Neurosurgery - Patient Care and Treatment
What is spasticity?
Spasticity is a tightness or stiffness of muscles during movement. Often there is a “catch” as the limb is moved passively by another. This abnormal muscle tone can interfere with voluntary or passive movement of the arms and/or legs. It can also interfere with activities of daily living, such as:
- Getting into and out of a wheelchair or car
Spasticity may also lead to pain and/or progressive limb deformities. Several conditions can cause spasticity, including:
- Cerebral palsy
- Brain infections
- Congenital (present at birth) disorders of the brain or spinal cord
One of the most common causes of spasticity in children is cerebral palsy, 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.
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.
We take a team approach to managing spasticity. We use a number of treatments provided by multiple specialists, including pediatric orthopedists, specialists in rehabilitation medicine, pediatric neurosurgeons, bracing specialists (orthotists), and physical and occupational therapists. The team evaluates each child with spasticity to determine which treatment options would be best for that child.
Treatment options include oral medications, injections with botulinum toxin-A (Botox, or BTX-A), intrathecal baclofen (ITB), orthopaedic surgery, or selective dorsal rhizotomy (SDR).
- Baclofen, the drug used in ITB therapy, works on nerve cells in the spinal cord, allowing abnormal reflexes to be reduced and muscles to relax. Baclofen may be provided as an oral medicine that can help many patients. For some patients, Baclofen becomes less effective over time, requiring dosing increases and undesirable side effects like drowsiness.
- Botox is a drug that’s injected into the affected muscles, often while the child is sedated. The drug begins to have an effect within about two weeks, and the effect generally lasts 4-6 months. The injections can be repeated. The number of muscles involved in many patients with spasticity, and the need for multiple injections, can limit the benefit of Botox.
- Orthopedic tendon release or lengthening can help reduce muscle contractures and increase range of motion. It does not address the underlying spasticity; it simply makes the muscle less effective in moving the limb when it contracts. Sometimes these tendon procedures must be repeated if the muscle contractures return.
Two procedures that directly affect the nerves that cause the spasticity are SDR and ITB. Our pediatric neurosurgeons are skilled at performing both ITB and SDR for children with spasticity.
About ITB therapy for spasticity
ITB therapy delivers baclofen directly to the spinal cord. This offers two key advantages:
- There are fewer side effects since the medicine does not circulate throughout the bloodstream.
- Unlike oral baclofen, the dose of ITB usually does not need to be increased over time to achieve the same benefit.
How ITB therapy works
- A pump is placed under the skin (usually on the abdomen), attached to a catheter (tube) that passes around the side to the back. Medicine is delivered through a small incision into the sac containing the cerebrospinal fluid around the spinal cord.
- The pump delivers tiny amounts of baclofen directly to the spinal fluid around the spinal cord, where it reduces the effect of nerve impulses on the spinal cord and allows the muscles to relax.
- ITB uses less than 1% of the oral dosage of Baclofen that is typically used.
- The pump is refilled by nurse specialists every 1-6 months.
- Partnering with PenTech Health, patients can receive refills in their home, at work or in school.
- Refilling the pump takes only minutes. The nurse inserts a needle through the skin into the pump, draws out the existing baclofen and replaces it with new baclofen.
- The pump also has a sophisticated computer that can easily be programmed through the skin. This lets us make dosing adjustments if needed.
- ITB is also reversible. The pump can be removed if the expected benefit is not seen.
- The pump battery lasts 7 years, at which time the pump needs to be replaced.
Possible ITB complications
Of course, as with any medical device or treatment, complications can occur, but these are uncommon and treatable. Complications of ITB therapy can include:
- Pump infection
- Spinal fluid leak
- Catheter problems
- Over or under treatment
About SDR therapy for spasticity
Selective Dorsal Rhizotomy (SDR) is another treatment for a highly select group of children with spasticity, usually due to cerebral palsy.
How SDR therapy works
- SDR involves an operation to selectively cut portions of the nerves in the lower (lumbar) spine.
- SDR cuts only portions of the dorsal nerves, which provide sensation to the legs, but do not make the leg muscles move.
- By selectively cutting only a portion of each nerve, the sensation in the legs remains largely unchanged, and the muscle strength is not affected.
Is SDR therapy right for your child?
Patient selection is crucial for successful SDR. Patients must have enough underlying muscle strength so that, when the spasticity is gone, they will still be able to stand and walk. Patients selected for SDR are generally those who:
- Have adequate underlying muscle strength
- Can walk with or without assistance
- Have reasonable cognitive function and motivation
- Expect to improve their walking abilities
- Have motivated and supportive families and therapists
SDR is generally followed by several weeks of intense in-patient therapy. The most important thing to remember about SDR is that it is permanent, unlike ITB. This can be a benefit because once the operation is done, it is very effective at reducing stiffness and no further operations are generally needed. However, this can also be a complication because if the expected benefit isn’t seen, the operation can’t be undone.
Possible SDR complications
Although rare complications of SDR can include:
- Future spine deformity
- Inflammation and scarring of the nerve roots, which can cause pain