Are results after single-event multilevel surgery in cerebral palsy durable?

Abstract

Background: Gait and function may deteriorate with time in patients with spastic diplegia. Single-event multilevel surgery often is performed to either improve gait or prevent deterioration. However it is unclear whether the presumed gait improvements are durable.

Questions/purposes: We therefore determined whether (1) single-event multilevel surgery improves gait in patients with spastic diplegia and (2) whether the improved function is durable.

Methods: We retrospectively reviewed the data of 14 patients with spastic diplegia. At the time of surgery, one patient had gross motor Level I function, 10 patients had Level II function, and three patients had Level III function. There were four females and 10 males with a mean age of 13 years (range, 7-18 years). The mean number of orthopaedic procedures per single-event multilevel surgery session was 7.4 ± 2.8 (median, 6.5; range, 4-15). We used instrumented gait analysis to determine joint ROM, movement analysis profiles, and the gait profile score. The minimum followup was 1 year (mean, 2 years; range, 1-3 years).

Results: At last followup, movement analysis profiles for knee flexion, for ankle dorsiflexion, and for foot progression improved as did the gait profile score. Additional surgery after the index procedure was performed in nine of the 14 patients because of relapse of the original or new gait problems. Major surgical adverse events occurred in one of the 14 patients.

Conclusions: Severe gait dysfunction in patients with spastic diplegia can be improved short-term in one operative session by single-event multilevel surgery, but to preserve the early improvements many patients require additional surgery. It is unknown whether the improvements will last for decades.

Level of evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1

These graphs illustrate the preoperative sagittal plane kinematics at the short-term and mid-term followups. The gray band is the normal reference range. The dotted line is the mean kinematic for the study group. The substantial improvements in the sagittal plane kinematic scan be seen; these are more clearly and quantitatively illustrated in Figure 2.

Fig. 2

The movement analysis profile and gait profile score are illustrated here at preoperative, short-term followup, and mid-term followups. Decreases in the movement analysis profile and gait profile scores are an improvement toward more normal gait.