Effect of caudal block on sevoflurane requirement for lower limb surgery in children with cerebral palsy

Background: Caudal block is a widely used technique for providing perioperative pain management in children. In this randomized double‐blinded study, we evaluated the effects of preoperative caudal block on sevoflurane requirements in children with cerebral palsy (CP) undergoing lower limb surgery while bispectral index (BIS) values were maintained between 45 and 55. Methods: 52 children undergoing Achilles‐tendon lengthening were randomized to receive combined general–caudal anesthesia (caudal group, n = 27) or general anesthesia alone (control group, n = 25). Caudal block was performed with a single dose of 0.7 ml·kg^?1 of 1.0% lidocaine containing epinephrine at 5 μg·ml^?1. The control group received no preoperative caudal block. The endtidal sevoflurane concentrations (ET_sev) were adjusted every minute to maintain the BIS values between 45 and 55. Results: The ET_sev required to maintain the BIS values were not significantly different between the control and caudal groups after induction of anesthesia [2.1 (0.2) vs 2.2 (0.4); P = 0.773]. However, significantly higher ET_sev was observed in the control group before surgical incision [2.0 (0.2) vs 1.8 (0.3); P = 0.013] and during the first 20 min after surgical incision [2.2 (0.3) vs 1.4 (0.3); P < 0.001]. There was no significant difference in BIS values between the control and caudal groups throughout the study period (P > 0.05). In the caudal group, the caudal block was successful in 25 of 27 (92.6%) patients. Conclusions: Caudal block effectively reduced sevoflurane requirements by 36% compared to general anesthesia alone in children with CP undergoing lower limb surgery while BIS values were maintained between 45 and 55.     

Oculomotor nerve palsy in patients with cerebral aneurysms

Twenty-six patients with oculomotor nerve palsy due to cerebral aneurysms were examined. There were six males and twenty females with a mean age of 55 years. 25 of the 26 aneurysms were located at the junction of the internal carotid and the posterior communicating artery and one was at the junction of the basilar artery and the superior cerebellar artery. Twelve patients had associated subarachnoid hemorrhage (SAH); the other 14 did not. The initial symptoms in many patients were ptosis and double vision. Twenty-one of the patients had total oculomotor nerve palsy, one had a sparing of medial rectus muscle; three patients had only ptosis and anisocoria, and one had oculomotor nerve palsy with pupillary sparing. All aneurysms, including giant aneurysms, were clipped under a microscope, and six oculomotor nerves were found to be decompressed at surgery. The follow-up periods were from six months to three years. Nine patients had a complete recovery of oculomotor function; thirteen had an incomplete recovery; and four remained unchanged. The mean interval between the onset of palsy and the time of surgery was 24 days in complete recovery cases, 42 days in incomplete recovery cases, and 119 days in unchanged cases. The recovery of oculomotor function started with the levator palpebrae muscle and followed by the medial rectus muscle. The recovery of pupillary function was, however, not consistent. Of the factors influencing recovery from oculomotor nerve palsy, the interval between the onset of palsy and the time of surgery was most important. Therefore, aneurysms with oculomotor nerve palsy should be operated on as early as possible, regardless of the presence or absence of SAH.     

Treatment of femur fractures in children with cerebral palsy

Purpose  Children with cerebral palsy may have low bone density stemming from various etiologies and are, thereby, at risk for fractures. The treatment of femur fractures in children with cerebral palsy may need to be tailored to address the management of spastic muscle tone and multiple medical co-morbidities. Methods  Our study is a retrospective review that evaluates the treatment of 47 femur fractures in children with cerebral palsy in both ambulatory and non-ambulatory patients. Results  Thirty-two fractures in non-ambulators were treated non-operatively, 11 of which resulted in malunions and five developed pressure sores. Six fractures in non-ambulators were treated operatively, one of which resulted in a malunion. In ambulators, five fractures were treated non-operatively; one of these fractures lost reduction after 2 weeks and required surgical intervention. One of four fractures in ambulators treated operatively developed a malunion. Conclusion  Our study results suggest that femur fractures in children with cerebral palsy can be treated non-operatively; however, because of the high risk of malunion in this patient population, fracture alignment needs to be followed closely during healing. Careful attention during casting is necessary to prevent pressure sores. Strong consideration should be given to initial operative treatment in ambulatory patients in order to preserve function.     

