Adductor release and chemodenervation in children with cerebral palsy: A pilot study in 16 children

Abstract

Purpose A pilot study with short-term outcomes of a combined surgical and medical intervention for management of generalized lower limb spasticity, hip displacement and contractures of adductors in children with bilateral spastic cerebral palsy. Methods A prospective cohort study of 16 children (9 boys and 7 girls) aged 2-6 years with bilateral spastic cerebral palsy was performed. At entry, 5 were classified as level III and 11 as level IV, according to the Gross Motor Function Classification System (GMFCS). The intervention consisted of surgical lengthening of adductor longus and gracilis combined with the phenolization of the anterior branch of the obturator nerve, using 1 ml of 6% phenol, applied under direct vision at the time of lengthening of adductor longus. The hamstring and calf muscles were each injected with Botulinum neurotoxin A at a dose of 4 U/kg/muscle. Serial clinical (hip, knee, ankle joint range of motion), radiographic (migration percentage) and functional data-taken from a functional mobility scale (FMS) or GMFCS-were collected at 3, 6, 12 and 24 months post-operatively.

The cerebral palsy hip classification is reliable

“…Basing the classification on the migration percentage allows comparison with studies reporting a change in the migration percentage in younger children. 19,20 However, these rarely show the morphological features which we found to be part of hip disease in adolescents with cerebral palsy. We believe that the changes in hip morphology accelerate during the adolescent growth spurt.…”

“…10,17 It is therefore widely used for the detection of early hip displacement, the longitudinal follow-up of children who have been identified with hip displacement and for monitoring the outcome of various interventions. [18][19][20] There are inherent limitations to the measurement of the migration percentage from a twodimensional anteroposterior radiograph of the hip. Dislocation of the hip is usually posterolateral in children with cerebral palsy, but is occasionally anterior.…”

Interventional Procedures for Chronic Pain in Children and Adolescents: A Review of the Current Evidence

“…The obturator nerve can be blocked to treat obturator neuralgia in children by either landmark or ultrasound‐based guidance. In addition, neurolysis of the obturator nerve has been described for treatment of spasticity in children with cerebral palsy …”

Intramuscular nerve distribution pattern of the adductor longus and gracilis muscles demonstrated with sihler staining: Guidance for botulinum toxin injection

“…Various surgical modalities, such as obturator neurectomy, selective dorsal rhizotomy, and orthopedic surgeries, have been used to reduce hip adductor spasticity 14, 23, 24. However, these therapeutic approaches cannot be applied to patients who are poor surgical candidates.…”