For many children with spastic cerebral palsy (CP), a major focus of treatment involves improving walking skills and maintaining that ability for life. Surgery often is the best way to help these children reach their full potential.

Introduced in 2019, the comprehensive, two-day mobility surgery evaluation at Cincinnati Children’s can provide answers and help families chart a clear path forward. Patient volume grows every year as families learn about the multispecialty evaluation through word-of-mouth and social media posts. The mobility visit includes:

• An evaluation in the Surgical Spasticity Clinic, where a pediatric neurosurgeon, physical medicine and rehabilitation (PMR) physician, orthopedic surgeon and physical therapist. examine the patient and consider options to reduce muscle spasticity and dystonia. Families are often surprised by the open forum, stadium-style nature of this visit, where they can weigh in on their child’s abilities and specific needs and freely ask questions of all the specialists concurrently.
• Testing in the Motion Analysis Lab to identify the underlying causes and patterns of the child’s walking difficulties. Afterward, the care team presents the data and reviews video footage with the family while making observations.

At the conclusion of the evaluation, the entire clinical team presents the family with a comprehensive plan of care, complete with treatment recommendations that may include the following:

• Selective dorsal rhizotomy (SDR), a surgery that involves electrically examining the nerve roots that connect the spinal cord to the leg muscles, then selectively cutting any roots that are involved in the conduction of spastic impulses to those muscles.
• Baclofen pump implantation, in which the pump delivers baclofen directly to the target nerves in and around the spinal cord to reduce severe spasticity and dystonia.
• An orthopaedic surgery, such as tendon lengthening, tendon transfer or guided-growth intervention for hip subluxation.
• Nonsurgical options, such as medication changes, local injections to reduce spasticity (e.g., botulinum toxin), brace modifications, functional electrical stimulation and specialized physical therapy and/or occupational therapy regimens.

About 30% of children who complete a surgical evaluation subsequently have surgery to improve their hypertonia and independent mobility. Surgical patients include toddlers and young adults who have been told elsewhere they are too young or too old for spasticity surgery.

Collaboration with the Child’s Primary Providers

“We offer individualized surgical treatment and therapy options that may not be available to families closer to home,” says Charles Stevenson, MD, FACS, who established the Surgical Spasticity Clinic about nine years ago. “That said, receiving follow-up care close to home is essential for patients to achieve the best possible outcomes. We work very closely with the referring physician and therapy team, providing resources, sharing post-op PT protocols, setting specific therapy goals, and establishing timelines for all metrics. We also collaborate directly with local physicians, therapists and orthotists when decisions need to be made about braces and other assistive devices.”

Patients return to the clinic every three to six months so the team can assess their functional gains and gauge their progress. “Our team loves those follow-up visits, because the kids are always so proud to show off their new skills,” Stevenson says.

When to Consider a Referral

The two-day mobility surgery evaluation is ideally suited for children with spastic CP who are 2 to 18 years old and can stand and take steps, with or without assistance, but could potentially improve their walking abilities. However, any child with an ability to make reciprocal leg movements, regardless of whether they are able to independently bear weight, crawl or walk, can potentially benefit from an evaluation. Good examples include:

• Toddlers who are not walking well or not meeting their mobility milestones or goals.
• Children who are losing early walking or crawling skills.
• Children who are no longer benefitting as much from therapies that seemed to help previously.

“Helping patients achieve their full ambulatory potential takes time, commitment and the implementation of a very personalized approach,” Stevenson explains. “It is always so rewarding to help them achieve a level of independence they have never experienced before.”

To learn more about the evaluation, refer a patient or request access to the parent Facebook page, contact Liz Downing, coordinator, at 513-517-1192 or elizabeth.downing@cchmc.org.