运动疗法在脑瘫儿童选择性脊神经后根切断术后康复中的应用

目的：分析运动疗法在脑瘫儿童选择性脊神经后根切断术后康复中的临床疗效,为脑瘫儿童的康复提供可靠方法。方法：2003年9月至2007年4月脑瘫患儿226例,男125例,女101例;年龄3～10岁,平均6．8岁;随机分为对照组113例和治疗组113例。治疗组：男66例,女47例;年龄3-8岁,平均（6．5±1．2）岁;采用选择性脊神经后根切断术同时辅以运动疗法。,对照组：男59例,女54例;年龄3～10岁,平均（6．9±1．5）岁;采用选择性脊神经后根切断术。两组治疗前后采用小儿脑瘫粗大运动功能测试量表（CMFM）、肌张力评分、被动关节活动度进行评估。结果：226例均获随访,时间6～18个月,平均8个月。治疗后组间进行比较：治疗组GMFM得分平均（134．29±46．43）分,高于对照组（P〈0．05）;肌张力评分平均（1．27±0．42）分,优于对照组（P〈0．05）;关节活动度中踝背屈角度平均（14．2±3．1）°,大于对照组（P〈0．05）。结论：运动疗法在脑瘫儿童SPR术后康复中具有明显效果,有助于减轻痉挛状态、降低肌张力、改善脑瘫儿童的运动功能。     

Botulinum toxin A treatment of the lower extremities in children with cerebral palsy

Objectives

In the last 2 decades, BTX-A is increasingly being used in the management of spasticity in children with Cerebral Palsy (CP) and there is no doubt about its effect on range of motion, spasticity reduction and gait pattern in this patient population. However, in daily practice, there is still an ongoing search for the best way to apply BTX-A. Two studies were set up to evaluate how successful an integrated multilevel treatment approach is in children with CP. The first study identifies crucial factors within the treatment strategy which may predict the outcome. The second study evaluates the efficacy of repeated BTX-A injections.

Methods

Patient selection was based on following criteria: diagnosis of CP, lower limb BTX-A treatment, age at time of treatment <24 years, no combined surgery at the time of BTX-A injections, 3D gait analysis and clinical evaluation pre and 2 months post BTX-A injections. The first study included the last treatment of 577 patients. In the second study, the first and last BTX-A treatment of 222 children were included. The Goal Attainment Scale (GAS) was used to evaluate the functional outcome of each treatment session.

Results

In the first study, the mean GAS score of the total group was 51.7 (±7.5). Considering a converted total score of 50 as cut-off score for successful treatment, 67.1 % of the treatments were successful. Significantly higher GAS scores were found in mildly involved children compared to more involved children (p < 0.0001) and for multilevel injections or injections in the distal muscle groups only compared to injections in the proximal muscles of the lower limb only (p < 0.0001). Other crucial factors for a successful outcome were amount of physical therapy per week (p=0.0026), post injection casting (p=0.005) and frequency of using day and night orthoses after injection (p < 0.0001). In the second study, the mean GAS score of the total group decreased from 54.8 (±6.8) at the first treatment to 50.7 (±6.9) at the last treatment, indicating that on average, repeated BTX-A treatment is successful.

Conclusion

The integrated multilevel BTX-A approach is successful in children with CP. Several factors might help the clinician to select patients that are most likely to benefit from the treatment, to assure the most optimal treatment strategy and to predict the outcome. Each treatment should be carefully planned and goals should be well chosen, because the effectiveness of the BTX-A treatment may decrease with increasing number of treatments in the same patient.     

点穴疗法治疗产伤性痉挛型脑瘫疗效评价

目的:通过点穴治疗痉挛型脑瘫的临床观察,探讨中医治疗脑瘫疗效的评价方法。方法:40 例痉挛型脑瘫患儿,男23例,女17例;年龄:1-3岁15例,4-6岁18例,7-9岁5例,10-12岁2例。将患儿的智力、语言、流涎、手持物、拇指内收、翻身、坐、站立、行走、剪刀腿10项指标分为正常、轻度、中度、重度异常(障碍)4级,分别评6、4、2、0分,治疗后每项每改善1级得2分;同时记录治疗前后肩外展、伸肘、伸腕、前臂旋后、髋外展、下肢直腿抬高、伸膝、踝背伸的度数并进行评分,治疗后挛缩关节活动度改善大于10°、15°、20°、25°、30°者,分别得1、2、3、4、5分。结果:18个观察项目除智力外,其余各项治疗前后有明显差异,治疗后改善明显(P<0.01),根据疗效评定标准:优5例,良17例,中15例,差3例。有效率92.5％。结论:制定的疗效评价标准能较好反映患者功能改善情况。     

