DOCUMENTATION OF COMPLICATIONS FOLLOWING MULTILEVEL SURGERIES IN CEREBRAL PALSY

*Gayatri Ajay Upadhyay, **Ajay Kumar Upadhyay, ***Krishna N. Sharma

ABSTRACT Purpose: The aim of the study is to document the complications following multilevel surgeries done in cerebral palsy in order to determine risk factors that would correlate with the post-operative complications. Design: Retrospective study. Setting: D.L.S. Institute for Health & Wellness, U.P, India Methodology: One hundred and ten children with cerebral palsy who underwent multilevel surgeries were studied retrospectively to document the post-operative complications and determine risk factors that would correlate with postoperative complications. Except for seven who left the rehabilitation, all of the children had six months of follow up. Results: Fifteen patients had at least one complication. 56 had myofascial pain syndrome, 39 patients had post-operative joint stiffness, 23 had osteoporosis, 12 sustained pathological fractures, 10 had anterior knee pain, 8 suffered meralgia paresthetica, 5 had hypertrophic scar, 3 had bed sores, 3 had patellar tendinitis, 3 had rickets, 2 had electrical burns, 2 had wound infection, 1 patient had complex regional pain syndrome, 2 had myositis ossificans, 1 had axillary nerve palsy. All were managed with appropriate treatment at the centre. Conclusion: In conclusion, documentation can help prevent the risk of complications after multilevel surgeries in cerebral palsy. A nonambulatory patient is at even greater risk. Fortunately the fractures and ulcers observed in this series healed uneventfully with no operative intervention. Clinical relevance of the study: To document the Complications following Multilevel Surgery in cerebral palsy children which have not yet been done well in the literature.

KEYWORDS: Cerebral palsy, Complications, Multilevel Surgery

1

INTRODUCTION

procedure,

requiring

only

one

hospital

Orthopedic surgery has a major role to play in minimizing the impairments and activity limitations associated with the development of musculoskeletal pathology in children with cerebral palsy (CP)1. CP can be considered to be a neuromusculoskeletal disorder2. Once the neurological impairments associated with CP are expressed, progressive musculoskeletal pathology develops to some degree in the affected limbs of the majority of children. Subtle degrees of muscletendon contractures seem to be the result of differential growth impairment of the muscletendon units, in relation to long-bone growth.
2-4

admission and one period of rehabilitation.5-8 This is variously described as multilevel surgery, gait-improvement surgery and, most frequently, single-event multilevel surgery to distinguish it from the birthday syndrome approach of the past.8 The main musculoskeletal problems which prevent the CP patients from functional activities, mobility, ADL and gait are

spasticity and lever arm dysfunction. It needs a complex but goal oriented surgical

procedure followed by a sequenced postoperative rehabilitation protocol. Complications with surgical procedures are common. Since multilevel surgeries are addressing musculoskeletal problems in

More severe

contractures are found in more severely involved children and may be more related to lack of mobility than to spastic hypertonia.2 In addition to soft-tissue involvement, the

multiple levels, the extent of complications are also high. The amount of discomfort and problems following surgery depends on the type of surgery performed. Sometimes

prevalence of torsion in long bones, and joint instability, is also high.2,5 The secondary musculoskeletal pathology contributes to gait impairments, fatigue, activity limitations, and participation restrictions.5 Orthopedic procedures have been designed to address the various components of the progressive including musculoskeletal tendon lengthenings,
5,6,7

complications can occur following surgery. However, individuals may experience

complications and discomforts differently. Complications following Multilevel Surgery in cerebral palsy children have not been documented well in the literature. The goal of the current study was to document and analyze the complications following multilevel

pathology tendon

transfers, rotational osteotomies, and joint stabilization procedures. More recently,

surgeries in children with cerebral palsy. Methods and Methodology After IRB approval, a retrospective review was performed to identify all complications
2

single-level surgery has been replaced by the concept of multilevel surgery in which multiple levels of musculoskeletal pathology, in both lower limbs during one operative

