Neuromuscular conditionsNeuromuscular conditions
Cerebral PalsyCerebral Palsy
Prof. Mohammed ZamzamProf. Mohammed ZamzamProfessor & ConsultantProfessor & Consultant
Pediatric Orthopedic SurgeonPediatric Orthopedic Surgeon
DefinitionDefinition
Non progressiveNon progressive, cerebral damage, cerebral damage
occurring before brain maturation occurring before brain maturation (1-2 years)(1-2 years) resulting in muscle weakness, spasticity resulting in muscle weakness, spasticity
and other symptomsand other symptoms
IncidenceIncidence
0.5-2/1000 in premature deliveries0.5-2/1000 in premature deliveries
CausesCauses Prenatal :Prenatal : Maternal disease/ ToxemiaMaternal disease/ Toxemia
Cerebral deformity/ HemorrhageCerebral deformity/ Hemorrhage Inborn error of metabolismInborn error of metabolism Perinatal :Perinatal : Labour/ Respiratory complicationsLabour/ Respiratory complications
Perinatal infectionsPerinatal infections
CausesCausesPostnatal :Postnatal : InfectionInfection
ViolenceViolence
ConvulsionConvulsion
ClassificationClassificationTopographic ClassificationTopographic Classification
Diplegia :Diplegia : (Arms & Legs much more in (Arms & Legs much more in
legs), most patients eventually walklegs), most patients eventually walk
Tetraplegia :Tetraplegia : (Arms & Legs & Trunk) (Arms & Legs & Trunk)
High mortality rate, most pts unable to High mortality rate, most pts unable to
walk. IQ is lowwalk. IQ is low
ClassificationClassificationTopographic ClassificationTopographic Classification
Hemiplegia :Hemiplegia : Upper & lower limbs on Upper & lower limbs on one side (upper more than lower limbs), one side (upper more than lower limbs), with spasticity, patients eventually walkswith spasticity, patients eventually walks
Bilateral Hemiplegia Bilateral Hemiplegia Paraplegia (Legs)Paraplegia (Legs) MonoplegiaMonoplegia TriplegiaTriplegia
ClassificationClassificationPhysiological ClassificationPhysiological Classification
Spastic :Spastic : Commonest 50-60%Commonest 50-60% Most important for the Orthopedic SurgeonMost important for the Orthopedic Surgeon Increased muscle tone (Jack knife spasticity) Increased muscle tone (Jack knife spasticity) Slow restricted movementsSlow restricted movements Increased reflexesIncreased reflexes Babinski +veBabinski +ve
ClassificationClassificationPhysiological ClassificationPhysiological Classification
Athetosis :Athetosis : 20-25%20-25% ? Kernicterus? Kernicterus Involuntary, uncontrolled slow movement Involuntary, uncontrolled slow movement
Normal reflexesNormal reflexes +/- Muscle rigidity or tremors+/- Muscle rigidity or tremors NOT FOR SURGERYNOT FOR SURGERY
ClassificationClassificationPhysiological ClassificationPhysiological Classification
Ataxia :Ataxia : 1-5%1-5% Inability to control /coordinate movement Inability to control /coordinate movement
when they startwhen they start Intention tremorIntention tremor Nystagmus / unbalanced gaitNystagmus / unbalanced gait NOT FOR SURGERYNOT FOR SURGERY
ClassificationClassificationPhysiological ClassificationPhysiological Classification
Rigidity :Rigidity : 5-7 %5-7 % Lead pipe rigidityLead pipe rigidity
Mixed type :Mixed type : A combination of spasticity and athetosis A combination of spasticity and athetosis
with whole body involvementwith whole body involvement
PresentationPresentation
33 year- old boyyear- old boy
Presented with Presented with Inability to stand Inability to stand or walkor walk
DeformitiesDeformities
Upper limb :Upper limb : Shoulder adduction/internal rotationShoulder adduction/internal rotation Elbow flexionElbow flexion Forearm pronationForearm pronation Wrist and fingers flexionWrist and fingers flexion
DeformitiesDeformities
Lower limb :Lower limb : Hip adduction/flexion/internal rotationHip adduction/flexion/internal rotation Knee flexionKnee flexion Feet equinus / varus or valgusFeet equinus / varus or valgus Gait scissoringGait scissoring
Spine :Spine : kyphoscoliosiskyphoscoliosis
The two most important x-rays during follow upThe two most important x-rays during follow up
ManagementManagement
Aim of treatment :Aim of treatment : AS INDEPENDENT AS POSSIBLEAS INDEPENDENT AS POSSIBLE Avoid pain (hip arthritis)Avoid pain (hip arthritis) Maintain sitting postureMaintain sitting posture Maintain spinal stabilityMaintain spinal stability Social benefitSocial benefit
ManagementManagement
Multidisciplinary :Multidisciplinary : Orthotics before and after surgeryOrthotics before and after surgery Physiotherapy/Occupational therapyPhysiotherapy/Occupational therapy Orthopedic SurgeryOrthopedic Surgery Neurosurgery/ Pediatric NeurologyNeurosurgery/ Pediatric Neurology Speech therapySpeech therapy
ManagementManagementHistoryHistoryExamExamInvestigationInvestigationTreatmentTreatment
The degree of retardation is of great The degree of retardation is of great
importance in treatment planningimportance in treatment planning
ManagementManagement
Exercise :Exercise : Start early (1Start early (1stst month) when suspected month) when suspected Qualified Physiotherapist/ Qualified Physiotherapist/ PARENTSPARENTS Prevent contracturesPrevent contractures Develop coordinationDevelop coordination Mental exerciseMental exercise Use Orthotics/POP/Casts if neededUse Orthotics/POP/Casts if needed
ManagementManagement
Surgery :Surgery :
Best in Spastic Hemiplegics and Best in Spastic Hemiplegics and severe deformitiessevere deformities
Contraindicated in Athetoid & AtaxicContraindicated in Athetoid & Ataxic
ManagementManagement
Goal of Surgery :Goal of Surgery : Decrease spasmDecrease spasm Release of contracturesRelease of contractures Correct deformitiesCorrect deformities Rebalance musclesRebalance muscles Stabilize flail jointsStabilize flail joints
ManagementManagement
Options of Surgery :Options of Surgery : Neurectomy Neurectomy TenotomyTenotomy TenoplastyTenoplasty Muscle lengthening (Recession)Muscle lengthening (Recession) Tendon TransferTendon Transfer Bony surgery Osteotomy/FusionBony surgery Osteotomy/Fusion Spinal surgerySpinal surgery
ManagementManagement
Intramuscular botulinum toxin:Intramuscular botulinum toxin:
Temporarily reduces dynamic spasticityTemporarily reduces dynamic spasticity
It is thought that its use promotes normal It is thought that its use promotes normal muscle growth and avoids the development muscle growth and avoids the development of soft tissue contractureof soft tissue contracture