Spasticity with Selective Posterior Rhizotomy

Cerebral palsy is a non-progressive motor disorder caused by injury to the brain during critical periods of brain development, usually within the first three years of life. It is one of the most common disabling conditions of childhood, and is among the most common conditions treated at Penn State Children's Hospital.

Many children with cerebral palsy are affected by spasticity characterized by tightness or stiffness of muscles during movement. This abnormal muscle tone creates difficulty with voluntary movement, passive movement of arms and legs and, ultimately, may produce pain and progressive deformities.

At Penn State Children's Hospital, we have developed a multidisciplinary spasticity management program which incorporates new treatments for spasticity. These treatments are available for children with cerebral palsy, spinal cord injury, and other disorders. This program provides evaluations by specialists in pediatric rehabilitation medicine, pediatric orthopedic surgery, and pediatric neurosurgery, as well as by specialists in pediatric physical and occupational therapy.

The team evaluates each child with spasticity and determines which individualized treatment approach would be the most beneficial for that child. Management options include oral medications, intramuscular injections with botulinum toxin-A (BTX-A), intrathecal baclofen (ITB), orthopaedic surgery, or selective posterior rhizotomy.

Baclofen, the drug used in ITB therapy, works at the spinal cord, allowing abnormal reflexes to be diminished and muscles to relax. Baclofen may be administered as an oral medication which helps some patients; but for others, it is not effective because the orally administered route does not provide enough relief and causes negative side effects.

What makes ITB therapy different from oral medication is that it delivers the drug baclofen directly into the spinal canal using a pump that is surgically placed in the body. It releases spasticity with only tiny amounts of the medication, less than 1% of the oral dosage typically used. The drug is delivered to its primary site of action, and does not circulate throughout the body and the bloodstream. This helps minimize side effects.

Similar benefits to children with severe generalized spasticity and spinal cord injury have been seen. Pumps are placed in children with traumatic spinal cord injuries, resulting in tetraplegia and severe spasticity, and the reduction of spasticity has had enormous functional benefits for some of the children. The pump is refilled by nurse specialists every six to twelve weeks in the outpatient clinic setting. Primary complications have been treatable and have included infection, spinal fluid leak, and catheter problems.

Children with cerebral palsy and more focal spasticity affecting isolated muscle groups have been treated for the short-term with intramuscular BTX-A injections. The purified neurotoxin (botulinum toxin-A) temporarily blocks transmission of signals between nerve and muscles. Muscle relaxation is achieved for periods of three to four months.

The use of BTX-A appears to be safe, but it is currently only F.D.A. approved for the treatment of strabismus and blepharospasm, associated with dystonia, in patients twelve and older. Use in cerebral palsy remains investigational. Many children's hospitals are currently investigating the role of BTX-A in improving spasticity and ambulation in cerebral palsy.

The specialists here at Penn State Children's Hospital continue to offer traditional orthopaedic surgery and selective posterior rhizotomy for children with cerebral palsy. Multidisciplinary management can offer the best treatment specifically tailored to a child's needs.

It is clear that the treatment of cerebral palsy continues to evolve, and the physicians at Penn State Children's Hospital continue to be involved by providing innovative and state-of-the-art management of spasticity and other movement disorders. In the last decade, there have been tremendous advances in the management of cerebral palsy and the contributions of Penn State Children's Hospital physicians will likely continue to benefit.