Treatment of spastic diplegia in patients with cerebral palsy

Appropriate treatment, which includes orthopaedic surgery, physical and occupational therapy, recreational therapy, orthotics, and utilization of assistive devices, will improve the functional outcomes of children with cerebral palsy. Medical modalities such as intramuscular injections of botulinum toxin, and constant intrathecal administration of Baclofen via an implanted pump may also be of benefit. There is a defined set of orthopaedic surgical procedures that can enhance function, and the challenge for the surgeon is to identify which combination of procedures is appropriate for each individual patient and at what point during development to implement them. Some surgeons prefer to wait until patients are older (8-10 years) and perform all of their surgical interventions in one sitting. We, however, favor a different approach wherein surgical procedures are done as indicated during childhood development to enhance function and allow further improvement of motor skills. We refer to this approach as 'Staged Multilevel Interventions in the Lower Extremity' or 'SMILE'. This paper will discuss the rationale for this approach and our recommendations regarding the indications and timing of surgical interventions, as well as techniques and outcomes as reported in the literature.