Minimally Invasive SPML Surgery for Children with Cerebral Palsy: Program Development

Abstract

Improvements in surgical and rehabilitation care are critical to lessen the burden of cerebral palsy (CP), the most common cause of severe physical disability in childhood. The selective percutaneous myofascial lengthening (SPML) surgical procedure is a minimally invasive method designed to improve ambulation by lengthening contracted musculoskeletal tissues. Information on surgical procedures, efficacy, and safety of SPML for children with CP is lacking. Phase 1 of our research is a "proof-of-principle" study for multisite SPML to improve functional mobility of children with CP, and Phase 2 assesses safety, reoperation rates, and efficacy over time in subsequent patient series. Phase 1 was a repeated measurement case series study of 17 children (mean age 7.6 years). One physical therapist, blinded to the surgeon's measurements, measured bilateral knee and ankle motion before and after SPML procedures, using video recordings of a standardized gait path. Functional Mobility Scale (FMS) 5, 50, and 500 outcomes were taken pre- and postoperatively and via telephone follow-up. In Phase 2, multisite SPLM surgeries were implemented in larger successive cohorts from 2006 to 2017. Complications, reoperation rates, and efficacy were retrospectively analyzed. Phase 1 results showed improvement in the children's knee and ankle motion while ambulating and improved FMS 5, 50, and 500 outcomes postoperatively (mean, 6.3 months). At second follow-up (mean 33.3 months), FMS 500 scores continued improvement, while FMS 5 and FMS 50 scores maintained. During Phase 2, the complication rate was 2.4%, and reoperation rates (including reoperations due to maturation) were between 8% and 13%. Improvements to correct ankle equinus were recorded in 498 cases. In conclusion, in a specialized center, single-event, multilevel SPML surgeries of children with CP safely improved ambulatory knee and ankle angle motion and daily mobility outcomes. Future educational studies of training needs for surgeons new to the approach are needed.

Figure 1

Surgical program development components.

Figure 2

Camera setup and example of drawing the range-of-motion lines.

Figure 3

Knee flexion during ambulation shows an improvement in knee flexion in stance and a decrease in knee flexion in mid swing (N = 17). Knee excursion during ambulation (between stance and mid swing) remained stable but shifted to a more desirable range in the gait cycle arc.

Figure 4

Twelve subjects had preoperative positive equinus ankles. Ankle equinus (equinus in stance, mid swing, and toe-off) for right positive equinus subjects shows a decrease (improvement) in equinus toward zero in all parameters.

Figure 5

Five subjects had preoperative negative ankle equinus during ambulation. Equinus in stance increased toward zero in stance, decreasing crouch gait pattern. Responses varied for right and left legs for mid swing. Equinus increased during toe-off.