Medical & Surgical

Management in Cerebral
Palsy
In cerebral palsy in addition to primary motor
deficitis,They have many other associated &
secondary conditions that need a
multidisciplinary approach to diagnosis &
medical & surgical management.
 Medical Mode Of Intervention
Medical mode of intervention aims to alleviate spasticity and
uncontrolled movements (dyskinesia).
Methods of applying medication include oral drugs, infusion into
the spinal cord, and injection into the spastic muscles.
Drugs for management of spasticity and dyskinesia:-
1. Oral
medications:Baclofen,Diazepam,Clonazepam,Dantrolene,Tizanid
ine.
2. Intrathecal medications:Baclofen,Morphine,Clonidine.
3. Neuromuscular blocks:Local anesthetics,Phenol,Botulinum toxin.
Agent Starting Maximum Adverse Monitorin Special
dosage recomme Effects g Attention
nded
dosage
Baclofen 5 mg/day 80 mg/day Muscle Periodic Abrupt
increasing in divided weakness, liver cessation
to 15 doses sedation, function associated
mg/day in fatigue, tests with
3 divided dizziness, seizures
doses nausea
Diazepam 2 mg/day 40-60 Sedation, Dependen Withdrawal
bid or 5 mg/day in cognitive ce syndrome
mg qhs divided impairmen potential
doses t,
depression
Tizanidine 2-4 36 mg/day Drowsines Periodic Not to be
mg/day in divided s, dry liver used with
doses mouth, function antihyperte
dizziness, tests nsives
reversible or clonidine
dose-
related
elevated
liver
Clonidine 0.1 Usual dose in Bradycar Add-on
mg/da hypertension dia, agent
y 0.2-0.6 mg/day hypotensi Hypotensio
on, n may
dry result
mouth, Not to be
drowsine used with
ss, tizanidine
constipati
ondizzine
ss,
depressio
n
Clonazepam 0.05 - It is available
( Rivotril): 0.3 as oral drops
This drug is mg/kg/ and may
particularly day increase oral
useful in divide secretions
patients who d 12 or and care
also have 8 ought to be
myoclonic hourly. taken in
epilepsy. patients with
swallowing
problems.

Dantrolene 25 400 mg/day in Hepatotoxi Periodic Hepatotoxicit

mg/da divided doses city liver y
y (potentially function
BOTULINUM TOXIN TYPE A:-

Botulinum toxin, produced by the anaerobic bacteria

Clostridium botulinum, is one of the most potent
poisons known to man.In the past two decades it has
been transformed into one of the most useful
antispastic agents.Of the seven distinct toxins from A
to G, only type A and B are used for therapeutic
purposes. The structure of all toxins and their
mechanism of action are similar, only their site of action
is different.
THE MECHANISM OF EFFECT

The toxin inhibits

acetylcholine release at the
neuromuscular junction
causing a reversible
chemodenervation.
Studies suggest that the
toxin affects the muscle
spindle and afferent nerve
fibers as secondary actions.
Recent research on BT in
patients with Estropia
This procedure is a reasonably less invasive and scar-
free procedure, providing more possible surgical
options in the future for these children. Performing the
procedure with light anesthesia and without EMG
monitoring might be a safe and simple method for the
injection of botulium toxin.
Lower age, more ptosis, larger pre-injection deviation,
and less esotropia one month after injection may be
accounted as predictive factors for achieving better
results.
(Ref:- Ahmad Ameri MD, Arash Mirmohammadsadeghi MD, Ali Makateb MD, Fatemeh
Bazvand MD & Simindokht Hosseini MD (2015) Clinical Outcomes of Botulinum
Toxin Injection in Patients with Cerebral Palsy and Esotropia, Strabismus, 23:1, 8-
13, DOI: 10.3109/09273972.2014.999798 )
 Surgical Mode Of Intervention
Common surgical managements performed in CP:-
Orthopaedic surgery :
Scoliosis- spinal fusion
Hip displacement/dislocation
Ankle, foot, hand, knee and shoulder deformities
Muscle lengthening
Tendon lengthening
Tendon transfer
Tenotomy/myotomy
Femoral osteotomy
Pelvic osteotomy
Arthodesis
DFEO(distal femoral extension osteotomy)
 Neurosurgery:
Selective dorsal rhizotomy :-Selective dorsal
rhizotomy is a surgical procedure that can help
children with particularly severe muscle
stiffness in their legs to improve their walking.
The operation involves cutting some of the
nerves in lower spinal column,which can help
to relieve leg stiffness
 Baclofen pump
1. The pump is a device that delivers the drug, baclofen (brand names:
Lioresal or Gablofen) to the spinal cord to control spasticity.
2. Baclofen tablets are given in milligrams and baclofen by pump is
given in micrograms. (1000 micrograms make one milligram.) The
intrathecal space contains the cerebrospinal fluid (CSF) the fluid that
surrounds the spinal cord and nerve roots
3. Some people have side effects such as drowsiness or seizures from
oral baclofen. Most of the time oral medications and injections are
tried before a pump is considered.
4. When baclofen is delivered into the intrathecal space, it inhibits or
stops the spasticity messages from reaching the brain. With the
implantation of a baclofen pump we hope to achieve the following:-
. reduction of severe spasticity
. reduction in the need for oral anti-spasticity medications
. improved ability to perform activities of daily living
. easier caregiving
. improved comfort
SOME OF THE RECENT RESEARCHES ON ORTHOPAEDIC SURGERIES
IN CEREBRAL PALSY
Tendon Transfer Surgery in Upper-Extremity Cerebral Palsy Is More Effective Than Botulinum Toxin
Injections or Regular, Ongoing Therapy (Ann E.Van
Heest,MD;AnitaBagley,PhD;FredMolitor,PhD;Michelle A.James,MD J Bone Joint Surg Am,2015
Apr 01;97(7):529-536. http://dx.doi.org/10.2106/JBJS.M.01577 )
For children with CP, inclusion of an FDO in the surgical intervention, when indicated, resulted in
improved outcomes. Overall gait kinematic improvements were significantly greater when an FDO
was included in the surgical management. (Outcomes of Orthopaedic Surgery With and Without an
External Femoral Derotational Osteotomy in Children With Cerebral Palsy.McMulkin, Mark L. PhD;
Gordon, Andi B. MPT; Caskey, Paul M. MD; Tompkins, Bryan J. MD; Baird, Glen O. MD)
Denervation of the infraspinatus and release of the posterior deltoid muscles in the management of
dyskinetic external shoulder rotation when other treatment alternatives are insufficient.Izabela
Blaszczyk,MD,Anna CeciliaGranstrm,MD, andMikaelWiberg,MD, PhD January 16, 2015; DOI:
10.3171/2014.9.PEDS14223.
concept of single event multi level orthopedic surgery along with well structured therapy program
gives rise to desired result in most of the properly selected patient with fixed contracture. In recent
years concept of Orthopaedic selective spasticity control surgery (OSSCS) has given new insight in
Single Event Multilevel Orthopedic Surgeries (SEMLOS). By this concept balancing of muscle tone is
possible by selective lengthening of multi-articular muscle and sparing of monoarticular muscles of
the limbs. Second add on in SEMLOS is lever arm restoration by correction of bony torsion by
derotational osteotomy.
(Jain J, Jain V, Shrivastav V. Single event multi level orthopedic surgery in a teenager having spastic
triplegic cerebral palsy. Indian J Cereb Palsy 2015;1:45-8)