Decision-Making for Treatment of Disabling Spasticity in Children

摘要

There are several effective neurosurgical treatments for spasticity in children with cerebral palsy. Pursuing neurosurgical treatment requires a consensus about the surgical goal among the surgeon, child, family, and reeducation team. The surgical goal is not always functional. The clinical examination includes assessment of spasticity but also must consider the child's general medical and orthopedic status as well as his or her functional evolution, cognitive abilities, habits, and general environment. The treatment of spasticity, which must be considered before muscular contractures, is part of a therapeutic program that extends over several years. For general spasticity of lower limbs, we propose posterior rhizotomy or intrathecal baclofen administration. Posterior rhizotomy is proposed when definitive action targeted on certain muscular groups is preferred. For focal spasticity, botulinum toxin injection permits delaying surgery until the child is old enough to undergo a selective neurotomy. For upper limb spasticity, botulinum toxin is first proposed. We consider the use of botulinum toxin as a test before neurosurgery. The muscles are injected to simulate the nerve that would be affected by a selective neurotomy. This test allows the child to appreciate the benefit that he or she would enjoy from a selective neurotomy.