Scientific Research Journal of India Volume: 3, Issue: 1, Year: 2014

following multilevel surgeries during the postsurgical rehabilitation by the authors from 2008-2013. 110 cerebral palsy subjects who underwent multilevel surgery were studied for the complications following the surgery. The present study analyzed the complications during post-surgical rehabilitation following multilevel surgery during a period of 5 years (2008-2013). All 110 children underwent multilevel surgeries followed by physical therapy for at least 6 months. For all of the patients, this therapy was accomplished as outpatients at the D.L.S. Institute for Health & Wellness, Mau. The therapists maintained a very high index of suspicion for any complication notified. Any erythema or swelling around the joints was assured if fracture. RESULTS Complications during post-surgical

syndrome, 2 had myositis ossificans, 1 had axillary nerve palsy. All were managed with appropriate treatment at the centre. DISCUSSION Complications with surgical procedures are common. Patients with cerebral palsy who undergo osteotomies surgical are at reconstruction significant risk with of

complications. The risk of complications following an osteotomy is significantly greater in the non-ambulatory population, and in a recent series a 69 percent complication rate was noted. Since multilevel surgeries are addressing musculoskeletal problems in

multilevel, the extent of complications were also high. The amount of discomfort and problems following surgery depended on the type of surgery performed. Sometimes

complications occurred following surgery. However, individuals experience

rehabilitation following multilevel surgeries during a period of 5 years (2008-2013) were analyzed. The range of the age of patients who underwent multilevel surgeries was 3- 20. The commonest complications was myofascial pain syndrome and post-operative joint

complications and discomforts differently. Pain after any orthopedic surgery is a recognized complication found to have an adverse impact on patient's quality of life, increasing psychosocial distress. We have noted many cases of myofascial pain

stiffness. 56 had myofascial pain syndrome, 39 patients had post-operative joint stiffness, 23 had osteoporosis, 12 sustained pathological fractures, 10 had anterior knee pain, 8 suffered meralgia paresthetica, 5 had hypertrophic scar, 3 had bed sores, 3 had patellar tendinitis, 3 had rickets, 2 had electrical burns, 2 had wound infection, 1 patient had complex regional pain
3

syndrome as a cause of postsurgery pain. Myofascial pain syndrome is a regional pain syndrome characterized by myofascial trigger points in palpable taut bands of skeletal muscle that refers pain a distance, and that can cause distant motor and autonomic effects. 56 out of the 103 patients with complications (54.36%) experienced MPS, the majority

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having onset within the first 6 months after surgery. This high incidence supports the need for identifying and treating the often

results in the control of pain of our patients by means of a specific physical therapy treatment of MTPs, the fact that we did not have a control group to evaluate the effectiveness of our treatment does not allow any conclusion to be drawn regarding this issue. Controlled studies with longer follow-up are needed to evaluate the effectiveness of different specific treatments of MPS in these patients to be certain about the real contribution of MTPs to their pain.26 The second most frequent complication was joint stiffness, which occurred in 39 patients (37.86%) and was characterized as diminished ROM after 4 weeks of surgery. Stiffness in knee and ankle joints is a common

underdiagnosed and misdiagnosed MPS found in these patients. Most patients with MPS had active MTPs in muscles of the shoulder girdle. This would be expected since the most likely activation factors in these patients would be related to positioning of the shoulder during surgery, maintaining muscles in a shortened position after surgery, the surgical scar, the manipulation, and excision of forearm fascia during surgery or the adaptation of upper extremity movement after surgery. There are at least 2 possible reasons to explain the tightness that is often found in the major muscle after surgery: (1) Immobilization and (2) the positioning of the arm in abduction and external rotation during surgery. The patients efforts to inhibit movement causing pain through thoracic flexion and scapular

complication after multilevel surgeries. It is mainly resulting from the post-operative immobilization, associated muscle and joint contractures also seen in early phases of rehabilitation. Very sensitive mobilization and stretching are essential for the recovery. Osteopenia and osteoporosis in children, not as in adults, are not easily defined and a more preferable term is low bone mass; this is defined as a bone mineral content or areal bone mineral density z score that is less than or equal to -2.0, adjusted for age, gender, and body size14. Many factors may contribute to poor bone mineralization in children with cerebral palsy. Duration of immobilization and some physical problems such as deformities leads to improper weight bearing and nonweight bearing may cause deficiency in bone
4

protraction may account for the high presence of MTPs in the pectoralis major, upper trapezius and sternocleidomastoid. The

pectoral tightness pulls the scapula into a protracted position, and the arm into internal rotation, increasing the risk of subsequent MTPs in shoulder rotators, and in scapula retractors, as well as in back and neck muscles. The diagnosis of MPS was made by an Rehabilitation Specialist (>5 years

experience treating MPS) using the Simons Criteria (Simons et al., 1999), that required 5 major and at least 1 of 4 minor criteria to be satisfied12. Although we achieved very good

