Does gender influence the long-term outcome of single-event multilevel surgery in spastic cerebral palsy?

Cerebral palsy and sex differences in children: A narrative review of the literature

In the last years, new evidence has increased the attention on sex differences in the development of children with cerebral palsy (CP). Males seem to present with a higher risk for severe motor impairment and in the response to chirurgical and rehabilitative interventions. The published data confirmed a higher incidence of CP in males than in females. The aim of this literature review was to evaluate the impact of the sex on the most important areas that characterized CP: motor function, comorbidities (pain, cognitive impairment, communications skills, epilepsy, sleep, and behavior), and the different kind of interventions.

A prospective assessment of the progression of flexed-knee gait over repeated gait analyses in the absence of surgical intervention in bilateral cerebral palsy

BACKGROUND

Flexed-knee gait is a common pattern associated with cerebral palsy (CP). It leads to excessive forces on the knee and is thought to contribute to pain and deformity. While studies have shown improvements in mid-stance knee flexion following surgery there remains a lack of prospective data on the progression of flexed-knee gait in the absence of surgery.

RESEARCH QUESTION

Does knee flexion progress over repeated assessments in the absence of surgery in a prospectively assessed cohort with CP?

METHODS

Inclusion criteria were a diagnosis of bilateral CP, knee flexion at mid-stance >19° and no surgery within one year of the first gait analysis. Gait analysis was carried out at six-month intervals (minimum of three and maximum of six assessments). The progression of knee flexion over repeated analyses was assessed. The association between changes in knee flexion between assessments and gender, age, GMFCS level, change in ankle dorsiflexion, change in height and change in weight was examined.

RESULTS

Forty-eight participants met the initial inclusion criteria and 32 (GMFCS I = 11, II = 17, III = 4) completed the minimum three assessments. Of the 32 included participants, 21 participants (66%) demonstrated decreased knee flexion at mid-stance (mean decrease 6.6° ± 3.4°; range 2.0°-13.0°) and 11 participants (34%) demonstrated increased knee flexion at mid-stance (mean increase 10.4° ± 7.1°; range 2.0°-20.0°) at one-year follow-up. Eighteen (56%) then demonstrated an overall decrease (mean 7.4° ± 5.1°) in knee flexion between the first and last assessment with last follow-up at 1-2 years (n = 3), 2-3 years (n = 3) and 3-4 years (n = 12). The majority of participants (78%) demonstrated episodes of both increasing and decreasing Knee flexion between individual assessments and further analysis found that age was associated with this inter-assessment variability in knee flexion.

SIGNIFICANCE

Flexed-knee gait is not always progressive in bilateral CP and demonstrated variability associated with age.

Frequency distribution in intraoperative stimulation-evoked EMG responses during selective dorsal rhizotomy in children with cerebral palsy-part 2: gender differences and left-biased asymmetry

INTRODUCTION

Spinal reflexes reorganize in cerebral palsy (CP), producing hyperreflexia and spasticity. CP is more common among male infants, and gender might also influence brain and spinal-cord reorganization. This retrospective study investigated the frequency of higher-graded EMG responses elicited by electrical nerve-root stimulation during selective dorsal rhizotomy (SDR), prior to partial nerve- root deafferentation, considering not only segmental level and body side, but also gender.

METHODS

Intraoperative neuromonitoring (IOM) was used in SDR to pinpoint the rootlets most responsible for exacerbated stimulation-evoked EMG patterns recorded from lower-limb muscle groups. Responses were graded according to an objective response-classification system, ranging from no abnormalities (grade 0) to highly abnormal (grade 4+), based on ipsilateral spread and contralateral involvement. Non-parametric analysis of data with repeated measures was primarily used in investigating the frequency distribution of these various EMG response grades. Over 7000 rootlets were stimulated, and the results for 65 girls and 81 boys were evaluated, taking changes in the composition of patient groups into account when considering GMFCS levels.

RESULTS

The distribution of graded EMG responses varied according to gender, laterality, and level. Higher-graded EMG responses were markedly more frequent in the boys and at lower segmental levels (L5, S1). Left-biased asymmetry in higher-graded rootlets was also more noticeable in the boys and in patients with GMFCS level I. A close link was observed between higher-grade assessments and left-biased asymmetry.

CONCLUSIONS

Detailed insight into the patient's initial spinal-neurofunctional state prior to deafferentation suggests that differences in asymmetrical spinal reorganization might be attributable to a hemispheric imbalance.

Multilevel Surgery for Children With Cerebral Palsy: A Meta-analysis

CONTEXT

Multilevel surgery (MLS) is standard care for reducing musculoskeletal disorders among children with spastic cerebral palsy (CP).

