Upper Extremity Surgery in Spastic Cerebral Palsy

Abstract

Involvement of the upper extremity in cerebral palsy often results in a typical pattern of spasticity, with elbow flexion, forearm pronation, ulnar deviation and flexion of the wrist, and adduction-flexion posture of the thumb. Although only a relatively small subset of cerebral palsy patients are candidates for surgery, properly selected patients and procedures yield a reasonable improvement. Nonsurgical treatment modalities include physical therapy, orthoses, and medications aimed at decreasing spasticity. Surgical options for the management of the spastic upper extremity vary with the specific parts, however they are focused around three basic principles: weakening the overactive muscle/tendons, strengthening the underactive muscle/tendons, and stabilizing non-stable joints. Surgical management of the spastic upper limb in cerebral palsy requires meticulous evaluation and planning. It is important to know that upper extremity deformities are secondary manifestations of the cerebral injury. Therefore, in addition to evaluation of upper extremity function, consideration should be given to the intelligence and motivation of the patient, and voluntary use of the upper extremity. Prior to surgery, the overall level of function needs to be considered. These are also important details for the patients and their families, who should know that surgery is aimed at improving the upper extremity deformity, and not the primary disorder. Appropriately indicated surgery can significantly contribute to upper extremity function. (JAREM 2012; 2: 43-54) Key Words: Cerebral palsy, spasticity, upper extremity surgery, tendon transfers ÖZET Serebral paralizide üst ekstremite tutulumu, tipik bir spastisite paterni oluşturur. Bunun sonucunda da sıklıkla dirsek fleksiyonu, önkol pronasyonu, el bileğinde fleksiyon ve ulnar deviasyon, başparmakta adduksiyon-fleksiyon postürüyle karakterize bir deformite meydana gelir. Serebral paralizi hastalarının yalnızca az bir kısmı cerrahi için uygun adaylar olsa da, uygun seçilmiş hastalarda cerrahi tedavi yüz güldürücü sonuçlar verebilmektedir. Cerrahi dışı tedaviler arasında fizik tedavi, ortezler ve spastisiteyi azaltmaya yönelik ilaçlar vardır. Spastik üst ekstremite tedavisindeki cerrahi seçenekler deformitenin bulunduğu bölgeye göre değişir, ancak üç temel özellik üzerinde odaklanır: aşırı aktif kas ve tendonların zayıflatılması, yetersiz aktiviteye sahip olan kas ve tendonların güçlendirilmesi ve stabil olmayan eklemlerin stabilizasyonu. Dirsek fleksiyon deformitesi serebral paralizide nadiren bir cerrahi endikasyon oluşturur, ancak ileri derecede olup işlevi engellediğinde biceps ve brachialis gevşetilmesi, fleksor pronator kas kaydırma gibi işlemler ile düzeltilebilir. Önkol pronasyon postürü, supinasyon gerektiren, ele alınan bir cismin avuç içinde tutulması veya kişisel hijyen gibi görevlerin yapılama-masına neden olabilir. Bu durumlarda ideal olan, mevcut pronasyonu bozmadan hastaya supinasyon hareketi kazandırmaktır. Fleksor karpi ulnarisin ekstansor karpi radialis brevis'...

Characteristics and assessment of children undergoing upper limb surgery for management of cerebral palsy

“…It is widely believed that early intervention is favourable. 5,7,18,22,29,30 posturing that an individual may find more difficult to control. 5,21,34,36 As such, it is interesting to see that rates of mixed motor impairment in this study are much higher than that recorded in the general population with CP.…”

“…Surgical approaches may include musculotendinous lengthening or releases of the deforming spastic muscles, tendon transfers to augment paretic muscles, and joint stabilisations. 7, [15][16][17][18][19] A SEMLS approach is the preferred method of surgical intervention as it reduces the quantity of hospital visits and anaesthetic episodes while maximising functional impact. 15 There is considerable variation in both research Assessing children with CP for potential upper limb surgery is complex.…”

Active Dynamic Tenodesis of Extensor Policis Longus by Palmaris Longus in Deficient Thumb Abduction and Extension

“…Manske took the EPL tendon first dorsal retinucular so eliminating the need for a new pulley. Rayan and Saccone transected EPL tendon proximal to the retinaculum then anastomosed the distal EPL tendon taken through the first dorsal compartment with the proximal strip [2]. Ricado Monreal [12] stated restoration of thumb extension as a great problem in cases of plexus hand, in EPL tenodesis, radiodosal deviation of the wrist joint is inevitable and adduction of the thumb during dynamic tenodesis of finger extension but rerouting of EPL beneath APL tendon and fixing to PL end to side functions well, stabilizing both the wrist and thumb MP and IP joints [12].…”

“…Dynamic tenodesis is transferring of the distal portion of the tendon to normal functioning tendon still its distal end is fixed to its insertion [2]. Tendons are strong enough to sustain the high tensile forces that result from muscle contraction during joint motion yet are sufficiently flexible to angulate around bone surfaces and to deflect beneath retinaculae to change the final direction of muscle pull.…”

Animal models of developmental motor disorders: parallels to human motor dysfunction in cerebral palsy

“…Contractures also start to develop near 2 yr of age (Willerslev-Olsen et al 2018), whereby joint range of motion is reduced and joint position is altered. Children with CP have fixed, flexed postures of upper and lower extremities that often require surgical correction (Horstmann et al 2009;Ozkan and Tuncer 2012;Shamsoddini et al 2014). It is unclear the extent to which muscle stiffness and contractures are a result of excessive, involuntary but neutrally driven muscle activity or the result of increased musculotendinous stiffness from mechanical changes in muscles (short- Young et al 1983 Continued ened muscles, changes in the structure of muscle fibers, connective tissue, and the extracellular matrix induced by muscle atrophy) (Lieber and Fridén 2019;Mathewson and Lieber 2015;Willerslev-Olsen et al 2013).…”