Cerebral palsy (CP) is a broad term for problems of movement or muscles caused by a brain injury or malformation early in development. The injury or malformation that causes CP is not progressive—that is, it will not worsen over the course of a lifetime. At the same time, unfortunately, the injury is not curable. The effects of cerebral palsy can often be managed with an individualized combination of therapy, medication, assistive technology,and/or surgery.
At Columbia Neurosurgery, we provide two types of surgery to help manage the spasticity that can be associated with cerebral palsy.
Cerebral palsy is very different from person to person. The type, severity and location of symptoms can vary widely.
- Type: Muscles may be unusually lax or tense; reflexes may be overactive; muscles may experience tremors or athetosis. Spasticity is a common presentation involving rigid muscles and overactive reflexes.
- Severity: Symptoms may range from mild tremor to complete muscle rigidity and paralysis.
- Location: CP may affect all limbs, or only the left or right, or only the upper or lower. Limbs may be affected to different degrees. Muscles of the trunk may also be involved. CP also often affects the muscles of the mouth and throat, which can lead to difficulty communicating or receiving adequate nutrition.
The brain injury or malformation that causes cerebral palsy may also cause other conditions, such as epilepsy, learning disabilities or mental retardation, bone abnormalities, bowel or bladder problems, or respiratory problems.
Each individual with CP must be evaluated carefully to determine his or her own individual capabilities and symptoms. Each plan to address those symptoms must be tailored to meet each individual’s needs.
The diagnosis is usually made between 6 and 24 months of age, as children fail to hit developmental milestones. Parents or caregivers may notice seizures, abnormal muscle tone, difficulty feeding, failure to sit up unassisted, lopsided crawling, or failure to meet other motor milestones.
The diagnosis of CP is made with a physical examination. During the examination, the physician obtains a complete prenatal and birth history of the child. The doctor will carefully review a child’s motor development.
Blood may be drawn to look for metabolic disorders or blood clotting disorders.
Imaging scans of the brain may be performed to look for damage, structural problems or other conditions. The quick and painless ultrasound scan can be performed during infancy when the skull is soft. It does not provide great detail, however. An MRI is usually the imaging scan of choice. It provides great detail and is also painless, but it is not quick. It requires a child to lie still inside an MRI scanner, which may be noisy. Young children are usually sedated for an MRI.
If seizures are suspected, an electroencephalogram (EEG) may be performed. This test uses devices placed on the scalp to measure electrical activity in the brain.
Cerebral palsy can be caused by a great number of factors, including structural abnormalities of the brain; a lack of oxygen before, during or after birth; infection; toxin; prematurity; intrauterine growth restriction and more.
In the past, it was believed that CP was usually caused by problems during birth. Today, research shows that problems during birth account for about 10 percent of cases. It is estimated that 70 to 80 percent of CP cases are due to events or problems during fetal development. However, often the exact cause is never known. Indeed, there may be several factors involved.
Over the last 40 years of research, despite astounding medical advances in the care of mothers, infants and young children, the incidence of CP has not changed. Its incidence is estimated at two to three per 1,000 live births.
Risk factors for CP include the following:
- Very low birth weight
- Chemical/substance abuse during pregnancy
- Bleeding in the brain
- Complications of labor and delivery
Management includes preventing or minimizing deformities and maximizing capability at home and in the community. An individual with CP is best treated with an interdisciplinary team that may include a nurse coordinator, neurologist, physical therapist, occupational therapist, orthopedic surgeon, and/or neurosurgeon.
Nonsurgical interventions may include rehabilitation, positioning aids, braces and splints, and medications. Surgical interventions may include orthopedic surgery for hip dislocations, ankle and foot deformities, and contracted muscles, or neurosurgery to reduce spasticity.
There are two neurosurgical treatments aimed at reducing spasticity from cerebral palsy.
- Selective dorsal rhizotomy is a procedure in which the neurosurgeon tests nerve fibers near the spinal column, cutting the ones most responsible for a patient’s spasticity. Selective dorsal rhizotomy is most effective in younger pediatric patients and is especially helpful in lower limb function. Depending on the individual, the goal of the procedure may be to improve a child’s walking (in children who can take at least a few steps unassisted already) or to make it easier for a child to sit for longer periods of time, allowing him or her to, for example, use a wheelchair more effectively.
- Intrathecal baclofen pumps deliver small amounts of the medication baclofen directly to the thecal sac around the spinal cord. This procedure is effective in adults or children. Baclofen is an anti-spasticity medication that works on the central nervous system. When it is delivered directly into the thecal sac, more of the medication reaches the nerves, where it can be more effective. At the same time, less of the medication is circulating elsewhere in the body, which reduces side effects.