Cerebral Palsy Surgery in India, Bangladesh, Nepal, UK, USA, Africa, UAE

 In Cerebral Palsy

Cerebral Palsy Surgery

Why we Perform Surgery for Cerebral Palsy:

Surgery is required to treat joint deformity, bony torsion & muscle contracture. Surgery in walking children is needed to correct the deformity so that they can walk more efficiently. Role of surgery in non-walker is to manage deformity so that transfer can be easier and brace can be given more comfortably.

Different types of Surgery for Cerebral Palsy:

Older traditional concept for surgery in CP was single or two level surgeries. It required repeated surgical intervention and did not give good results. In traditional orthopedic surgery tendon lengthening & tenotomy is the main surgery. Muscles in cerebral palsy are already weak and by doing surgery on muscle led to increase in weakness and child losses all the possibility of improvement.  Even some times ambulatory children became non-ambulatory.

Advancement in Orthopedic Surgery:

In last two decade we have seen much new advancement in orthopedic surgical planning. Because muscles are already weak in CP, so surgeries on muscle are not preferred. So whenever we need surgery on muscle then we lengthen the muscle by myofascial release rarely by tendon lengthening and some-time we transfer the tendon to other places to save some function of muscles.

Usually in long term bone develop torsional deformity & joint deformity. So nowadays to correct this lever arm restoration, bony osteotomy is being done to correct torsional deformity. Joint deformity is being corrected by osteotomy. Orthopaedic surgery is not advised before the age of 8 years.  Surgery is contemplated once child develop fix deformity & bony torsion.  All the deformity in children with cerebral palsy is being managed in single event anaesthesia.

Surgical planning is based on repeated evaluation preoperatively by gait analysis, detail musculoskeletal evaluation and during surgery.

What are the advantages of surgery: advantage of surgery is to correct the fix joint & bony deformity, lengthen short muscle so physical therapy can be performed in much better ways.

What is the appropriate time to perform Surgery:

No age is appropriate. Surgery is contemplated once it is needed. Surgery is usually delayed till the age of 8 years. Surgery again may be needed after 15 year of age. Orthopaedic surgery is needed only when child develops fix deformity. Surgery is needed only in spastic CP.

Why Surgery Timing is Important:

Child achieves maturity of gait pattern at the age of 6-7 years & in cerebral palsy it is delayed. So surgery in cerebral palsy is delayed beyond 8 year age or till the age when they achieve maximum functional capability with good therapeutic protocol and start developing fix deformity that start interfering in further progress. Second age of surgery is completion of growth around the age of 15-16 year, when they will not have any chance of increase in height.

Problem with late Surgery:

Risk of deformity spread to adjacent joints and to the skeleton during the ‘waiting-time’ for surgery , there can be over lengthening of  some tendon ( Tendo Achilles, Patellar tendon ) or development of non correctable deformity . Other complications like bony torsion, mid foot break and Plano valgus foot can develop. Ultimately degenerative changes in joint start developing.

Cerebral Palsy Surgery as an Option

Surgery is not the mainstay in the treatment of cerebral palsy. It is needed in less than 10% cases and only in spastic and mixed cerebral palsy. Surgery should not be done in dyskinetic variety. Surgery is not the alternative way of physical therapy but once it needed it should be done. Detail evaluation including physical examination, gait analysis and examination under anesthesia is mandatory for good surgical planning.

Benefits of Surgery for Cerebral Palsy Patients

Selective dorsal rhizotomy reduces generalized tone of lower limb but selective neurectomy reduces tone of affected spastic muscle. But some time it creates more weakness and increases disability of child. Orthopaedic surgery is meant to manage fix bony and joint, bony deformity, muscle contracture, joint subluxation, dislocation etc. Tendon transfer benefit in muscle weakness and contracture, myofascila release benefit in muscle shortening, bone shortening in muscle contracure, osteotomy in bony torsion and deformity. Usually in ambulatory children (GMFCS1-3) our aim of surgery is to make them better and correct the deformity that they can walk in much better way. In non walker children our aim is to give braceable foot, correct the massive deformity so that they can wear brace and can be transferred easily and can use wheel chair safely.

