Neuromuscular conditions Cerebral Palsy Prof. Mohammed Zamzam Professor & Consultant Pediatric...

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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

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

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

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

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

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

Surgery :Surgery :

Best in Spastic Hemiplegics and Best in Spastic Hemiplegics and severe deformitiessevere deformities

Contraindicated in Athetoid & AtaxicContraindicated in Athetoid & Ataxic

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

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

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

Neuromuscular conditions Cerebral Palsy Prof. Mohammed Zamzam Professor & Consultant Pediatric...

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