Gait before and 10 years after rhizotomy in children with cerebral palsy spasticity.

OBJECT: Selective dorsal rhizotomy is a neurosurgical procedure performed for the relief of spasticity in children with cerebral palsy, but its long-term functional efficacy is still unknown. The authors sought to address this issue by means of an objective, prospective study in which quantitative gait analysis was used. METHODS: Eleven children with spastic diplegia (mean age at initial surgery 7.8 years) were evaluated preoperatively in 1985 and then at 1, 3, and at least 10 years after surgery. For comparison, 12 age-matched healthy individuals were also studied. Retroreflective targets were placed over the hip, knee, and ankle joints, and each individual's gait was videotaped. The video data were subsequently entered into a computer for extraction and analysis of the gait parameters. An analysis of variance yielded a significant time effect (p < 0.05), and post hoc comparisons revealed differences before and after surgery and with respect to the healthy volunteers. The knee and hip ranges of motion (59 degrees and 44 degrees, respectively, for healthy volunteers) were significantly restricted in children with spastic diplegia prior to surgery (41 degrees and 41 degrees, respectively), but were within normal limits after 10 years (52 degrees and 45 degrees, respectively). The knee and hip midrange values (31 degrees and 3 degrees, respectively, for healthy volunteers), indicative of posture, were significantly elevated preoperatively (42 degrees and 15 degrees) and increased sharply at 1 year (56 degrees and 18 degrees), but by 10 years they had decreased to within normal limits (36 degrees and 9 degrees). Step length and velocity improved postoperatively but were not within the normal range after 10 years. Ten years after surgery these patients not only had increased ranges of motion, but also used that movement at approximately a normal midrange point. CONCLUSIONS: Selective dorsal rhizotomy is an effective method for alleviating spasticity. Furthermore, the authors provide evidence to show that lasting functional benefits, as measured by improved gait, can also be obtained.

Experience with botulinum toxin in the treatment of cerebral palsy.

OBJECTIVES: To assess the effect of botulinum toxin on dynamic spasticity and dystonic posturing in children with cerebral palsy. DESIGN: Assessment and documentation of the motor disability of children with cerebral palsy followed by injection of botulinum toxin into selected muscle groups. Reassessment of motor function after injection. SUBJECTS: Fifteen children with cerebral palsy: 5 with dynamic spasticity, 5 with dystonia and 5 with a mixed picture. RESULTS: On a standard scoring system, 13 of the children showed improved function at reassessment. CONCLUSION: Intramuscular injection of botulinum toxin is effective in the treatment of selected children with spastic and dystonic forms of cerebral palsy. Improvement is not permanent, but the injection can be repeated.

Selective posterior lumbosacral rhizotomy in teenagers and young adults with spastic cerebral palsy.

The outcome of 30 teenagers and young adults who have had selective posterior lumbosacral rhizotomy for cerebral palsy spasticity was analysed. This age group was selected because the full benefits of physiotherapy and maturation of the central nervous system would be likely to have accrued prior to rhizotomy and the post-operative function could be related more directly to the surgery per se. All 30 patients had satisfactory long-term tone reduction, sitting and standing were improved in 21 and 17, respectively, and walking patterns of the 25 of 26 spastic diplegic patients were improved. Five patients had dysaesthetic sensations in their legs and feet, and seven had patchy inconsistent areas of pin-prick loss which persisted for more than 2 years post-operatively. Touch was preserved in all cases and there were no patients with incontinence. Twenty-three patients were unequivocally positive about the benefits of this procedure.

Selective posterior lumbosacral rhizotomy for the management of cerebral palsy spasticity. A 10-year experience.

One hundred and sixty-eight patients had selective lumbosacral posterior rhizotomies for the treatment of cerebral palsy spasticity at Red Cross War Memorial Children's Hospital and Groote Schuur Hospital during the 10-year period 1981-1991. There was no mortality and insignificant early postoperative morbidity. Long-term follow-up on 110 patients has revealed satisfactory tone reduction in 95% of cases. The majority showed improvement in standing, sitting and locomotion. Thirteen patients had minor persistent sensory disturbances and 20% have developed asymptomatic spondylolysis or grade I spondylolisthesis. Most therapists, patients and parents remain enthusiastic about the results of this procedure.

Spondylolysis and spondylolisthesis after five-level lumbosacral laminectomy for selective posterior rhizotomy in cerebral palsy.

Of 163 children who have undergone five-level lumbosacral laminectomies for selective posterior rhizotomy, 20% of those re-X-rayed post-operatively (19/99) have developed incidental isthmic spondylolysis or grade I spondylolisthesis. The majority of patients were ambulatory, active, spastic diplegics. There were five children with isthmic defects at L3-4, three at L4-5 and 11 at L5-S1. Six of the 19 children had grade I spondylolisthesis, but none were symptomatic nor has there been any evidence of further slipping to date. It is postulated that the laminectomy, associated lordosis and increased mobility after rhizotomy may be factors in the causation.

Causes of mental handicap in Cape Town.

A cross-cultural study of the cause of the mental handicap of greater than 1,000 children born in the Cape Town area between 1974 and 1986 was carried out. Acquired causes were noted to be more prevalent among the black ethnic group. This study showed that at least 80-100 additional cases of moderate-severe mental handicap can be expected in the Cape Town area each year. Attention is drawn to the expanded facilities that will be required to provide for the ongoing special needs of these children. Possible areas for prevention of mental handicap are discussed.

Incidence of spinal deformity in children after multiple level laminectomy for selective posterior rhizotomy.

