A comparison of hip dislocation rates and hip containment procedures after selective dorsal rhizotomy versus intrathecal baclofen pump insertion in nonambulatory cerebral palsy patients.

BACKGROUND: Spasticity is the major etiology for hip dislocation in nonambulatory cerebral palsy patients. Selective dorsal rhizotomy (SDR) was used to control lower extremity spasticity, but is now done infrequently in nonambulatory cerebral palsy. Current surgical treatment is usually intrathecal baclofen pump (ITBP) placement. A major theoretical difference between SDR and ITBP is the effect on the iliopsoas through the L1 nerve root. This study compares the rate of hip dislocation and the need for further hip surgeries in SDR and ITBP patients. METHODS: All nonambulatory cerebral palsy patients who had either an SDR or ITBP and had minimum follow-up of 2 years were retrospectively reviewed for demographic data and timing, total number, and type of hip procedures (soft tissue vs. bony), and occurrence of hip dislocation. χ (2)test was used to assess for statistical significance. RESULTS: Sixty-nine patients who underwent SDR (40 males) and 50 patients who underwent ITBP (27 males) were included in the study. Average age at spasticity intervention was 6 years 11 months for SDR and 9 years 8 months for ITBP. In the SDR group, 25% of hips underwent reconstruction versus 32% of hips in the ITBP group. There were a total of 19 hip procedures in the SDR group and 20 in the ITBP group (P = 0.15). Seventeen soft-tissue procedures were performed in both SDR and ITBP groups (P = 0.265). Six bony procedures (0 salvage) were performed in the SDR group and 10 in the ITBP group (4 salvage; P = 0.075). At final follow-up the hip dislocation rate was 10.6% in the SDR group and 7.4% in the ITBP group. CONCLUSIONS: There was no significant difference in the rate of secondary hip reconstructive surgery or dislocation between nonambulatory cerebral palsy patients who underwent SDR versus ITBP. Reconstruction was required for 25% to 32% of hips despite spasticity intervention with either procedure. This suggests that the L1 nerve root alone does not play a major role in the progression of hip dislocation. LEVEL OF EVIDENCE: Level 3--therapeutic study.

Outcomes of posterior spinal fusion and instrumentation in patients with continuous intrathecal baclofen infusion pumps.

STUDY DESIGN: In this retrospective study, 20 spastic quadriplegic cerebral palsy (CP) patients with baclofen pumps, who underwent spinal fusion and instrumentation for neuromuscular scoliosis, were matched for weight, age, and type of fusion with patients without pumps. OBJECTIVE: The objective of this study is to determine the rate of complications, adverse outcomes, and curve correction after spinal fusion in patients with CP and baclofen pumps compared with similar patients without pumps. SUMMARY OF BACKGROUND DATA: CP patients treated with continuous intrathecal baclofen (ITB) can develop neuromuscular scoliosis and may require spinal fusion with instrumentation. ITB pumps may increase complications with this procedure. METHODS: Medical records were examined, and preoperative risks, intraoperative complications, postoperative complications, and pump-specific complications were documented. Cobb angles were measured throughout the treatment to determine surgical correction. RESULTS: Pump patients more frequently required reoperation (9 vs. 4, P = 0.039) and rehospitalization (8 vs. 2, P = 0.008). There was a trend toward more wound infections in pump patients (5 vs. 0, P = 0.063). Nine pump patients (45%) had a pump-related complication; 5 of these patients required pump removal or revision. Complications included durotomy, tubing problems, and deep spinal infection. Average surgical correction in pump patients was 42% (81 degrees -48 degrees ) versus 50% (81 degrees -39 degrees ) in nonpump patients, with no significant difference between pairs (P = 0.11). CONCLUSION: CP patients with baclofen pumps who underwent spinal fusion had more complications compared with similar patients without pumps. There was no significant difference in surgical correction between matched pairs. Physicians and families should be aware of the increased risks of reoperation and rehospitalization after spinal fusion in the presence of baclofen pumps.

Weight gain in children with hypertonia of cerebral origin receiving intrathecal baclofen therapy.

OBJECTIVE: To identify the pattern of weight change in children receiving intrathecal baclofen (ITB) therapy. DESIGN: A retrospective medical chart review was conducted to identify weight status before and after ITB pump implantation. SETTING: Tertiary care children's hospital and academic medical center. PARTICIPANTS: All children and adolescents with hypertonia of cerebral origin who were younger than 19 years of age at the time of pump placement and followed in our pediatric baclofen pump program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A linear mixed model was used to examine the rate of change in weight (weight-gain velocity) before and after surgery. Weight change was adjusted for age, sex, functional level determined by the Gross Motor Functional Classification System, tube feeding, dystonia, and other comorbidities. RESULTS: The average weight-gain velocity was 2.32 kg/y presurgery and 2.93 kg/y postsurgery, adjusted for potential confounders. The 0.61 kg/y increase in weight-gain velocity attained statistical significance (P = .028). CONCLUSIONS: Although excessive weight gain is not a common problem in children with cerebral origin spasticity, increased weight-gain velocity is prevalent in children receiving ITB therapy. Health care providers may anticipate a welcome weight gain in the underweight child. This consequence should be considered when managing children receiving ITB therapy, and health care providers must appropriately intervene to prevent excessive weight gain. Further studies exploring the reasons for the increased weight-gain velocity are warranted.