How surgery can help
Surgery is one of the many options available to help children with cerebral palsy improve mobility, posture and ensure healthy growth. Most doctors recommend physical therapy and medication before surgery.
Surgery can correct or improve movement and alignment in the legs, ankles, feet, hips, wrists and arms. These operations are performed on the muscles, tendons, bones and nerves.
As is the goal with all treatment of cerebral palsy, surgery aims to give children the greatest chance of living as independently as possible. Movement problems caused by cerebral palsy can improve over time, but they also carry the risk of getting worse.
The main purpose of surgery is to make a child's cerebral palsy more manageable and prevent future complications.
Surgery is used to:
- Relieve stiff muscles
- Correct spinal curvatures (scoliosis)
- Reduce tremors
- Correct foot deformities
- Improve posture
- Improve balance and coordination
- Relieve pain
- Correct fixed joints and tendons
- Prevent spinal deformities
- Free permanently tightened muscles (contractures)
- Prevent hip dislocation
- Treat co-occurring conditions
Considerations before settling on surgery
It’s impossible to offer a one-size-fits-all treatment plan for children with cerebral palsy—a surgery that is successful in one scenario may not be in another. Additionally, the potential benefits must be greater than the risks at stake.
For example, children who are able to walk with or without assistance tend to have better results from surgery than non-ambulatory children. Therefore, parents of non-ambulatory children may not want to put their child through surgery if there is a lower chance of correcting movement.
Parents considering surgery to improve their child’s well-being should be aware of the risks and benefits involved.
Types of surgery
There are a variety of procedures that can correct many issues and secondary conditions of cerebral palsy. Orthopedic surgery is generally used to improve movement, posture and gait. Other surgeries may be used to correct co-occurring conditions, such as issues with feeding or hearing impairment.
Orthopedic surgery (also spelled orthopaedic) is a type of surgery that is used to improve mobility. These procedures are beneficial in treating spasticity, or jerky, exaggerated movements. This surgery is usually suggested after previous therapies and medications have proven unsuccessful. Orthopedic surgery can also prevent future complications, such as contractures and hip dislocations.
If your child is exhibiting rotational abnormalities, joint dislocation, pain or problems when wearing shoes, orthopedic surgery may be able to help improve their condition and overall comfortability.
The 6 main types of orthopedic procedures are:
- Muscle lengthening – Surgical lengthening of the muscles used to relieve tightness in the hands and fingers. Lengthening the arm muscles can help children grasp objects more easily and improve fine motor skills.
- Tendon lengthening – Lengthening tendons can reduce painful contractures, which is a permanent tightening of the tendons or muscles. This surgery is often used to improve a child’s ability to walk and sit upright.
- Tendon transfer – Tendon transfers typically involve the cutting and replacement of a tendon. The goal of tendon transfers is to ensure that the muscles in the body are properly aligned. This surgery also helps reduce any pain or walking problems that children with CP may be experiencing, as well as improving extension and flexibility of the wrists.
- Tenotomy/myotomy – Tenotomy describes the cutting of the tendon, whereas myotomy involves cutting the muscle. This procedure is used to improve muscle function, increase control of the upper limbs and enhance ability to grasp objects with hands and feet.
- Osteotomy – This procedure is used to realign joints for better posture and mobility. It involves repositioning bones at angles more conducive to healthy alignments and is commonly used to correct hip dislocations in children with CP.
- Arthrodesis – In severe cases of spasticity, when splints and casts aren’t enough, arthrodesis may be used to permanently fuse bones together. Fusing the bones in the ankle and foot can make it easier for a child to walk.
The type of orthopedic surgery that would be best for your child depends mostly on whether they are considered to be ambulatory or not. An ambulatory child is able to walk around independently or with the use of mobility aids such as crutches or walkers. A nonambulatory child is unable to walk or requires the use of a wheelchair in order to move about.
Ambulatory children with cerebral palsy may have a tendency to step mostly on their toes, cross their hips while walking or bend their knees when taking strides. These issues can be caused by tight muscles, weakness, or misalignment of the joints or bones.
