I have been working as a pediatric orthopedic surgeon for the past 27 years. Before starting my practice, treating polio was the main focus in pediatric orthopedics; later it was myelomeningocele and now treating cerebral palsy (CP). CP is the most common motor disability in childhood, and its prevalence has been reported to be between 2 and 2.5 per 1,000 live births. Every day we are faced with more CP patients in our practices with a wide spectrum of expressions. The main reason for this new rise in incidence is the improvements in perinatology, neonatology, genetics, and general pediatrics knowledge about CP as well as improved technology.
Nowadays, one of the biggest challenges in the management of CP patients is its diagnosis and early recognition. In the past, the diagnosis was primarily based on a pre-natal, perinatal, and postnatal brain insult events. Currently, however, other etiologies are considered as possible risk factors for a cerebral palsy diagnosis, such as accidents, toxic drug exposures, infections, or genetic factors. Several centers are working to understand the complex genetic behavior behind the condition, especially since a consistent and reliable genetic test for CP has not yet been identified.
Once the diagnosis has been established, it is important to understand the great variability in the CP population. CP patients are usually classified by 1) topography, 2) tone/movement disorder, and 3) functional level. The use of a reliable classification will help the clinician determine the natural history, expectations, treatment, and family orientation. The manifestations could range from a mild Achilles tendon contracture to total body involvement with cognitive impairment. Many of my CP patients have been diagnosed with hemiplegia after gait evaluation of patients referred to my clinic due to a suspected internal tibia torsion. I believe that function is the most important parameter to understand the patient disease spectrum. The Gross Motor Function Classification System (GMFCS) is the most commonly used classification tool to evaluate function. This classification objectively classify the severity of disease, from level I (ambulates without aids, keeps up with peers) to level V (unable to transfer, propel a wheelchair, or support the trunk)
The treatment of children with CP is highly variable given the heterogeneous nature of the condition. Treatment can be considered within the framework of the International Classification of Functioning, Disability, and Health for Children and Youth (ICF-CY). This framework was created by the World Health Organization to serve as a common language for clinicians, researchers, policymakers, and the public to describe health-related outcomes and determinants. Treatment of children with CP is generally focused on reasonable goals for the child and family in the context of the child’s functional level
The mainstay of management for children with CP is conservative and includes therapy (physical, occupational, speech, communication), bracing equipment, and medications. If the patient demonstrates a progression of their limitations in daily common activities with conservative treatment, surgery can be considered as an option. Surgical treatments have developed during the past 30 to 40 years. From an orthopedics perspective, the most common issues are joint contractures, hip dysplasia, scoliosis, rotational deformities (femoral anteversion, tibial torsion), patella maltracking, and foot deformities (equinovarus, equinovalgus). The treatment will be determined by the child’s disease topography and GMFCS level. The orthopedic surgical options include soft tissue procedures or bone procedures.
The Pediatrics in Review Chronic Conditions article on Cerebral Palsy: Current Concepts and Practices in Musculoskeletal Care (10.1542/pir.2022-005657) highlights a key message that we are facing a rise in the cerebral palsy population, and we need to identify early for prompt referral to rehabilitation and orthopedic specialists to maximize their functional outcomes.