OBJECTIVE

To summarize the literature examining effects of MLS and satisfaction with MLS for children with CP.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched.

STUDY SELECTION

Studies in which authors reported effects of or satisfaction with MLS in children with CP were selected.

DATA EXTRACTION

Two authors screened and extracted data on gross motor function, gait speed, gait (eg, Gait Profile Score), range of motion, strength, spasticity, participation, quality of life, satisfaction, and adverse events.

RESULTS

Seventy-four studies (3551 participants) were identified. One was a randomized controlled trial (RCT) (n = 19); the remainder were cohort studies. Pooled analysis of cohort studies revealed that MLS did not have a long-term effect on gross motor function (standardized mean difference [SMD]: 0.38; 95% confidence interval [CI]: -0.25 to 1.01) or gait speed (SMD: 0.12; 95% CI: -0.01 to 0.25) but did improve gait (SMD: -0.80; 95% CI: -0.95 to -0.65). The RCT also revealed no effect of MLS on gross motor function but improvements in the Gait Profile Score at 1 year. Participation and quality of life were reported in only 5 studies, and adverse events were adequately reported in 17 studies.

LIMITATIONS

Data were largely from cohort studies.

CONCLUSIONS

Findings reveal that gait, but not gross motor function, improves after MLS. RCTs and improved reporting of studies of MLS are required.

A single-center retrospective review of factors influencing surgical success in patients with cerebral palsy undergoing corrective hip surgery

PURPOSE

To identify factors associated with success of corrective bony hip surgery among patients with cerebral palsy (CP).

METHODS

A retrospective review was conducted of medical records of patients diagnosed with CP and hip displacement who underwent surgery from 2004 to 2016 at the authors' institution and who had a one-year minimum follow-up. Patient age, sex, Gross Motor Function Classification System (GMFCS) level, surgical procedure(s), type and extent of CP, presence of preoperative and postoperative hip pain, and hip migration percentages (MPs) were recorded. Surgical success was defined as a postoperative MP ⩽ 30% and no hip pain at final follow-up.

RESULTS

Thirty-eight patients (55 hips) met the inclusion criteria. Mean age at surgery was 10.2 years (range, 2-24 years). Mean MP (standard deviation) improved from 64 ± 29% preoperatively to 22 ± 30% at a mean 1.7-year follow-up (p< 0.001). The absence of preoperative hip pain (p= 0.014), surgery after age 5 (p= 0.041), and a milder preoperative MP (p< 0.001) were significantly associated with surgical success.

CONCLUSION

In patients with CP and hip displacement, early preventative correction of hip displacement after age 5 may improve clinical outcomes, though future studies are needed to provide more definitive clinical direction.

Predictors affecting outcome after single-event multilevel surgery in children with cerebral palsy: a systematic review

AIM

To review the potential predictors of outcome after single-event multilevel surgery (SEMLS) in children with cerebral palsy (CP).

METHOD

A literature search using the following criteria was performed in six electronic databases: (1) children with cerebral palsy; (2) analysed potential predictors of outcome after SEMLS; (3) minimum 12 months follow-up. The potential predictors were predefined: sex; topographical distribution; socio-economic status; Gross Motor Function Classification System (GMFCS) level; preoperative kinematic summary statistic; age at surgery. Study quality was appraised with the methodological index for non-randomized studies (MINORS) and the Oxford Centre for Evidence-Based Medicine scale.

RESULTS

Of the seven studies identified, the MINORS scores ranged from 9 to 11 and all were graded 2b on the Oxford Centre for Evidence-Based Medicine scale. There was little or no evidence to support sex, topographical distribution, or socio-economic status as predictive factors after SEMLS. Preoperative Gait Profile Score (GPS) was the best measure of expected improvement in gait kinematics. Parent-reported satisfaction and GPS were best after SEMLS in children graded GMFCS II. The best long-term results were seen in those aged between 10 years and 12 years of age.

INTERPRETATION

The candidate who might expect to realize the most improvement from SEMLS is aged between 10 years and 12 years, is in GMFCS level II, and has a poor preoperative GPS.

WHAT THIS PAPER ADDS

Children aged 10 to 12 years, in Gross Motor Function Classification System level II, with a poor preoperative Gait Profile Score might expect to realize the most improvement after single-event multilevel surgery.

Sex differences in cerebral palsy on neuromotor outcome: a critical review

Sex differences have been reported in children with cerebral palsy (CP), with males having a higher risk of developing CP, but it is not entirely clear whether sex may also affect the severity of motor impairment. The aim of the present study was to critically review the existing literature on sex influence on neuromotor outcome in children with CP. The published papers confirm that CP occurs more frequently in males than in females. Within different types of CP or individual level of impairment, however, there was limited evidence that sex also had an effect on their performance.