When to intervene in cerebral palsy: A discussion with Dr. David Siambanes

By John Murphy, MDLinx
Published April 27, 2016

Key Takeaways

Cerebral palsy (CP) is not a single disease or disorder, but a group of disorders that affect movement, balance, and posture. CP is caused most often before childbirth due to damage to the developing brain or by abnormal brain development. It is the most common cause of chronic disability in childhood, occurring in 2% to 2.5% of births.

Treatment for children with cerebral palsy is multifaceted and requires involvement from multiple disciplines and specialties, including physical therapy, physiatry, neurology, neurosurgery, and orthopedic surgery.

David Siambanes, DO, is a pediatric orthopedic surgeon and Medical Director of the Scoliosis Center at St. Joseph’s Children's Hospital in Tampa, FL. He has a large interest in treating kids with spasticity, specifically those with cerebral palsy. MDLinx editors recently interviewed Dr. Siambanes about the latest surgical interventions, and the critical window of intervention, for children with CP.

MDLinx: What’s your focus in the treatment of children with CP?
Dr. Siambanes: Cerebral palsy means a failure or delay in motor function due to spasticity, and that's difficult to detect until the child is about 2 years of age. But as these kids get older, many of them don’t receive expedient and appropriate care. There’s a lack of awareness that these kids have intervals in their lifetime where interventions—specifically surgical interventions—will help them get the most benefit. And if you miss those intervals, often you lose the ability to improve their status.

MDLinx: When are these intervals in childhood?
Dr. Siambanes: Age 6 to 12 is the opportune time, while they’re compensating and struggling to walk. You want to catch them before they have their typical adolescent growth spurt, so any intervention by 12 years of age is of benefit. At this age, they can remodel and “grow into” the surgery that’s been performed. But once they get to be 16, 17, or 18 and they start putting on their adolescent weight, they’ll stop walking. And once they become wheelchair dependent, you've lost your opportunity.

MDLinx: What interventions can be done during this interval?
Dr. Siambanes: It depends on the child’s involvement. Broadly speaking, there are two kinds of kids with CP—those who are walking and those who are wheelchair bound.

For the kids who are walking, our goal is not only to improve their walking, but to keep them walking. There’s a misconception that people have. They think, “Well, this child is never going to walk perfectly, but he seems to be getting by. Why subject him to major surgery if he’s still getting around?”

But caregivers have to understand that even if the child is walking adequately now, he or she won't continue to do so in the future. What happens is the child slowly begins to lose that mobility as the years go by. Before you know it, the child becomes a wheelchair-bound adult. So, kids who are struggling to walk need to be properly evaluated now to maximize their ability and decrease how much they compensate.

MDLinx: Where should they go for a proper evaluation?
Dr. Siambanes: An appropriate assessment can be done by a pediatric orthopedist who has an interest in these conditions, especially one who has the availability of a gait lab. Gait labs are great to take objective measurements of walking, and they can really benefit any intervention that's contemplated.

MDLinx: What about the children who are already wheelchair bound?
Dr. Siambanes: The other group is the even more difficult one—the kids who are more involved, often not communicating, and wheelchair dependent. There’s a misconception about these kids, too. People say, “Well, this child is not walking, so what's the point of doing surgery to straighten out his spine, or to put his dislocated hips back in the socket?”

The point of doing surgery is that the scoliosis can continue to progress and can lead to respiratory failure and distress. I've seen these curves get over 120 degrees. These kids can end up dying an early death or unable to be transported because no one had addressed them aggressively when they were younger. You know, no one questions scoliosis surgery for a child who’s idiopathic. But those kids aren't going to die from it. These kids will.

MDLinx: You indicated that they progress quickly. How fast are you talking about?
Dr. Siambanes: They can progress up to 4 degrees a year, even as an adult. You find that these curves have progressed so bad that in some cases we’re unable to do surgery because the patient won’t survive. What I often see is a child who comes to me when everybody understands it's a problem. The child’s spinal curve is 110 or 120 degrees and then it's likely going to be life threatening, or the child’s hips have been dislocated for 6 months now and you can’t reposition the hip in the socket because the pain is so severe.

So, the time to address these spinal curves is when they are 60 or 70 degrees, or the child with hip dislocation is beginning to have sitting intolerance or issues. These are the kids who have to be addressed more assertively, because we know where that pathology is going to end up.

MDLinx: What are the latest surgical interventions you’ve implemented?
Dr. Siambanes: Most hip dislocations in children age 6 to 12 are better treated with surgical reconstruction rather than replacement. But there are some new ways to address hip surgery in adolescent patients where if the hip is too degenerative, we can actually perform a partial replacement to relieve the pain. In this procedure, a custom femoral prosthesis or shoulder prosthesis, which is small enough for this age group, replaces the painful degenerative head while maintaining motion.

For scoliosis, the time to intervene is when the spinal curvature becomes 60 to 70 degrees or at any time it becomes severe enough to alter the child’s function—perhaps at 9 years to 12 years old, when you know it's going to become a problem.

But when I see a child for surgery who's got a 120-degree curve and I explain to the mother the risks and why we should have done it earlier, the mom usually says to me, “No one's ever told me that; I didn't know there was an option.”

Again, the caregiver has to be aware of how these conditions are going to evolve, so we need to get these kids evaluated during this early interval—while their orthopedic problems are still evolving—so they can get the aggressive treatment or intervention that will give them their maximum function both now and for later in life.

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