Sacral neuromodulation and lower urinary tract dysfunction in cerebral palsy

Given the emerging role of sacral neuromodulation in treatment of neurogenic voiding dysfunction, the author describes the use of sacral neuromodulation in a patient with voiding dysfunction caused by cerebral palsy (CP). A 45-year-old patient with cerebral palsy presented with progressive complaints of urgency and overflow incontinence and was found to be in retention. She underwent sacral neuromodulation and had complete resolution of her symptoms. The literature of lower urinary tract dysfunction in CP is reviewed. It is concluded that sacral neuromodulation may be a valuable tool in treating storage and voiding disorders associated with CP.     

Overview of foot deformity management in children with cerebral palsy

Foot deformities in children with cerebral palsy are common. The natural history of the deformities of the feet is very variable and very unpredictable in young children less then 5 years old. Treatment for the young children should be primarily with orthotics and manual therapy. Equinus is the most common deformity, with orthotics augmented with botulinum toxin being the primary management in young children. When fixed deformity develops lengthening only the muscle which is contracted is preferred. Varus deformity of the feet is often associated with equinus, and can almost always be managed with orthotics until 8 or 10 years of age. Planovalgus is the most common deformity in children with bilateral lower extremity spasticity. The primary management is orthotics until the child no longer tolerates the orthotic; then surgical management needs to consider all the deformities and all should be corrected. This requires correcting the subtalor subluxation with calcaneal lengthening or fusion, medial midfoot correction with osteotomy or fusion.     

点穴推拿治疗痉挛型脑瘫的临床观察

小儿脑瘫是小儿发育期的非进行性脑损伤综合征，主要表现为中枢性运动障碍及姿势异常，经常伴有其他多种残疾。是儿科疾病中常见的一种疑难病症。从1996年至今运用点穴、推拿、穴位注射、运动疗法综合治疗640例患儿，取得较好的效果，现报告如下。     

选择性颈段脊神经后根部分切断椎体侧块内固定配合运动疗法治疗脑性瘫引起的上肢痉挛型瘫

目的：探讨采用选择性颈段脊神经后根部分切断椎体侧块内固定配合运动疗法治疗脑性瘫引起的上肢痉挛型瘫的可行性及疗效。方法：自2004年3月至2008年4月,采用选择性颈段脊神经后根部分切断椎体侧块内固定配合运动疗法对27例上肢痉挛的脑瘫患者进行治疗,其中男19例,女8例;年龄13～21岁,平均15岁。手术方式为以AXIS8孔钛板依次植入颈椎侧块,在神经刺激仪指导下挑选阈值低神经后根的小束,将其切断并切除1.5cm。术后2周拆线后进行运动疗法训练。训练内容包括卧位姿势、翻身、坐位、爬行、跪立位及站立位、行走等练习,其中鲍巴斯（Bobath）抑制异常痉挛模式手法贯穿训练的全过程。治疗后对肌张力、运动功能（GMFM）和功能独立性（WeeFIM）进行评分。结果：27例均获得随访,时间4～16个月,平均6个月。治疗前后肌张力评分分别为3.30±0.47和1.25±0.44,GMFM评分分别为107.82±55.17和131.28±46.45,WeeFIM评分分别为57.61±25.51和87.91±22.39,治疗后患者的肌张力、运动功能和功能独立性均有所改善（P〈0.01）。结论：选择性颈段脊神经后根部分切断椎体侧块内固定配合运动疗法治疗脑性瘫引起的上肢痉挛型瘫能明显降低患者的肌张力、改善运动功能,是一种安全有效的治疗方法,值得进一步推广。     

