Posted by: seserdr1975 | November 19, 2013

Getting sidetracked

So I have been fighting a bug for the last week or so. Its been hard to tell whether the aches and pains are the bug, the CP, or being closer and closer to 40.  The chiropractor and exercises seem to be doing the trick. Mel, has pushed me to drink lots of water as well, since the wear and tear needs to be kept hydrated! She has been a huge help!

Posted by: seserdr1975 | November 14, 2013

Spinal Surgery for CP Patients

Morning all. I want to address a topic that came up on Facebook today. Spinal surgery for Scoliosis patients with Cerebral Palsy. First of all, I am not a Dr, nor an expert. This is just my opinion, but I think a very serious topic that affects Adults with CP as well.

Surgery is a very tough choice to make, whether you are a patient or a parent of a patient. This biggest advise I want to relay is do whats best for the long term quality of life for the CP patient. Not every surgery is successful, nor is it needed in all cases. The number one goal for anyone who has CP is to positively impact the day to day quality of life.  If you have a spinal curvature over 20% then I encourage a surgical evaluation. Some of the issues of no surgery is that the curvature can worsen at a much higher rate then Idiopathic Scoliosis, which can lead to more serious complications, like respiratory issues, digestive issues and more.

Please read the below text taken from: http://www.orthobullets.com/spine/2057/cerebral-palsy-spine-disorders

