Neurological Surgery
Treatment Options
Treatment options for spasticity include a range of nonsurgical and surgical approaches that vary based on the nature and severity of symptoms. One child may benefit from a tendon release to improve range of motion, but their ability to improve function may also depend on physical therapy or physical therapy in combination with pharmacological therapy, such as Botox injections or muscle relaxants.
While a substantial proportion of patients seen at the Spasticity Center have cerebral palsy, there is a broad spectrum of disorders that result in spasticity. Improving mobility and function may involve treatments that address nerves, tendons, muscles, bones, or some combination. There are advantages and disadvantages to many of these treatments and our team works with children and their parents to identify an approach with which they are most comfortable.
Treatment options include:Physical Therapy
Physical therapy consists of activities that will help to improve flexibility, strength, mobility, and function. A physical therapist also designs, modifies, and orders adaptive equipment. A physical therapy program should consist of exercises that include stretching, strengthening, and positioning to reduce muscle tone, maintain or improve range of motion, coordination, and improve care and comfort. In order to stretch the muscles, the arms and legs must be moved in ways that produce a slow, steady pull on the muscles to keep them loose. The increased muscle tone of a patient with spasticity generally causes muscles to tighten.
Comprehensive muscle strength and tone evaluations are performed at each visit to assess initial and follow-up effectiveness of treatments.
Occupational Therapy
Occupational therapies are targeted at reducing muscle tone, improving range of motion, mobility, comfort, and strength, and enhancing independence and the performance of activities of daily living, such as dressing, eating, transferring, and bathing. Fostering independence increases self-reliance and self-esteem, and helps reduce demands on parents and caregivers.
Orthotics
Orthotics are designed to help provide support to weakened muscles and minimize the risk of joint deformity. There are a number of orthotics made from a variety of materials that can give support depending on a child's pattern of movement, avoid skin breakdown, and to make the child more comfortable. Orthotics include:
- Ankle foot orthoses
- Leg braces or casts
- Hand splints
- Soft body jackets
Medications
A variety of medications are available for the treatment of spasticity. When spasticity is focal rather than diffuse in nature, the sedation and confusion associated with the use of oral medications may limit their effectiveness.
Intramuscular Injections (Botox)
Botulinum toxin injections are intramuscular injections done in children and adults to reduce spasticity and/or abnormal movements in a specific muscle or muscle groups.
Minimally Invasive Selective Dorsal Rhizotomy
Selective dorsal rhizotomy is a type of surgery used primarily to treat children with lower extremity spasticity, although some children with both arm and leg involvement will also benefit. The surgeon operates on the nerve roots leading to sensory nerves in the legs. The patient receives general anesthesia for the surgery.
The surgeon first makes an opening in the lower back to see the nerve roots in the spinal column. Next, the nerve roots are separated into their smaller rootlets. Each of these rootlets is then stimulated with a small amount of electricity. When a muscle responds abnormally to the stimulation, this rootlet may be surgically cut in order to reduce tightness. Usually, less than half the total number of rootlets is cut.
Why is it called minimally invasive?It is called minimally invasive because the surgery is performed through a small (one- to two-inch) incision and by removing only one level of bone. NewYork-Presbyterian Morgan Stanley Children’s Hospital is only one of three centers in the United States and the only center in the Tri-State area that is performing this minimally invasive surgery. This procedure is very different from the traditional approach of performing the operation in which a much larger incision (several inches) is made and five levels of bone are removed. This minimally invasive approach is made possible by utilizing the intraoperative ultrasound and operating microscope.
Which children might benefit from selective dorsal rhizotomy?Rhizotomy can significantly decrease spasticity, however, doing so may reveal underlying muscle weakness. Thus, it is important for a child to have relatively good strength in the legs to benefit from this procedure. Children with spastic diplegia cerebral palsy usually benefit the most. It is also best if a child has a low number of fixed contractures, a high level of motivation, and spasticity rather than other types of abnormal muscle tone like dystonia or athetosis.
What are the potential risks?As with any surgical procedure, selective dorsal rhizotomy does have some risks. Typically these risks are small when compared with other major procedures involving the central nervous system. There is a very small risk of infection and bleeding. Your child may experience some areas of numbness in the legs. This usually goes away, but small areas of numbness may last. As mentioned above, reducing the spasticity may reveal some weakness. Selective dorsal rhizotomy decreases only spasticity and not contractures. Additional orthopedic surgery may be needed at some point after the dorsal rhizotomy surgery.
What happens after the surgery?For the first day after surgery, your child must remain flat in the hospital bed and will receive pain relievers. Most children are ready to go home or to inpatient rehabilitation after two to three days allowing them to begin the process of retraining their relaxed muscles with physical therapy and rehabilitation. The spasticity team will help arrange this prior to surgery.
Intrathecal Baclofen Therapy
Baclofen is a medication that can be used to decrease spasticity. The effectiveness of oral baclofen is often limited by dose-related side effects such as sedation, increased drooling, and confusion. Therefore, for greater effectiveness, baclofen may be administered via an implanted pump into the intrathecal space around the spinal cord. By delivering bacloven directly into the spinal fluid with an implantable pump, dramatic reductions of tone in both the arms and legs can be achieved with much smaller dosages.
The pump is programmable with an external magnet, so the dose can be easily adjusted to determine the best dose for the patient. An intrathecal baclofen pump is used primarily to treat children with severe spasticity in both the arms and the legs. Potential candidates for this therapy are first evaluated with a trial injection of intrathecal baclofen, and a positive response is seen in approximately 90 percent of patients.
Intrathecal Baclofen TrialTo determine if a child is a candidate for a baclofen pump or a selective dorsal rhizotomy, a test dose of baclofen (baclofen trial) may be given to monitor the effect the medication has on spasticity.
How is an intrathecal baclofen trial performed?A lumbar puncture is performed in the operating room, and a small dose of baclofen is injected into the fluid space around the spinal cord. The medication will reach a peak approximately four hours after the injection and will wear off in approximately eight hours. Before and during the trial, the child’s muscle tone will be closely monitored. The child may also be videotaped. The trial does not show exactly how a child will function during continuous infusion with a pump, but does give an estimate of the effect of the pump.
A baclofen trial gives the family, patient, physician and therapists valuable information regarding the types of tone, underlying problems that may be present, and the patient’s sensitivity to the medication. It also helps to establish a “road map” for future care.
What are the risks and side effects?The risks of a baclofen trial are minimal. The procedure is performed in the operating room with pediatric anesthesiologists. The patient is monitored with vital signs taken frequently until the medication has worn off. A few patients have experienced a headache following the lumbar puncture. As with any injection, there is a very small risk of infection.
What happens after an intrathecal baclofen trial?There are no restrictions with the exception of light activity for 24 hours, with close monitoring during walking until the effects of the medication have completely worn off. The patient and family, together with the spasticity center team, will discuss the results of the trial and the treatment options that are appropriate for spasticity management. The ultimate decision is left to the family and patient.
Orthopedic Surgery
A wide variety of orthopedic surgical options are available to treat spasticity and its long-term consequences on the musculoskeletal system. In general, orthopedic procedures have been used to improve the biomechanics of spastic patients. Some common goals of surgery include lengthening of contracted muscles, balancing of joint forces, reduction of joint subluxation, fusion of unstable joints, and diminishment of painful spasticity.
The surgical techniques include:
- tenotomy
- arthrodesis
- osteotomy
- tendon transfer or lengthening
The procedures used are tailored to the clinical situation and age of the patient. The natural course of the specific musculoskeletal abnormality is also factored into the decision making process.
Contact
- Spasticity Center
- (212) 305-9606
