Neuromuscular conditions Cerebral Palsy

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Neuromuscular conditionsCerebral Palsy

• Dr. Mohammed M. Zamzam
• Associate Professor Consultant
• Pediatric Orthopedic Surgeon

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Definition

• Non progressive, cerebral damage
• occurring before brain maturation (1-2 years)
  resulting in muscle weakness, spasticity and
  other symptoms

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Incidence

• 0.5-2/1000 in premature deliveries

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Causes

• Prenatal
• Maternal disease/ Toxemia
• Cerebral deformity/ Hemorrhage
• Inborn error of metabolism
• Perinatal
• Labour/ Respiratory complications
• Perinatal infections

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Causes

• Postnatal
• Infection
• Violence
• Convulsion

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ClassificationTopographic Classification

• Diplegia (Arms Legs much more in legs), most
  patients eventually walk
• Tetraplegia (Arms Legs Trunk) High
  mortality rate, most pts unable to walk. IQ is low

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ClassificationTopographic Classification

• Hemiplegia Upper lower limbs on one side
  (upper more than lower limbs), with spasticity,
  patients eventually walks
• Bilateral Hemiplegia
• Paraplegia (Legs)
• Monoplegia
• Triplegia

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ClassificationPhysiological Classification

• Spastic
• Commonest 50-60
• Most important for the Orthopedic Surgeon
• Increased muscle tone (Jack knife spasticity)
  
• Slow restricted movements
• Increased reflexes
• Babinski ve

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ClassificationPhysiological Classification

• Athetosis
• 20-25
• ? Kernicterus
• Involuntary, uncontrolled slow movement
• Normal reflexes
• /- Muscle rigidity or tremors
• NOT FOR SURGERY

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ClassificationPhysiological Classification

• Ataxia
• 1-5
• Inability to control /coordinate movement when
  they start
• Intention tremor
• Nystagmus / unbalanced gait
• NOT FOR SURGERY

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ClassificationPhysiological Classification

• Rigidity
• 5-7
• Lead pipe rigidity
• Mixed type
• A combination of spasticity and athetosis with
  whole body involvement

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• Presentation
• 3 year- old boy
• Presented with Inability to stand or walk

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Deformities

• Upper limb
• Shoulder adduction/internal
  rotation
• Elbow flexion
• Forearm pronation
• Wrist and fingers flexion

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Deformities

• Lower limb
• Hip adduction/flexion/internal rotation
• Knee flexion
• Feet equinus / varus or valgus
• Gait scissoring
• Spine
• kyphoscoliosis

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The two most important x-rays during follow up
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Management

• Aim of treatment
• AS INDEPENDENT AS POSSIBLE
• Avoid pain (hip arthritis)
• Maintain sitting posture
• Maintain spinal stability
• Social benefit

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Management

• Multidisciplinary
• Orthotics before and after surgery
• Physiotherapy/Occupational therapy
• Orthopedic Surgery
• Neurosurgery/ Pediatric Neurology
• Speech therapy

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Management

• History
• Exam
• Investigation
• Treatment
• The degree of retardation is of great
• importance in treatment planning

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Management

• Exercise
• Start early (1st month) when suspected
• Qualified Physiotherapist/ PARENTS
• Prevent contractures
• Develop coordination
• Mental exercise
• Use Orthotics/POP/Casts if needed

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Management

• Surgery
• Best in Spastic Hemiplegics and severe
  deformities
• Contraindicated in Athetoid Ataxic

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Management

• Goal of Surgery
• Decrease spasm
• Release of contractures
• Correct deformities
• Rebalance muscles
• Stabilize flail joints

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Management

• Options of Surgery
• Neurectomy
• Tenotomy
• Tenoplasty
• Muscle lengthening (Recession)
• Tendon Transfer
• Bony surgery Osteotomy/Fusion
• Spinal surgery

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Management

• Intramuscular botulinum toxin
• Temporarily reduces dynamic spasticity
• It is thought that its use promotes normal muscle
  growth and avoids the development of soft tissue
  contracture

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Thank You