surgery is considered when other less invasive treatments and therapies have been exhausted without success. Orthopedic surgery can be performed on bones, ligaments, joints, tendons, muscles, and nerves.
The location of surgery can vary from the upper extremities (wrists, arms, shoulders, spine, and back) to the lower extremities (feet, ankles, legs and hips). Orthopedic surgeries performed on those with cerebral palsy are more often performed on lower extremities, versus upper extremities, due primarily to the possible risk of sensory damage and loss of functional abilities.
Each individual’s condition is unique, therefore treatment and surgery on cerebral palsy doesn’t follow a set protocol or certain time parameters. The extent, location and severity of the impairment vary amongst individuals. Their abilities, home environment, support structure, educational situation, compensation factors, and associated conditions all contribute to decisions on quality-of-life and surgery decisions.
The focus of orthopedic surgery is to “manage” impairment, control pain, optimize independence and self-care, maximize movement, balance and coordination and maintain functionality. When considering orthopedic surgery options, the benefits are weighed against the risk surgery. Not all deformities need to be corrected, nor is it advisable to try.
Surgery is often used to optimize potential for:
Orthopedic surgeries focus on improving mobility and body movement, such as:
- Fine motor skills – hand, wrists, finger, foot, ankles, toes, lip, and tongue movements
- Gross motor skills – sitting, standing, crawling, walking, running, wheeled mobility, and adapted mobility
- Balance and coordination – head control, trunk control, posture, and standing
Surgery risks may include:
- The surgery may not be effective
- The surgery may only achieve minimal results
- The surgery may require more surgery later, or repeated surgery
- The surgery may only produce temporary results
- The surgery may solve one problem while creating another
- The surgery may require extensive post-operative care and discipline in order to be successful
- Rehabilitation may not be within the child’s abilities
Timing considerations for orthopedic surgery may include:
- The child’s growth factors
- The developmental stage of the child
- The status of associative conditions
- The body’s compensation patterns
- The child’s school schedule
- The child’s ability to undergo the rehabilitation program
- Whether other surgeries are scheduled or need to be combined
The goal of orthopedic surgery depends on the surgery being contemplated, but may include:
- Pain management
- Minimizing impairment
- Maximizing motor function
- Achieving posture stability and balance
- Increasing muscle strength
- Optimizing muscle tone
- Decreasing spasticity
- Minimizing joint deformity while maximizing joint functionality
- Optimizing oral motor functioning to eat properly and communicate
- Achieving optimal activities of daily living skills
- Promoting self-care
The surgery goals may be obtained through surgery procedures which:
- Correct anatomical abnormalities (hip dislocation, uneven leg length, and scoliosis)
- Decrease spasms</li>
- Improve bone deformation
- Improve rigidity, choreoathetosis, and tremors
- Lengthen muscles and tendons
- Prevent spinal deformities and contractures
- Control pain
- Release contractures
- Release fixed joints
- Release tight muscles
- Restore control and coordination
- Restore muscle balance
- Stabilize joints
The type of movement dysfunction, along with the location and number of limbs involved and the severity of impairment will vary, but is taken into consideration when designing a surgical plan. Other considerations are the individual’s age, functional ability, associative conditions, pain level, previous treatments, access to treatment, and family dynamics for rehabilitation.
The body’s muscular and skeletal structures are complex. The National Institute of Neurological Disorders and Stroke (NINDS) report that it may take 30 major muscles working in tandem to simply walk. Optimal mobility for independence and self-care are the main focus, but not all those with cerebral palsy will walk. The goal is to maximize the child’s ability to be self-sufficient at home, at school, in-house, and at outdoor venues. For some, this may require the assistance of adaptive equipment, assistive technology, and caregivers even after surgery.
Vision surgery can help improve vision impairment and loss. Vision surgery usually addresses problems with the eye and the retina, but can involve the muscles that support the eye’s functioning. It is common in children with cerebral palsy to have a vision impairment or vision loss.
Some common vision challenges in individuals with cerebral palsy, include:
- Cortical blindness – partial, temporary, or complete eye loss due to damage to the occipital cortex, the brain’s visual center
- Hemianopia – loss of half the visual field (either right or left) often due to damage to the primary visual cortex
- Strabismus – misalignment of both eyes, due to imbalance of the eye muscles
In some cases, eyeglasses or contacts will suffice. Surgery may be considered when corrective lenses are not effective.
Restoring or optimizing vision allows the child to communicate, learn, socialize, and perform activities of daily living with greater ease. Vision contributes to quality of life. Visual acuity is often hailed as an important factor in life expectancy.