Single‐event multilevel surgery for children with cerebral palsy: a systematic review

Abstract

AIM To conduct a systematic review of single-event multilevel surgery (SEMLS) for children with cerebral palsy, with the aim of evaluating the quality of the evidence and developing recommendations for future research.METHOD The systematic review was conducted using standard search and extraction methods in Medline, EMBASE, CINAHL, and Cochrane electronic databases. For the purposes of this review, SEMLS was defined as two or more soft-tissue or bony surgical procedures at two or more anatomical levels during one operative procedure, requiring only one hospital admission and one period of rehabilitation. Studies were included if: (1) the primary focus was to examine the effect of SEMLS in children with cerebral palsy; (2) the results focused on multiple anatomic levels and reported findings of one or more World Health Organization International Classification of Functioning, Disability and Health (ICF) domains. Studies that focused on a single intervention or level, or on the utility of a specific outcome measure were excluded. Study quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) and the Oxford Centre for Evidence-Based Medicine scale. The review also examined the reporting of surgery, adverse events, and rehabilitation.RESULTS Thirty-one studies fulfilled the criteria for inclusion, over the period 1985 to October 2010. The MINORS score for these studies varied from 4 to 19, with marked variation in the quality of reporting. Study quality has improved over recent years. Valid measures of gait and function have been introduced and several of the most recent studies have addressed multiple dimensions of the ICF. A statistical synthesis of the outcome data was not conducted, although a trend towards favourable outcomes in gait was evident. Caution is advised with interpretation owing to the variable study quality. Uncontrolled studies may have resulted in an overestimation of treatment efficacy.INTERPRETATION The design and reporting of studies of SEMLS are improving with the development of multidisciplinary teamwork and frameworks such as the ICF. However, the evidence base is limited by the lack of randomized clinical trials, especially when compared with other surgical interventions such as selective dorsal rhizotomy.

Stability of the Gross Motor Function Classification System after single‐event multilevel surgery in children with cerebral palsy

“…However, in a systematic review of SEMLS, changes in gross motor function were generally small and inconsistent. 29 This is in keeping with other interventions such as selective dorsal rhizotomy, which may result in large improvements in gait pattern and efficiency but small improvements in gross motor function. 30 Given that both neurosurgical procedures and orthopaedic surgery do not change the cerebral lesion, this is not surprising.…”

“…This is supported by a number of cohort studies, a systematic review, and one randomized controlled trial. [11][12][13]29 Changes after SEMLS may include large improvements in gait, especially when musculoskeletal deformities are severe and underlying strength and selective motor control are relatively good. However, in a systematic review of SEMLS, changes in gross motor function were generally small and inconsistent.…”

“…8 Reported changes in gross motor function after SEMLS vary from 0% to 4.9%, again with a significant standard deviation about the mean. 11,13,29 Given the direct relationship between GMFM and GMFCS it is readily apparent that some changes in GMFCS level can be expected after interventions that result in a measurable change in GMFM. Equally, the magnitude of change in GMFM reported after both selective dorsal rhizotomy and SELMS would not be expected to result in improvements in GMFCS in the majority of patients.…”

Can robotic-based top-down rehabilitation therapies improve motor control in children with cerebral palsy? A perspective on the CPWalker project

“…One of the best treatments used in musculoskeletal impairment in CP is orthopedic surgery with its main technique being single-event multilevel orthopedic surgery (SEMLS) [4]. This surgical procedure consists of two or more soft-tissue or bony surgical techniques at two or more anatomical levels during one sole operative procedure [5]. After this procedure, a period of 2 years is often required in order to obtain an appropriate functional level.…”

Stability of the Gross Motor Function Classification System after single‐event multilevel surgery in cerebral palsy

“…The addition of the Gross Motor Function Classification System (GMFCS) 2,3 and gait analysis 4 are true landmarks in this regard. Clinicians providing advice in the area of single-event multilevel surgery for children with cerebral palsy continue to deal with limitations in the literature including small study size, incomplete description of the population, retrospective design, 5 and conflicting outcomes. 6,7 Generalizing results to provide clinical guidance is therefore still challenging.…”