Cerebral Palsy Spine Disorders

Author:
Topic updated on 09/26/13 12:58pm
 
Introduction  
  • Scoliosis common in children with cerebral palsy
    • overall incidence is 20%
    • the more involved and severe the cerebral palsy, the higher the likelihood of scoliosis
      • spastic quadriplegic at highest risk, especially if no ability to sit independently.
      • for bedridden children incidence approaches 100%
      • spinal deformity is rare in children who are able to ambulate
  • Scoliosis in patients with cerebral palsy differs from idiopathic scoliosis in that
    • curves are more likely to progress
      • (scoliosis progresses 1° to 2° per month starting at age 8 to 10 years)
    • curve begins at earlier age
    • curve is a long, c-shaped curve in CP
    • bracing is less effective
  • Etiology
    • muscle weakness and truncal imbalance has been implicated as primary etiology (little evidence to support)
    • pelvic obliquity leads to deforming forces on spine and scoliosis
  • Natural history
    • the larger the curve the more likely it is to progress
      • larger curves are associated with pelvic deformity and obliquity
      • some studies show increase incidence of decubitus ulcer in patients with larger curves, other studies did not
Evaluation
  • Treatment of cerebral palsy spine disorders requires a careful risk-benefit analysis. Therefore it is important to have a thorough understanding of the medical history and functional status.
  • History
    • clinical history
      • perinatal history
      • growth & development
      • all medical treatment
    • functional status
      • patients nutritional status
      • respiratory function
      • sitting / standing posture
      • upper and lower extremities function
      • communication skills
      • acuity of hearing and vision
  • Physical Exam
    • muscular-skeletal exam
      • motion, tone, and strength
      • hamstring contracture’s (lead to decreased lumbar lordosis)
      • hip contractures (lead to excessive lumbar lordosis)
    • spine exam
      • look at flexibility of curve
      • spinal balance and shoulder height
      • pelvic obliquity
Classification
  • Weinstein classification
    • Group I – double curves with thoracic and lumbar component and minimal pelvic obliquity
    • Group II – large lumbar or thoracolumbar curves with marked pelvic obliquity
Imaging
  • Radiographs
    • introduction
      • important just to use same radiographic technique in patients over time
        • technique often determined by functional status of patient
        • do standing or erect films whenever possible
    • standard AP & lateral
      • look for rib deformity, wedging, and spinal rotation
      • be sure to evaluate for spondylolithesis on lateral (incidence of 4-21% in patients with spastic diplegia)
    • bending films
      • important to evaluate flexibility of curve
      • use push-pull radiographs or fulcrum bending radiographs if patient can not cooperate
  • MRI
    • preoperative MRI is not routinely performed for patients undergoing spinal deformity surgery
    • indications for MRI include
      • rapid curve progression
      • change in neurologic exam
Treatment
  • Nonoperative
    • observation, custom seat and/or bracing, botox injections
      • indications
        • nonprogressive curves < 50°
        • early stages in patients < 10 years of age
          • goal is to delay surgery until an older age
      • outcomes
        • custom seat orthosis
          • helpful with seating but does not affect natural course of disease
        • bracing
          • TLSO is helpful to improve sitting balance but does not affect natural course of disease
          • some studies have supported use as a palliative measure to slow progression in skeletally immature patients only
        • botox
          • competitive inhibitor of presynaptic cholinergic receptor with a finite lifetime (usually last 2-3 months)
          • provide some short term benefit in patients with spinal deformity
  • Operative
    • goals of surgery
      •  obtain painless solid fusion with well corrected, well balanced spine with level pelvis
      • decision to proceed with surgery must include careful assessment of family’s goals and careful risk-benefit analysis
    • PSF with/without extension to the pelvis
      • indications
        • Group I curves 50° to 90° in ambulators that is progressive or interfering with sitting position
        • patient > 10 yrs of age
        • adequate hip range of motion
        • stable nutritional and medical status
      • technique
        • treated as idiopathic scoliosis with selective fusion
        • can result in worsening pelvic obliquity and sitting imbalance
    • PSF +/- ASF with/without extension to pelvis
      • indicated for
        • Group I curves >90° and in non-ambulators 
        • Group II curves 
        • children who have not yet reached skeletal maturity (avoid crankshaft phenomenon)
    • extension to pelvis
      • indications
        • pelvic obliquity > 15°
        • required due to increased pseudoarthosis rate if you do not do it
Preoperative Assessment & Planning
  • Overview
    • treatment of cerebral palsy spine disorders is complicated by medical comorbidities
      • all patients should have a thorough multidisciplinary approach
  • Nutritional status
    • increase complications (infection, length of intubation, longer hospital stays)
      • associated with poor nutritional status (weight less than fifth percentile)
      • be sure patient has adequate nutrition before surgery (serum albumin > 3.5 g/dL, consider gastrostomy tube if not)
  • Respiratory status
    • difficult to do formal pulmonary functional capacity testing
    • can use respiratory history, clinical evaluation, and chest radiographs
  • GI evaluation
    • preoperative management of GERD is important in prevention of aspiration pneumonia
  • Neurologic function
    • if patients have seizure disorder (common) be sure it is under control
      • if patient taking valproic acid, obtain bleeding time as these patients may have increased risk of bleeding
Surgical Techniques
  • Fusion levels
    • proximal fusion should extend to T1 or T2 (otherwise risk of proximal thoracic kyphosis)
    • distal fusion depends on curve pattern
      • due to long curves in CP often extends to L4 or L5
      • extend to pelvis whenever pelvic obliquity is > 15°
  • Posterior fixation techniques
    • Luque rod with subliminar wires technique 
    • Unit rod with sublaminar wires technique 
    • Pedicle screw fixation technique 
      • may provide better correction and eliminate need for anterior surgery
  • Pelvic fixation techniques
    • Galveston Technique 
      • technique to fuse to pelvis with goal of a stability and truncal balance and a level pelvis
      • caudal ends of rods are bent from lamina of S1 to pass into the posterosuperior iliac spine and between the tables of the ileum just anterior to the sciatic notch
    • bilatral sacral screws
    • iliosacral screws 
    • spinopelvic transiliac fixation
    • Dunn-McCarthy technique (S-contoured rod that wraps over sacral ala)
  • Anterior and Posterior Techniques
    • use of anterior procedures decreasing with improved posterior constructs
    • higher complication rate in anterior surgery in CP spinal deformity than idiopathic scoliosis
      • decrease complication rate if A/P done on same day verses staging procedure (improved nutritional status, decreased blood loss, short length of hospitalization)
  • Preoperative traction
    • may be option in severe and rigid curve
  • Postoperative bracing
    • usually not required
      • may be used in patients with osteoporosis or tenuous fixation
Complications
  • Implant failure
    • sometimes may be asymptomatic and not require treatment
    • includes penetration of pelvic limb of unit rod into pelvis
  • Pulmonary complications
    • chronic aspiration
    • pulmonary insufficiency most common complication in recent study
    • pneumonia
  • GI complications
    • GERD
    • poor nutrition and delayed growth
  • Neurologic complications
    • seizures
  • Wound infection
    • more common in CP than idiopathic scoliosis
    • occurs in 3-5% and usually can be treated with local wound debridement alone 
  • Death (0-7%)
Posted by: seserdr1975 | November 13, 2013

A new tool

Tonight I got my pro stretch in the mail! This thing is so cool. I get into a calf stretch and hold it for a minute at a time and do 5 sets 4 times a day. So far I’m sore but I see that it is going to make a big difference. Yesterday I had my arm worked on and now its black and blue!! The battle continues!