Scientific Research Journal of India Volume: 3, Issue: 1, Year: 2014

mineralization Anticonvulsant

and

leads

to and

factures14. limited

long bones have increased propensity to fracture from bending and torsional loads. Those with impaired mobility, stiff or

medication

sunlight exposure may further cause low serum vitamin D levels, and thus, calcium content of bone may be decreased15. Sufficient daily intake of calcium and vitamin D is of major importance in youth in general and in children with cerebral palsy in particular14. Weight bearing exercises to the legs reduces the risk of fracture and improves the bone strength. During rehabilitation, there was no instance when there was a forcible manipulation, a sudden increase in pain, a visible deformity or an audible snap that is usually associated with a fracture. The pathological fracture was found during a routine X-ray done by the orthopedic to investigate pain in their legs. A

contracted joints, quadriplegia or with poor nutrition are at greater risk of fragility fracture. 24 Myositis Ossificans is a non-neoplastic, heterotopic ossification of soft tissues i.e. skeletal muscle, tendons, aponeurosis and fascia. Many cases are clearly related to major or minor trauma. In case of multilevel surgeries the post-surgical scar may cause the myositis ossificans. Common area affected are the distal femoral region and humeral region. Common symptoms are pain, warmth and swelling. On diagnosis of myositis ossificans the manual mobilizations and techniques should be avoided. Rest and active assisted exercises should only be encouraged. Anterior knee pain arising from the

pathological fracture can very well happen during transfers at home, for instance. The factors that may contribute to poor bone mineralization (Rickets) in children after multilevel surgeries are duration of

Patellofemoral joint is a relatively uncommon yet significant problem in the pediatric cerebral palsy (CP) population. Knee flexion deformity caused by hamstring contracture and rectus femoris spasticity increases the forces across the Patellofemoral joint and causes Patella Alta in most children with CP. On examination, all patients had tenderness at the inferior pole of the patella. Anterior knee pain is very common in children after multilevel surgeries.16 The etiology of anterior knee pain after multilevel there surgeries may be is a

immobilization, poor feeding and oral motor dysfunction may lead to inadequate caloric, protein and calcium intake and limited sunlight exposure may further cause low serum vitamin D levels. The complications of rickets in post-surgical children are pain, delays in the child's motor skills development, failure to grow and develop normally and skeletal deformities. Immobilization after surgery results in endosteal bone loss with thinning of cortices. These narrow and thin
5

uncertain,

although

combination of factors responsible. In few

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case reports, the rate of postoperative anterior knee pain ranged from 4% to more than 40%.21 Also crouched knee standing position during post-operative rehabilitation may leads to this condition. This was treated by using McConnell regimen for anterior knee pain17. Sachs et al first proposed the association between anterior knee pain with post-operative flexion contracture and quadriceps weakness.
22

Paresthetica includes sensory desensitization technique, neural mobilization and

electrotherapeutic modalities like interferential therapy or TENS. Hypertrophic scars are firm, raised, and erythematous and, by definition, remain within the boundaries of the original wound found approximately 1 to 2 weeks following injury16. Some of these scars will gradually regress over time, whereas others may continue to enlarge and become permanent19. Treatments may include scar mobilization, electrotherapy modalities such as ultra sound, laser therapy. Pressure ulcers are a frequent complication in patients with marked increase in muscle tone. In patients with spasticity, the pressure ulcers usually develop at exposed locations,

Later Fisher and Shelbourne documented

their series of arthroscopic scar resection and restoration of full knee hyperextension in a group of patients with symptomatic flexion contracture after reconstructive surgery.23 After restoration of extension, patients of

exhibited extension,

significant patients

improvement exhibited

significant

improvement in anterior knee symptoms. These findings have contributed to the widespread acceptance of the importance of obtaining full extension post operatively after reconstructive surgery to diminish anterior knee pain. Meralgia Paresthetica characterized by pain, paresthesia (abnormal sensation of burning, tingling, etc.) and numbness on the lateral surface of the thigh in the region supplied by the lateral femoral cutaneous nerve. Mainly it occurs due to scar tissue adhesion in the thigh and partial tear of the nerve from the incision of psoas. The usual diagnosis of the condition is made on the description given by the child. An examination will check for any sensory differences between the affected leg and the other leg. The management of Meralgia
6

especially pre sacrally, over the trochanters, or at the heels. Commonest area after multilevel surgeries is heels. As a precaution the parents were instructed to keep glove with water under the heel to reduce the pressure or to use water bed. The pressure ulcers occur due to the weight of the body pressing on the skin or when the child's skin is repeatedly rubbed against a surface like a mattress, bedding or other equipment or when the child's skin is pulled across a surface in opposite directions. Moisture can make child's skin more prone to pressure ulcers. If proper precautions are not taken the pressure ulcers can retard the speed of rehabilitation. Proper medical attention,

use of water bed and physiotherapy was given to heal the condition.