选择性脊神经后根切断术对脑瘫患儿膀胱功能的影响

目的：探讨功能性选择性脊神经后根切除术,（F－SPR）对脑瘫儿童膀胱功能的影响,方法：本组病例为行F－SPR的脑瘫儿童97例,术前1周和术后6个月行膀胱平均功能容量（AFBV）测定和尿液动力学检查。结果：痉挛型脑瘫术前下尿路症状（LUTS）发生率为34．24％,混合型发生率为58．33％;术后分别下降至20．54％和29．165。尿流动力学检查36例中术前26例（72．22％存在尿流动力学指标异常,其中18例（69．23％）无临床症状,AFBV和尿流动力学指标术后改善明显,I2－S1节段SPR较L5－S1节段SPR改善明显。结论：约50％脑瘫儿童合并有临床静止性膀胱功能障碍。F－SPR在有效缓解下肢痉挛的同时,可改善膀胱贮尿功能,减少上尿道并发症。     

C8神经根切断治疗上肢脑瘫的重新评价

目的 重新评价C8神经根切断治疗上肢脑瘫的疗效。方法 对6例C8神经根切断治疗上肢脑瘫的患者进行术后6个月至5年以上的功能随访，并对同期2例患者进行肌腱切断与移位的术后功能进行评价。结果 6例C8神经根切断治疗上肢脑瘫仅短时间内有效（术后10～30d），长期无效。1例单纯切断痉挛肌腱短期内关节能放松（1～3个月），长期无效。1例痉挛肌腱切断后移位至松弛肌，腕手功能明显好转，并长期有效。结论 经长期随访，C8神经根切断治疗上肢脑瘫是无效的手术方法。经典的切断痉挛肌腱，并移位于无力肌腱是可靠的治疗方法。     

SPR治疗脑瘫手术前后上肢微循环变化的观测

目的 :探讨腰骶段选择性脊神经后根切断术 (SPR)治疗痉挛型脑瘫 ,上肢甲襞微循环的变化。方法 :用国产XG -8多媒体多功能微循环检测仪 ,观察腰骶段SPR治疗脑瘫手术前后上肢微循环的变化。结果 :手术后患儿甲襞微循环较术前明显改善。结论 :腰骶段SPR治疗能改善上肢微循环     

Changes in gait patterns after operations in children with spastic cerebral palsy

Summary We have utilised a scoring system with the aid of a specially designed worksheet to measure gait ability in spastic children with cerebral palsy before and after corrective soft tissue operations. Postoperatively, there were obvious improvements in gait especially in the mobility of the leg and the foot. Comparison between a visually assessed score and objectively recorded values using foot-switches showed a good correlation. The postoperative improvement was most obvious in hemiplegic children, but was also present in diplegic children following both single and complex one-stage operations.

---

Résumé Afin de mesurer les possibilités de marche chez les enfants spastiques atteints de paralysie cérébrale, nous avons utilisé une cotation obtenue grâce à une abaque spécialement réalisée pour cette investigation. Les mesures ont été faites avant et après les opérations correctrices portant sur les parties molles.En post-opératoire on a noté une amélioration indiscutable de la marche, notamment en ce qui concernait la mobilité de la jambe et du pied. La comparaison entre l'estimation visuelle et les enregistrements objectifs a montré une bonne corrélation. L'amélioration post-opératoire est plus marquée chez les enfants hémiplégiques, mais elle existe aussi chez les enfants diplégiques, tant après des interventions simples que complexes.

     

胫神经肌支切断术治疗脑瘫痉挛性马蹄内翻足

目的：评价胫神经肌支切断术治疗脑瘫痉挛性马蹄内翻足的疗效。方法：52例痉挛型脑瘫SPR术后马蹄内翻足畸形患者,男33例（38足）,女19例（26足）;年龄6～10岁,平均7.8岁。Ashworsh分级：Ⅲ级34例,Ⅳ级18例;踝阵挛阳性者42例。采用胫神经肌支切断术治疗。结果：随访1～3年,平均2.6年,痉挛步态明显改善,畸形均无复发。根据足部畸形矫正程度及患者的满意程度进行综合判定：优32例,良14例,差6例。结论：胫神经肌支切断术治疗小儿脑瘫痉挛性马蹄内翻足是一种安全、有效的手术方法。     

