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>> Varghese: It's important to see an orthopedic surgeon
right from the start.
There are some risk factors for the hip
that the hip can come out of the socket or the spine
can develop a curve,
which is not obvious right from the start
and it is good to see an muscular skeletal specialist
to try and screen for these conditions and I would
always encourage parents to see to get the children
to see an orthopedic surgeon
from the beginning.
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Surgery and cerebral palsy can involve the upper limbs,
lower limbs, or the spine or hips.
Most often we do surgeries for the lower limbs
in cerebral palsy because one of our primary issues
for children with cerebral palsy is difficulty walking
or in a normal pattern of walking which we want to
improve on.
We also do surgeries for the spine and the hips in
cerebral palsy in children who are not walking
because of the high risk of spinal deformity
development or hip subluxation.
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The timing of surgery for children with cerebral palsy
depends on whether they're walking, they're not walking.
It also depends upon the degree of cerebral palsy they
have, the degree of contractures, and the factors that
play into that.
We usually optimize the surgery depending on the underlying
conditions of the child and there's no set timing
of pre determined protocol that we follow for the timing
of surgery.
Having said that, for a lot of children with cerebral
palsy who are ambulant we do aim to do all the surgeries
one shot, which is called a single event multiple level
surgery, which is surgeries at multiple areas addressing
multiple issues one stage.
And we like to time that before the big growth spurt starts
or after the growth spurt has ended.
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The risks of orthopedic surgery in children with cerebral
palsy are generally slightly higher.
These risks often related to the degree and extent
of cerebral palsy that the child has.
In children who are non ambulant who have feeding issues
and seizure issues, their nutrition is compromised,
and so wound healing and bone healing is a area of
concern.
In children who are walking and ambulant who have a lot
of spasticity, the predominant concern is recurrence
of the deformities that we correct over time as they
grow.
To avoid this we often have an integrated program
where we have our therapists working with the children
before and after surgery and we use orthotics
to try and maintain the corrections that we have update.
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All orthopedic deformities in cerebral palsy do not need
surgery, we always look at what are we trying to achieve
in terms of maximizing function or improving the ability
of caregivers to give care to the totally dependent
child.
There are often deformities that are present that do not
interfere with these functions and so we always try to
balance risk versus benefit to determine if whatever
we're doing for the child is beneficial and if it
isn't we don't need to and in children with cerebral palsy
like I said, there are deformities that actually don't
interfere with their function.
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The role of orthopedic surgery is to try and reduce
tone, correct muscle imbalance, prevent dislocations,
align the lower extremities, so that the child can walk
to the best capacity.
And in this way surgery helps to improve their gait,
reduce the energy required for walking and thereby
increase their stamina and endurance.
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There are different forms of cerebral palsy based on the
type of neurological involvement depending on the injury
to a portional segment of the brain.
In children with spastic and mixed cerebral palsy
orthopedic surgery has a big role in improving the
quality of life.
However in children with ataxic cerebral palsy
and dyskinetic cerebral palsy surgery is not known
to play a significant role in altering their function.
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Cerebral palsy's a neurological condition that arises
from damage to the immature brain.
The damage to the brain results in the child being
unable to use the muscles appropriately and this leads
to problems with function and gait.
Problems in cerebral palsy can be put into two
categories, primary problems and secondary problems.
The primary problems are related to the brain injury
and include muscle tone issues, weakness, lack of
coordination and balance, gait and posture issues.
The secondary problems in cerebral palsy come from
distorted growth of bones and muscles that occur
as the child grows,
due to the primary problems that are in the background.
And so we end up getting upper limb contractures,
lower limb contractures, spinal deformities, hip
dislocation, gait issues in children walking
that preclude their gait.
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The results from orthopedic surgery that we obtain
are not temporary, they are gainful benefits that last
for the child, however there are as factors in a child
with cerebral palsy the risk of recurrence with growth
or new deformities or new issues that creep up.
And a strong way to try and minimize that is to be
in an active rehabilitation program with the occupation
therapist and the physical therapist involved,
and that's the kind of program that we have.
The other important issue is the use of braces,
and repeated follow ups over time to ensure that we have
maintained the successes that we have obtained.
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Here at Johns Hopkins we have a multi disciplinary
approach and we have multiple specialists from
each of these fields that could evaluate the child
with cerebral palsy and help in determining the right
pathway.
We have physical therapists, occupational therapists,
physiatrists, neurologists, neurosurgeons, in addition
two pediatric orthopedic surgeons.
Our approach is team work to determine the best pathway,
and we have an excellent rehabilitation program.
This team approach for us I think is the biggest
strength that Johns Hopkins has in helping children
with cerebral palsy.
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