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[Neurosurgical treatment of spasticity: indications in children]
1Service de Médecine Physique et Réadaptation Pédiatrique, L'Escale, Centre Hospitalier Lyon-Sud, Pierre-Bénite. isabelle.hodgkinson@chu-lyon.fr
Insights
Effective neurosurgical treatments for spasticity in children with cerebral palsy require a multidisciplinary consensus on surgical goals. Treatment decisions consider the child's overall condition, environment, and spasticity type, guiding interventions like rhizotomy or baclofen therapy.
Area of Science:
- Neurosurgery
- Pediatric Neurology
- Rehabilitation Medicine
Context:
- Cerebral palsy (CP) frequently causes spasticity in children, impacting motor function and quality of life.
- Current neurosurgical interventions offer efficient management options for pediatric spasticity.
- Establishing a consensus among the surgical team, child, family, and therapists is crucial for successful treatment indication.
Purpose:
- To outline current neurosurgical treatment strategies for spasticity in children with cerebral palsy.
- To emphasize the importance of a holistic assessment, including functional, cognitive, and environmental factors, beyond just spasticity analysis.
- To differentiate treatment approaches for lower and upper limb spasticity, and for generalized versus localized presentations.
Summary:
- For generalized lower limb spasticity, posterior rhizotomy or intrathecal baclofen administration are proposed. Posterior rhizotomy is favored for more aggressive interventions or when complex medical care is challenging.
- Localized spasticity, particularly in the upper limbs of children with hemiplegia, is initially managed with botulinum toxin injections to delay more invasive procedures like neurotomy.
- For upper limb spasticity in quadriplegic children, physical and occupational therapy are the primary interventions, as rhizotomy and baclofen lack significant positive effects on upper limb function.
Impact:
- Informed decision-making for neurosurgical interventions in pediatric spasticity.
- Improved functional outcomes and quality of life for children with cerebral palsy through tailored treatment plans.
- Guidance for clinicians on selecting appropriate spasticity management strategies based on individual patient characteristics and needs.
Abstract:
Today, we have several efficient neurosurgical treatments of spasticity in children with cerebral palsy. A good indication is possible only if a consensus about the goal of the surgery is found between the surgeon, the child and his/her family, and the reeducation team. This goal is not always functional. Clinical examination is not limited to the analytical assessment of spasticity, but must take into account the general and orthopedic state of the child, and his/her functional evolution, cognitive abilities, habits and general environment. The struggle against spasticity is part of a therapeutical programme which extends over several years. It must be considered before muscular contractures. On lower limbs, in the cases of general spasticity, we propose posterior rhizotomy or intrathecal baclofen administration. Posterior rhizotomy is proposed when a more aggressive intervention is preferred for some muscular groups or when the child's general environment does not allow for the medical care imposed by intrathecal administration. In the case of localized spasticity, botulinum toxin injection permits delaying until the child reaches the age for selective neurotomy. On upper limbs, in children with quadriplegia the indication is essentially physical and occupational therapy. We cannot count on the positive side effects of rhizotomy or intrathecal administration of baclofen on the upper limbs. In children with hemiplegia, with localized or global spasticity of the upper limb, botulinum toxin is proposed as the first form of treatment. Neurotomy or rhizotomy can follow toxin, according to the efficacy of the toxin.