Types of CP Surgery

Methods of surgery include neurosurgery and orthopaedic surgery. Neurosurgery includes selective dorsal rhizotomy (SDR), selective neurectomy. Selective rhizotomy are being performed on rootlets coming out from spinal cord and in selective neurectomy few fibre of peripheral motor nerve are resected. But both surgical techniques also have lots of complication so not much of much useful. Orthopaedic surgery is the main surgical methods of intervention. In last two decade many advancement has been seen in orthopaedic surgical planning. It happens because of our better understanding biomechanics and gait analysis.

Now days we don’t prefer muscle surgery except in few condition. Because muscle tenotomy can cause severe weakness that increases disability of child so we do only fascial release and tendon transfer if really needed. Most of the time we prefer to correct the bony deformity by osteotomy and muscle contracture by bone shortening. By this concept we are getting execellent recovery without any muscle weakness.

A Cerebral Palsy is a group of neuro-motor disorder which comprise of the problem in ambulation along with a problem in cognition, perception, vision, hearing, speech, oromotor problem etc. Usually, treatment of cerebral palsy requires good rehab measure which includes multimodal physiotherapy, training in ADL activity & brace. If we look into the history, innovations in cerebral palsy management started only a few decades back. Main issues in Cerebral Palsy are a problem in balance, muscle tone, abnormal movement disorder, muscle weakness & absence of selective fine motor function. So we have to manage the entire problem simultaneously through cerebral palsy surgery and therapy treatment.

Cerebral palsy surgery is only required to correct bony & fix joint deformity in children with spastic & mixed cerebral palsy and not in dyskinetic cerebral palsy. It should be planned meticulously only after detail evaluation. A few decades back, we used to plan surgery in staged manner for correcting deformity of one joint at a time. Then came the concept of single event multilevel surgery (SEMLS), in which all the contracted & shorten muscle are lengthened in single stage surgery but both concepts don’t give much hope to these children. Most of the time, these children get lots of problem because of over-lengthened & weak muscle. Sometimes child deteriorates very fast because of weakness & progressive deformity. Initially, tendon was lengthened or cut completely. Then the concept of doing aponeurotic release of affected long musculo-tendinous unit (OSSCS) came. In this concept, only superficial facial coverage of all affected multiarticular muscle are released & short monoarticular muscle is not touched so that weakness does not occur but still there are chances of over-lengthening of tendon in long term.

Now, gait analysis in the evaluation of cerebral palsy has paved a new path in the management of cerebral palsy. It is proven by many types of cerebral palsy research that all seemingly contracted muscles are not always short. Sometimes these muscles can be longer than normal. Most of the times these muscles are weak so lengthening of these muscles weaken them further. But still few muscles may require lengthening in the presence of muscle shortening.

Second issue is that muscle can’t generate enough power if bone & joint are not in proper alignment. Muscle will not be able to work properly in the presence of mal-alignment of bone & joint (lever arm problem). This mal-alignment can be in the form of angular, rotational bony & joint deformity. So along with strength training of muscles, these deformities require multi-level correction by corrective bony osteotomy as well. Common problem in lever arm problem is increase anteversion of femur neck (internal femur torsion), tibial external rotational deformity & planovalgus feet. All these problems should be managed to get best outcome. Some muscles are too weak or malfunctioning, so we also supplement them with full or partial tendon transfer. Common sites of tendon transfer are wrist, knee & foot problem in cerebral palsy. Aponurotic Lengthening of musculotendinous unit is required only in the cases with very short muscle length. Some time, shortening of bone is being done to save the muscle from weakness by over lengthening during correction of lever arm restoration Now days we utilize the concept of lever arm restoration, tendon transfer & aponurotic release of contracted long mutiarticular muscle in single stage. I had given the name single event multilevel orthopaedic surgery (SEMLOS) for this new concept. Usually, we delay cerebral palsy surgery till certain age when gait of the child become mature; it usually happens around 6-7 year in cp children. So if CP surgery is required it is recommended before puberty between 7-10 years and at maturity around 15 years age. Surgery at early age is required only in cases with hand deformity & dislocation of hip joint. Continuous use of brace & physical therapy is mandatory after surgery to maintain the physical status of the child.

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