The purpose of surgery for ambulatory children is to improve their ability to walk, which is essential to improving self-reliance. For example, a child who "toe-walks" may have their stride corrected with a tenotomy or tendon lengthening procedure. Orthopedic surgery can also correct issues caused by poor alignment of the hips or knees.
Non-ambulatory children are unable to walk, which is why the goal of orthopedic surgery is more centered around increasing comfort and avoiding any further mobility complications.
Orthopedic surgery is used to stop certain complications from getting worse. Surgeries correcting spinal curvature, hip dislocations and contractures alleviate pain and promote a comfortable, well-aligned sitting position. Osteotomy may be used to fuse bones in the spine to correct severe scoliosis.
The benefits of orthopedic surgery aren’t immediate. Children often require physical therapy to ensure a successful recovery and to keep muscles strong and flexible.
Selective dorsal rhizotomy
Selective dorsal rhizotomy (SDR) is an aggressive procedure that helps reduce pain and spasticity. SDR is typically recommended in severe cases of spasticity when other treatments have failed to make an impact. Children with spasticity in the legs (spastic diplegia) tend to benefit more than children with spasticity in other locations (quadriplegia, hemiplegia).
Selective dorsal rhizotomy gets to the root of spasticity issues by cutting the nerves in the spinal column responsible for muscle stiffness. This procedure requires navigating the complex network of nerves to pinpoint which nerves are causing movement issues. SDR can be used to relax muscles in the upper and lower limbs.
Selective dorsal rhizotomy improves:
- Deformities in tendons, muscles, feet and hips
- Voluntary movement
Recovery from selective dorsal rhizotomy requires intensive physical therapy to relearn muscle control and movement.
Cerebral palsy affects every child differently, and most children who have it experience secondary conditions, such as hearing loss or acid reflux. These secondary conditions can be a result of limited movement caused by cerebral palsy, or they may be a direct result of the brain injury experienced at birth.
Many children with cerebral palsy have a hearing impairment. Those with severe hearing loss may benefit from cochlear implants—a surgically implanted hearing device. Congenital hearing impairment (loss of hearing present at birth) can be caused by the same factors that cause cerebral palsy, such as oxygen deprivation during birth. As many as 15 percent of children with CP have a hearing impairment.
Children with low muscle tone often have issues with feeding. Their lack of muscle control can make it hard for them to swallow and chew. They may also have severe acid reflux or experience aspiration (food and drink entering the lungs) as a result of low muscle tone. Children can avoid these complications by having a feeding tube surgically implanted. For children with severe cerebral palsy, this may be the only way they can stay healthy. It also makes feeding time less demanding for parents. For children with less severe diagnoses, speech therapists can help with chewing and swallowing.
This is a rare condition that can require surgical treatment. Hydrocephalus is a complication involving the buildup of cerebrospinal fluid in the skull, causing an abnormal increase in the size of the head. Untreated, this condition can be fatal. Treatment can include the implantation of valves to drain off excess fluid. Few children with cerebral palsy have hydrocephalus.
When is surgery appropriate?
Every surgery has its risks. Collaboration between parents and doctors can help families weigh the possible benefits with the risks of surgery. It takes careful consideration to determine when surgery is appropriate because every child is different.
Doctors have differing opinions about the best time in a child’s life to suggest surgery. Some doctors think surgery offers the greatest benefit when children are young; others think it’s best to wait until children are older, recommending physical therapy and medication in the meantime. Generally, children with cerebral palsy are treated between the ages of 3 and 10, but the exact age depends on the individual.
Why is timing so important?
Timing is essential because as a child with cerebral palsy grows, it becomes more apparent where they are having movement problems. Movement issues can be secondary to a larger issue that is hard to recognize until the child is older. Acting too early can result in a needless surgery with no tangible benefit.
For example, a deformity in the knees could be caused by an imbalance in the hips. Surgery to correct the straightening of the knees may have little effect if the issue resides in the hips.
Conversely, performing surgeries too late means posture and joint alignments could already be established, further illustrating the importance of timing.
An experienced specialist can evaluate the best course of action for your child. Discussing your child’s specific medical needs with care providers can help determine the best timing for your unique situation. You can learn more about surgical specialists in our free Cerebral Palsy Guide.