Fifty-five children with cerebral palsy had multiple-level laminectomies for selective posterior rhizotomies for the relief of spasticity. They were followed up clinically and radiologically to assess their spinal stability and the possible development of post-laminectomy deformity of the spine. The majority of the deformities found were related to cerebral palsy and did not appear to be due to the laminectomy: 16% had scoliosis, 5% kyphosis, 7% lordosis, and 9% spondylolysis/spondylolisthesis. Spondylolysis is the only abnormality that appeared to be more common in this group than in children with cerebral palsy.

Selective posterior rhizotomy: a long-term follow-up study.

Fifty-one spastic children who had undergone selective posterior lumbar rhizotomy between 1981 and 1984 were re-examined to determine whether the gains achieved had persisted and to look at other aspects that had not previously been explored in detail. The reduction of tone was maintained in all cases, while motor function continued to improve in 42 cases. Functional gains were greatest in children operated on under the age of 8, but pleasing results were also achieved in older children. Forty-five children continued to receive physiotherapy, particular attention being paid to building up muscle strength. Sensory disturbances were minimal, and there was no evidence of spinal instability. Post-rhizotomy orthopaedic surgery for fixed-joint contractures generally brought further improvement. Parents and older children were also questioned and almost all were enthusiastic about the outcome. Rhizotomy can be of considerable benefit to spastic children, but great care must be taken in the selection of suitable cases.

A comparative study of postnatally-acquired cerebral palsy in Cape Town.

The importance of socio-economic conditions in the causation of postnatally-acquired cerebral palsy has not been stressed in previous studies. A comparative survey was undertaken in Cape Town, South Africa. Three ethnic groups were compared--white, coloured (mixed ancestry) and black. The percentage of postnatally-acquired cerebral palsy in these groups was 13.2, 24.0 and 36.1 per cent, respectively. These figures can be explained by the differing socio-economic conditions of each group, the white group belonging to the highest socio-economic stratum and the black group to the lowest. The main causes of postnatally-acquired cerebral palsy were cerebral infections (particularly meningitis), cerebral trauma and cerebrovascular accidents. The proportion in each group, the main causal factors, age at onset, types of cerebral palsy and intellectual status are similar to those of most previous studies.

Cerebral palsy spasticity. Selective posterior rhizotomy.

We have performed selective posterior rhizotomies on 60 children with cerebral palsy. The procedure involves lumbar laminectomy with stimulation of the rootlets (fascicles) of the second lumbar to the first sacral posterior roots bilaterally; those rootlets associated with an abnormal motor response, as evidenced by sustained or diffused muscular contraction, are divided leaving intact rootlets associated with a brief localized contraction. The patients were between 20 months and 19 years of age representing all degrees of physical handicap and ranging from profoundly retarded to normal intelligence. Follow-up has been from 1 to 5 years. Each child was assessed pre- and postoperatively and graded in the following categories: muscle tone, power, sitting, standing, walking, upper limb function, and speech. The patients whose function improved most dramatically following rhizotomy were purely spastic and intelligent, were significantly more affected by spasticity in the lower than the upper limbs, had some degree of forward locomotion, and could side-sit independently. Patients with severe athetosis or marked contractures improved least.

Ataxia-telangiectasia. X,14 translocation, progressive deterioration of lymphocyte numbers and function, and abnormal in vitro immunoglobulin production.

Three children with ataxia-telangiectasia have been followed up since their early childhood. Sequential immunological, biochemical and chromosome studies have been performed over the last 7 years. All the children showed progressive cerebellar ataxia and inexorable neurological deterioration. Further evidence for the progressive nature of this condition is the fall in lymphocyte counts, deterioration of lymphocyte transformation responses to mitogens, and an increase in chromosomal translocations and breakage. Elevated serum alpha-fetoprotein levels are a highly characteristic and useful diagnostic finding in this condition. Two of the patients had an X,14 translocation. In vitro studies of immunoglobulin synthesis suggest an intrinsic defect in B-cell synthesis as well as decreased helper T-cell activity. In spite of moderately severe and progressive abnormalities in the immune system, sinopulmonary infections have not been prominent in our patients.

Tuberculous meningitis in children in the Western Cape. Epidemiology and outcome.

The incidence of tuberculous meningitis in children was determined using hospital records as well as local authority notifications. One hundred and eighty-five cases occurred over a 3-year period. The age-specific incidence in the 0-14-year-old group was 7,5/100 000. In only 28 cases was the disease at an early stage when treatment was commenced. Young age and late-stage disease at presentation were associated with a poor outcome. The associated morbidity and mortality rates were high; the mortality rate was 24%, and nearly 50% of patients were left with a residual disability.

Selective posterior rhizotomy for the relief of spasticity in cerebral palsy.

Twenty children with increased muscle tone of cerebral origin have been subjected to selective posterior spinal rootlet section. A significant reduction in tone resulting in improvement in motor function was achieved in every case. The first 15 cases are reviewed in detail. The procedure is of value not only in the intelligent ambulant patient but also in the mentally retarded and severely spastic child because handling is facilitated and bladder and bowel control improved. Speech and hand function were improved in a number of patients in whom they had previously been major problems.

Cerebral palsy in Cape Town: A review of 389 coloured children.

Three hundred and eighty-nine Coloured cerebral palsied children were reviewed with regard to clinical type and its relationship to aetiological factors. There was no significant change in type or severity of case over two 6-year periods. Associated handicaps were also analysed, and the prevalence of these stresses the need for comprehensive assessment and treatment clinics so that multidisciplinary treatment can minimize the extent of the disabilities.