Scientific Research Journal of India Volume: 3, Issue: 1, Year: 2014

After an upper extremity surgery, complex regional pain syndrome (CRPS) may

surgeries

Cerebral

Palsy

rehabilitation.

Axillary nerve palsy is an iatrogenic artifact due to BWSTT when the harness is tight and supported at the axillary region. Due to recurrent compression in axilla, nerves get compressed and leads to axillary nerve palsy. It was mainly and treated with electrical exercise

complicate recovery, delay return to work, diminish health-related quality of life, and increase the likelihood of poor outcomes and/or litigation. CRPS Type I (CRPS I), is a pain syndrome characterized by an

exaggerated response to a painful stimulus. Management of CRPS included both

stimulation programme.

functional

physiotherapy & medical management. The treatment protocol used was soft tissue mobilization followed by myofascial release therapy, trigger point release, stress loading, wax bath and finally TENS. Body-weight supported treadmill training (BWSTT) is task-dependent training that has been used successfully in post multilevel

However, none of the complications were life threatening or permanent. According to the observation of our pediatric therapist they found a co relation between cerebral palsy patients with speech mental and language of

impairments,

retardation,

uneducated parents and aged to suffer more with complications then others.

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11. Gage J. Gait analysis in Cerebral Palsy. London: Mac Keith Press, 1991. 12. Simons, D.G., Travell, J.G., Simons, L.S., 1999. Travell & Simons Myofascial Pain and Dysfunction: The Trigger Point Manual, second ed. Williams & Wilkins, Baltimore, p. 132. 13. Michal Cohen, Eli Lahat, Tzvy Bistritzer, Amir Livne, Eli Heyman, and Marianna Rachmiel : Evidence-Based Review of Bone Strength in Children and Youth With Cerebral Palsy; Journal of Child Neurology 1-9 2009. 14. Bulent Unay, S. Umit Sarycy, Sabahattin Vurucu, Neriman Ynanc, Rydvan Akyn, Erdal Gokcay; Evaluation of bone mineral density in children with cerebral palsy; The Turkish Journal of Pediatrics ; 45: 11-14;2003. 15. Hakan Senaran, Candice Holden, Kirk W. Dabney, and Freeman Miller ; Anterior Knee Pain in Children With Cerebral Palsy:Journal of Pediatric Orthopaedic & Volume 27, Number 1, January/February 2007. 16. McConnell J, Gresalmer R, (1998), The Patella - A Team Approach. Aspen Publications. 17. Tina Alster, Laser Scar Revision: Comparison Study of 585-nm Pulsed Dye Laser With and Without Intralesional Corticosteroids; Dermatol Surg 29:1:January 2003. 18. Shahram Aarabi, Kirit A. Bhatt, Yubin Shi, Josemaria Paterno, Edward I. Chang, Shang A. Loh, Jeffrey W. Holmes, Michael T. Longaker, Herman Yee and Geoffrey C. Gurtner; Mechanical load initiates hypertrophic scar formation through decreased cellular apoptosis ;The FASEB Journal. 2007;21:3250-3261. 19. http://www.ehealthme.com/ds/baclofen/myofascial+pain+syndrome 20. Bach BR Jr, Jones GT, Sweet FA, et al: Arthroscopy-assisted anterior cruciate ligament reconstruction using patellar tendon substitution: Two to four-year follow-up results. Am J Sports Med 22: 758767,1994 21. Sachs RA, Daniel DM, Stone ML, et al Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med 17 760-765,1989 22. Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction Am J Sports Med 52581-56:4, 1993 23. Pediatric Bone: Biology & Diseases - Francis H. Glorieux, John M. Pettifor, Harald Jppner 2011, Page 299 24. P. Curley., K. Eyers, V. Brezinova et al. Common Peroneal Nerve Dysfunction after high tibial osteotomy. Journal of Bone and Joint Surgery, Vol. 72 B, No. 3, May 1990 25. Maria Torres Lacomba, PhD et al. Incidence of Myofascial Pain Syndrome in Breast Cance Surgery: A Prospective Study, Clinical Journal of Pain 2010, 26: 320 -325. 26. Zhongyu Li et al. Complex Regional Pain syndrome, Hand Clin 26 (2010) 281289.

CORRESPONDENCE * MPT (Neurology). Email: drmitrphysio@gmail.com, Academics Training and Research Manager, D.L.S. Institute for Health & Wellness, U.P ** MSPT (Sports and Ortho), Assistant professor, Ayushman College of physiotherapy, Bhopal. *** MPT (Neurology), PhD, Dean of Studies and Head of Department (Physiotherapy) at St. Louis University, Cameroon, Africa. Email: dr.krisharma@gmail.com