The aim of this study was to investigate upper limb botulinum toxin A (BTX-A) injections in children with spastic hemiplegia. Ten children with hemiplegia, aged 10–17 years, received upper limb BTX-A injections and 6 weeks therapy. BTX-A was injected using EMG guidance into elbow and wrist flexors, and forearm pronators (dose 1–2 units/kg body wt (Botox®) per muscle). Follow-up assessments continued to 24 weeks post BTX-A. Outcome measures included three-dimensional (3-D) upper limb analysis of functional tasks, Melbourne Assessment; passive range of motion (PROM), and muscle tone. There were no serious adverse effects. Elbow flexor muscle tone was reduced to 12 weeks post BTX-A (p <
0.05). Mean passive elbow supination increased by 19 degrees (not significant, p= 0.3). Pre-injection 3-D analysis showed that, compared to controls, children with hemiplegia were slower at performing upper limb reaching tasks, using less elbow extension and supination, and utilising increased compensatory trunk forward flexion. Post BTX-A, the time to complete upper limb tasks did not change (p>
0.15). However, at least six subjects had increased elbow extension (average 17 degrees) and decreased trunk forward flexion (average 16 degrees) during upper limb reaching tasks. Five subjects improved their Melbourne Assessment score by 5% or greater. Decreased tone and individual improvements in upper limb functional tasks were seen post BTX-A and therapy. However deficits in timing of upper limb movements did not change post BTX-A.
Summary of Background Data: Spinal deformities, occurring in patients with cerebral palsy and good ambulatory capacity, are infrequently associated with pelvic obliquity, and so instrumented spinal fusions traditionally do not extend to the pelvis.
Objective: To identify the demographics, risk factors and guidelines for treatment in a population of cerebral palsy (CP) children with fractures. Materials and Methods: One hundred and fifty children with CP received treatment for fractures from 1948 through 2000. To identify changes in demographics, patients treated before 1992 were compared to those treated after 1992. The latter group was matched by age and gender to a group of CP children without fractures and compared for: CP pattern, bone density, ambulatory status, presence of G-tube, weight for height-age Z score, surgical procedures during the previous year, presence of contractures in the proximity of the fracture and seizure medications. All data was analyzed statistically. Results: 67% of patients had a spastic quadriplegic pattern of CP and 89% were non-ambulatory; 78% of fractures occurred in lower limbs, 48% of the fractures were delayed in diagnosis, and 62% of patients showed osteo-penia. Children treated after 1992 had higher incidence of multiple fractures, less contractures, and less surgical procedures. The risk factors identified for increased fracture risk were: the use of seizure medication (p=.001), quadriplegic CP pattern (p=.005), decreased ambulatory status (p=.001), and lower bone density (p=.001). Most fractures were treated with soft bulky dressing. Conclusions: Ambulatory status and the presence of seizure medication are the greatest risk factors for fracture in children with CP. As a consequence, a low bone density occurs. Future research should focus on underlying fracture mechanisms and prevention.
Purpose. The aim of this study was to document rate of survival among 288 severely affected pediatric patients with spasticity and neuromuscular scoliosis who underwent spinal fusion and to identify exposure variables that could significantly predict survival times. Methods. Kaplan-Meier survivorship analysis was performed and Cox’s proportional hazards model was used to evaluate predictive efficacy of exposure variables such as gender, age at surgery, level of ambulation, mental ability, degree of coronal and sagittal plane spinal deformity, intraoperative blood loss, surgical time, days in the hospital, and days in the intensive care unit (ICU). Results. The statistical analysis demonstrated a mean predicted survival of 134.3 months (11.2 years) after spine surgery for this group of globally involved children with cerebral palsy (Figure 1). The number of days in the ICU after surgery and the presence of severe preoperative thoracic hyperkyphosis were the only factors affecting survival rates. ICU stay of greater than five days, which was usually associated with respiratory problems, substantially increased the risk of death. Thoracic hyperkyphosis of greater than 70° caused a considerable increase in the predicted mortality rate. Conclusions. Our study demonstrated a relatively long mean predicted survivorship for children and adolescents with severe spastic cerebral palsy and neuromuscular scoliosis who underwent spine surgery, which is consistent with the current concept of increased life expectancy even for the total-body involved patients. The most accurate determinants for survival rates among this population group were the number of days the patient had to spend postoperatively in the intensive care unit, and the presence of excessive thoracic hyper-kyphosis.
Purpose: To evaluate the outcome of spinal fusion with unit rod in pediatric patients with cerebral palsy who were treated by the two senior authors using the same operative technique. Methods: This is a retrospective study of 288 patients with mean age at surgery 13.9 years (SD: 3.26), whose medical charts and radiographs were reviewed. A questionnaire including 14 questions assessing patients’ functional improvement was given to the caretakers. Results: Mean radiographic follow up of 3.2 years (range: 1-9.9) was available in 213 patients. In 46 patients anterior-posterior fusion was performed and in 242 only posterior. The preop. Cobb angle was 740(range: 6-176°) corrected by 68% to 230 (p<
.01) and increased by 20 in the last follow-up (p<
.01). The preop. pelvic obliquity was 170(range: 0-57°), corrected by 73% to 4.70 (p<
.01) and increased by 0.40 at follow-up. The preop. kyphosis angle was 560(range: -44-130°), corrected by 37% to 350 (p<
.01) and increased by 20 at follow-up. The preop. lordosis angle was 380(range: -50-140°), corrected by 14% to 430 (p<
.05) and increased by 1.40 at follow-up. There was a strong correlation between hyperlordosis and days of hospitalization, blood loss and surgical time (r= -.22, .23, .24). Patients with lordotic angle >
600 developed 15.1% technical problems related to pelvic fixation, whereas only 3.4% of those with <
600. The mean days of hospitalization were 19.6, the mean blood loss 2.9lt (1.2BV), the mean surgical time 4.4h (Anterior-Posterior: 7h, Posterior only: 3.9h) and the mean ICU stay 5 days. There was a difference only in surgical time (p<
.01) if an anterior procedure was required. The major complications included 3 perioperative deaths, 14 deep infections, 13 (4.5%) reop-erations for mechanical problems and no detected pseud-arthrosis. The answers received by the caretakers were 99% positive, emphasizing the improvement in child’s appearance, sitting ability and respiratory function. Conclusion: Spine surgery in patients with cerebral palsy was accompanied by a considerable blood loss and multiple medical complications. A very satisfactory correction of spinal curvatures was achieved and maintained in follow up. Excessive lumbar lordosis was associated with a high incidence of technical problems and an increased morbidity. There were no pseudarthrosis and the overall number of reoperations for technical reasons was very low. The caretakers were extremely pleased with the outcome of this procedure.