Orthopedic Selective Spasticity Control Surgery for Children with Spastic Cerebral Palsy
Control
of spasticity has become an urgent need for orthopedic surgeons in the
treatment of cerebral palsy. Many approaches for control of spasticity
have been advocated. However, control of spasticity is not so easy and
at times seems to cause serious drawbacks such as sensory disturbance,
recurrence and loss of stability.
Orthopedic selective spasticity
control surgery [OSSCS] is an orthopedic procedure designed to control
or reduce hypertonicity in cerebral palsy. Various types and severity of
hypertonicity can be appropriately controlled by the use of selective
muscle release surgery. The spasticity control surgery not only corrects
deformities such as shoulder retraction, elbow deformity, scoliosis,
flexion deformity of hip, knee and ankle- foot, but also promises better
hand and finger skills and reach movements of the upper extremity,
stabilizes the trunk and lower extremities and relives the hypertonicity
in the cervical, thoracic and lumbar spine. It also facilitates
respiration and speech while lessening drooling remarkably. By combining
the spasticity control surgery with conventional orthopedic surgery,
such as open reduction, VDRO, pelvic osteotomy for dislocation of hip,
arthrodhesis of wrist and ankle, spinal fusion, we can deal with wide
range of problems in motor activities and activities of daily living
with encouraging results while providing a new path for functional
improvement and for active life styles in most patients with cerebral
palsy. OSSCS can provide us with an opportunity to assist
physiotherapist and occupational therapist by controlling hypertonicity
in the whole body while making it easy to facilitate basic motor
functions such as rolling, crawling, sitting, kneeling, standing and
independent gait.
The fundamentals of OSSCS are clear and
uncomplicated and are based on the physical and biological findings.
OSSCS is based on the concept that muscles are classified into two types
– monoarticular and multiarticular. Electromyographic studies proved
that multiarticular muscles are spastic or hypertonic and are
responsible for various deformities in cerebral palsy and the
monoarticular muscles are normal and responsible for joint stability and
erect posture in human being. Thus by selectively releasing these
multiarticular muscles we can activate the monoarticular muscles to
facilitate function and erect posture.
The most important aspect of
OSSCS is postoperatively there is no decrease of motor function as
monoarticular muscles are preserved. There is no loss of sensations as
seen in many spasticity reducing procedures. The technique is quite
reliable and promising procedure for control of spasticity.
Another
important aspect of OSSCS is that its indications are wide and
hypertonicity in the entire body can be relieved. All kinds of
hypertonicity – spasticity, rigospasticity and athetosis can de
corrected.
The decision making and treatment techniques are
demanding. In order to achieve successful results, orthopedic techniques
should be skillfully conducted since we are going to correct complex
motor disorders which have not responded to other procedures. Which
muscles should be released? Which end should be released proximal or
distal? What kind of release should be done? Intramuscular lengthening?
Sliding lengthening? Z lengthening? Tenotomy? How much and how long
these lengthening should be done? What other conventional orthopedic
surgeries should be combined? All these questions and problems have to
be answered correctly.
When the Orthopedic surgeon applies these
principles of OSSCS accurately in the management of cerebral palsy, he
will be able to promise definite improvements for patients with cerebral
palsy. Here, we would like to present ideas and techniques of OSSCS and
show how these approaches can be used in the treatment of cerebral
palsy.