Neuromuscular conditions Cerebral Palsy Dr. Mohammed M. Zamzam Associate Professor & Consultant Pediatric Orthopedic Surgeon Pediatric Orthopedic Surgeon

Definition Non progressive, cerebral damage occurring before brain maturation (1-2 years) resulting in muscle weakness, spasticity and other symptoms

Incidence 0.5-2/1000 in premature deliveries

Causes  Prenatal : Maternal disease/ Toxemia Maternal disease/ Toxemia Cerebral deformity/ Hemorrhage Cerebral deformity/ Hemorrhage Inborn error of metabolism Inborn error of metabolism  Perinatal : Labour/ Respiratory complications Labour/ Respiratory complications Perinatal infections Perinatal infections

Causes  Postnatal : Infection Infection Violence Violence Convulsion Convulsion

Classification Topographic Classification  Diplegia : (Arms & Legs much more in legs), most patients eventually walk  Tetraplegia : (Arms & Legs & Trunk) High mortality rate, most pts unable to walk. IQ is low

Classification Topographic Classification  Hemiplegia : Upper & lower limbs on one side (upper more than lower limbs), with spasticity, patients eventually walks  Bilateral Hemiplegia  Paraplegia (Legs)  Monoplegia  Triplegia

Classification Physiological Classification Spastic :  Commonest 50-60%  Most important for the Orthopedic Surgeon  Increased muscle tone (Jack knife spasticity)  Slow restricted movements  Increased reflexes  Babinski +ve

Classification Physiological Classification Athetosis :  20-25%  ? Kernicterus  Involuntary, uncontrolled slow movement  Normal reflexes  +/- Muscle rigidity or tremors  NOT FOR SURGERY

Classification Physiological Classification Ataxia :  1-5%  Inability to control /coordinate movement when they start  Intention tremor  Nystagmus / unbalanced gait  NOT FOR SURGERY

Classification Physiological Classification Rigidity :  5-7 %  Lead pipe rigidity Mixed type : A combination of spasticity and athetosis with whole body involvement A combination of spasticity and athetosis with whole body involvement

Presentation 3 year- old boy Presented with Inability to stand or walk

Deformities Upper limb :  Shoulder adduction/internal rotation  Elbow flexion  Forearm pronation  Wrist and fingers flexion

Deformities Lower limb :  Hip adduction/flexion/internal rotation  Knee flexion  Feet equinus / varus or valgus  Gait scissoring Spine : kyphoscoliosis kyphoscoliosis

The two most important x-rays during follow up

Management Aim of treatment :  AS INDEPENDENT AS POSSIBLE  Avoid pain (hip arthritis)  Maintain sitting posture  Maintain spinal stability  Social benefit

Management Multidisciplinary :  Orthotics before and after surgery  Physiotherapy/Occupational therapy  Orthopedic Surgery  Neurosurgery/ Pediatric Neurology  Speech therapy

Management  History  Exam  Investigation  Treatment The degree of retardation is of great importance in treatment planning

Management Exercise :  Start early (1 st month) when suspected  Qualified Physiotherapist/ PARENTS  Prevent contractures  Develop coordination  Mental exercise  Use Orthotics/POP/Casts if needed

Management Surgery :  Best in Spastic Hemiplegics and severe deformities  Contraindicated in Athetoid & Ataxic

Management Goal of Surgery :  Decrease spasm  Release of contractures  Correct deformities  Rebalance muscles  Stabilize flail joints

Management Options of Surgery :  Neurectomy  Tenotomy  Tenoplasty  Muscle lengthening (Recession)  Tendon Transfer  Bony surgery Osteotomy/Fusion  Spinal surgery

Management Intramuscular botulinum toxin:  Temporarily reduces dynamic spasticity  It is thought that its use promotes normal muscle growth and avoids the development of soft tissue contracture