选择性限制性脊神经后根切断术后脑瘫患儿腰椎稳定性的变化

目的观察痉挛型脑瘫患儿选择性限制性脊神经后根切断术(limitedselectiveposteriorrhizotomy,LSPR)后,腰椎稳定性、切除椎板再生及脊柱生长发育情况。方法将125例痉挛型脑瘫患儿根据年龄(<8岁、≥8岁)及手术方式(软组织矫形手术、LSPR手术、软组织矫形 LSPR手术)分组。在手术前、后及随访时,分别摄站立位及动力位腰椎正侧位X线片,测量手术前、后腰骶角、L5S1矢状位椎体位移率等指标。分析比较各组之间及手术前、后各项指标的差异。观察术后切除椎板再生及脊柱生长发育情况。结果(1)软组织矫形手术组手术前、后各项指标差异无统计学意义;(2)LSPR组及软组织矫形 LSPR手术组手术前、后各项指标差异显著;(3)行LSPR手术的<8岁组手术前后各项指标差异有统计学意义,≥8岁组手术前后仅L5S1矢状位椎体位移率差异显著;(4)LSPR术后发现L5S1Ⅰ度滑脱3例(3.90%),脊柱侧凸4例(5.19%,Cobb角15°～34°),腰椎前凸3例(3.90%);(5)LSPR术后见切除椎板部分再生。结论LSPR手术对脑瘫患儿腰椎稳定性有一定影响,但不是惟一的因素。儿童LSPR术后,切除的椎板有再生能力。Lumbar stabilityobservationofchildrenwith cerebralpalsyafterlimitedselectiveposteriorrhizoto-my YANG Chao,WANG Qiu-gen,ZHANG Qiu-lin,etal.Department     

Pes planovalgus deformity surgical correction in ambulatory children with cerebral palsy

Purpose

Planovalgus foot deformity is common in diplegic and quadriplegic patients. Surgery is the definitive treatment to restore the alignment of the talus, calcaneus, and navicular bones. We aimed, in the current study, to compare the effectiveness of subtalar fusion and calcaneal lengthening, and to assess the recurrence in ambulatory children with cerebral palsy.

Methods

This is a retrospective study of 78 patients (138 feet diagnosed with planovalgus deformity) who underwent surgical correction using subtalar fusion or calcaneal lengthening. Range of motion, radiographic indices, kinematic, and pedobarographic data were used to examine the deformity and the outcome of surgery. A repeated measures analysis of variance (ANOVA) was used to test the study hypothesis.

Results

Most of the patients were diplegic (87.2 %) and the mean age at surgery was 11.9 ± 2.9 years (range from 4.7 to 18.3 years), with a mean follow-up of 5 ± 4.4 years (range from 1 to 15.4 years). Sixty-three feet were treated with calcaneal lengthening, while 75 were treated with subtalar fusion. The feet treated with subtalar fusion were more severe preoperatively. However, both surgery groups showed improvement postoperatively. Among 12 cases of recurrence, medial column fusion was the main surgery performed to correct the deformity.

Conclusions

Surgery is effective in the treatment of planovalgus deformity in ambulatory children with cerebral palsy. Severe and rigid planovalgus feet can be treated effectively with subtalar fusion. Feet with milder deformity show good results, with calcaneal lengthening. Surgery provides good correction in young patients, but there is a higher recurrence rate.

Electronic supplementary material

The online version of this article (doi:10.1007/s11832-012-0413-3) contains supplementary material, which is available to authorized users.     

脑性瘫痪周围神经及骨骼肌亚显微病变研究

目的 探讨痉挛性脑竣周围神经及骨骼肌的病理改变特点。方法 取材于２５例临床确诊为痉挛性脑竣患者的周围神经及骨骼肌组织,进行术中大体观察、光镜和电镜观察。结果 大体观察基本正常,光镜下,骨骼肌纤维有集簇性变性、结缔组织增生,观察到的肌梭结构尚好。电镜下,周围神经广泛脱髓鞘病变,Ｓｃｈｗａｎｎ细胞病变先于并严惩于轴索;有髓纤维病变重于无髓纤维。神经束膜内微血管财有淋巴细胞浸润;骨骼肌纤维线粒体多,三联     

Correction versus bedding: wheelchair pressure distribution measurements in children with cerebral palsy

Purpose  

Most children with cerebral palsy classification Levels IV and V in the Gross Motor Function Classification System (GMFCS) are unable to walk and, therefore, spend almost all day in a sitting position in their wheelchairs. As a result of the spastic muscle contraction, malpositions of joints or a scoliosis develop, which require a decision to be made on whether to correct the posture or simply find the best soft bedding position.