Posted by: seserdr1975 | November 10, 2013

The grind continues

Happy weekend everyone. Yesterday I had another session . Today was arm day. I have been sore since the last leg session, so Kip and I agreed that the best course is to alternate arm then leg . The best way to describe my right arm is a stale old rubberband  soaked in glue! Ha. The diagnosis is severe scar tissue that has spread like tentacles. So, remember when I mentioned the handlebar deal that Kip used on leg? Well it’s got a baby brother! Grinding and tearing at my arm to try to straighten it out as well as make it more nimble. Happily it felt like a wet noodle after he was done. I’ve been doing regular stretching and it seems to be working. 

So..what’s the lesson? I know that there are kids and adults a lot worse off then me. Try using deep tissue massage and stretching by an expert to help loosen those tight muscles. This is a life long fight, and it needs to be fought on many fronts. This is just one. 

Posted by: seserdr1975 | November 7, 2013

Slow Progress

So today I met with the Chiropractor for the 4th time. He crushed my interior calf muscles again. The upside is that I showed nearly 30% improvement in range of motion. Its a case of two steps forward, one step back. The big key is trying to keep loose in between sessions. I’m looking forward to getting my pro stretch calf deal. I’m looking forward to working through to my arm. Lord knows there is a lot of work to do.

Posted by: seserdr1975 | November 5, 2013

Meatgrinder

Evening all. Today was rough. I had my third chiropractic visit. I felt like a wet noodle after the session, but by now I am really sore. The key now is to tear down the inner leg muscles. The way my CP presents itself is that my right leg wants to turn in due to atrophy. The PT wants to loosen those muscles up to they can be built up to create more stability. 

Imagine this pain, he takes a metal rod about a foot long and is about 3/4 in in diameter and he rolls it against those weak muscles to tear them down. All I can say is OWWWWWW! But as “they” say, no pain, no gain. 

A shout out to my love, Melanie who is working her butt off studying her classes!

Posted by: seserdr1975 | November 3, 2013

Family

Hey y’all, I hope everyone is having a great weekend. I had my second therapy session on Thursday. Man was I sore. So my doc got me a pro stretch calf stretch. It looks like it will be a huge help. Should be here on Tuesday!! Anywho, I have cousins in from NM! Check ya later all!

Posted by: seserdr1975 | October 31, 2013

Home Improvement Therapy

So tomorrow I have my second appointment with the Chiropractor! I’m still a bit stiff but not sore. Whoo hoo! 

I still needed to make sure on my off day to do…something. So I spent my lunch spackaling our guest bathroom. The one thing that bugs me is that when I do a lot of repetitive action, like painting or spackaling my left or non CP arm will start to tingle. Hope its just wear and tear. 

I’ll grit through it, cuz I love doing the house projects! 

Posted by: seserdr1975 | October 30, 2013

A breakthrough

Today I met with a chiropractor and I think a may have found a path to healing.

 His plan was multilayered. First, beat the heck out of me with deep tissue massage, then gradual stretching, followed by private yoga sessions to develop balance and strengthen my core. Finally to tighten things up , isolated exercises to create “strength balance” on both the left and right side. 

I have an incredible sense of relief that finally there is a clear path to begin taking the fight to this CP.  The one thing I know for sure over the next few weeks is I’m going to be SORE! 

Posted by: seserdr1975 | October 29, 2013

My Daily Motivation

Having CP can be very frustrating. When I was single, it was more frustrating than now. When you’re single, CP or no CP, you need that extra oomph to work a little harder, or exercise a little more, or to loosen those obnoxious stiff muscles. And let’s be honest, cats aren’t the biggest motivators. 

But my motivator..my compass is my wife. She has shown me that any disability shouldn’t be ignored. It should be embraced. It is who we are, and the experiences and challenges we face that are shared, will hopefully make someone else’s situation just a bit better.

 

Tomorrow’s a huge day! Not only am I getting a head to toe CP check up…finally, but Melanie is starting school to be an EEG tech. Good luck to both if us!!

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