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Sierra-Núñez D, Zuriguel-Pérez E, Bosch-Alcaraz A. Postsurgical pain assessment in children and adolescents with cerebral palsy: A scoping review. Dev Med Child Neurol 2022; 64:1085-1095. [PMID: 35490248 DOI: 10.1111/dmcn.15259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 02/20/2022] [Accepted: 04/04/2022] [Indexed: 01/13/2023]
Abstract
AIM To investigate factors that influence the assessment of postoperative pain in children and adolescents with cerebral palsy (CP) and the tools available to determine pain intensity. METHOD The search was performed in January 2022 using six databases. Articles focused on paediatric patients with CP; we included instruments for postsurgical pain assessment in this population published in the last 11 years. RESULTS Eight of 441 studies were included. Males and females behave differently; their families can be called on to describe their pain responses. Seven instruments for pain assessment were identified: the Non-Communicating Children's Pain Checklist and its Postoperative Version; the Paediatric Pain Profile; the revised Face, Legs, Activity, Cry and Consolability (FLACC) pain scale; the Douleur Enfant San Salvador scale; the Pain Indicator for Communicatively Impaired Children; the University of Wisconsin Children's Hospital Pain Scale; and the Individualized Numeric Rating Scale. INTERPRETATION The revised FLACC pain scale is suited to postsurgical units because of its ease of use and the fact that parental collaboration is not required. More studies are needed to demonstrate the clinical utility of these scales in postsurgical units and the factors that influence pain assessment. WHAT THIS PAPER ADDS Families should be asked to collaborate when assessing pain in children and adolescents whenever possible. Larger studies that focus on the factors influencing pain assessment in this population are required.
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Affiliation(s)
- Débora Sierra-Núñez
- Paediatric Surgery Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Esperanza Zuriguel-Pérez
- Department of Knowledge Management and Evaluation, Vall d'Hebron University Hospital, Barcelona, Spain.,Multidisciplinary Nursing Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
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Goyal N, Arora S, Kulshreshtha P, Gupta P. Microsurgical DREZotomy in Spastic Cerebral Palsy: Poor Man's Baclofen Pump. World Neurosurg 2021; 149:e170-e177. [PMID: 33618044 DOI: 10.1016/j.wneu.2021.02.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Using an intrathecal baclofen (ITB) pump for severe refractory spastic cerebral palsy is not a viable option in resource-constraint settings. Therefore authors assessed the role of microsurgical dorsal root entry zone-otomy (MDT) as an alternative for patients in whom the circumstances did not allow ITB pump placement. METHODS A prospective clinical study was conducted from August 2016 to July 2020. All patients of spastic cerebral palsy (with III-IV Ashworth grade) who underwent MDT were included. Preoperative and postoperative Ashworth grade and Gross Motor Function Classification System level were assessed along with any change in power, sensation, and bladder functions postoperatively. At last follow-up, the patients' main care providers were asked to rate the effect of surgery (on scale of 0-5) on ease of providing care related to 6 activities of daily living. RESULTS Seven patients (5 males, 2 females) of spastic cerebral palsy with an age range of 6-21 years underwent MDT over the study period. Six patients had spastic diplegia, and 1 had spastic hemiplegia. Preoperative Ashworth grade in all patients was 3-4 in various involved muscle groups. Four patients with spastic diplegia underwent MDT at L3-S1 level bilaterally, 2 patients with spastic diplegia and spastic bladder underwent MDT at L3-S4 level bilaterally, and 1 patient with right-sided spastic hemiplegia underwent MDT at C5-T1 level and L3-S1 level on the right side. Postoperative Ashworth grade in all patients improved to 0-1. The improvement in mean Ashworth grade was from 3.14 ± 0.378 preoperatively to 0.29 ± 0.488 (P value = 0.000). Most care providers reported improvement in their ability to do physiotherapy, position, clothe, ambulate, and maintain patient's personal hygiene. Care providers of 6 patients reported that they were likely to recommend MDT to another similar patient. CONCLUSIONS MDT is a cost-effective tool in deceasing limb spasticity in spastic cerebral palsy, especially for those who cannot afford ITB placement.
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Affiliation(s)
- Nishant Goyal
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, India.
| | - Shobha Arora
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, India
| | - Poorvi Kulshreshtha
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, India
| | - Priyanka Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, India
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Allen J, Zareen Z, Doyle S, Whitla L, Afzal Z, Stack M, Franklin O, Green A, James A, Leahy TR, Quinn S, Elnazir B, Russell J, Paran S, Kiely P, Roche EF, McDonnell C, Baker L, Hensey O, Gibson L, Kelly S, McDonald D, Molloy EJ. Multi-Organ Dysfunction in Cerebral Palsy. Front Pediatr 2021; 9:668544. [PMID: 34434904 PMCID: PMC8382237 DOI: 10.3389/fped.2021.668544] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/15/2021] [Indexed: 11/20/2022] Open
Abstract
Cerebral Palsy (CP) describes a heterogenous group of non-progressive disorders of posture or movement, causing activity limitation, due to a lesion in the developing brain. CP is an umbrella term for a heterogenous condition and is, therefore, descriptive rather than a diagnosis. Each case requires detailed consideration of etiology. Our understanding of the underlying cause of CP has developed significantly, with areas such as inflammation, epigenetics and genetic susceptibility to subsequent insults providing new insights. Alongside this, there has been increasing recognition of the multi-organ dysfunction (MOD) associated with CP, in particular in children with higher levels of motor impairment. Therefore, CP should not be seen as an unchanging disorder caused by a solitary insult but rather, as a condition which evolves over time. Assessment of multi-organ function may help to prevent complications in later childhood or adulthood. It may also contribute to an improved understanding of the etiology and thus may have an implication in prevention, interventional methods and therapies. MOD in CP has not yet been quantified and a scoring system may prove useful in allowing advanced clinical planning and follow-up of children with CP. Additionally, several biomarkers hold promise in assisting with long-term monitoring. Clinicians should be aware of the multi-system complications that are associated with CP and which may present significant diagnostic challenges given that many children with CP communicate non-verbally. A step-wise, logical, multi-system approach is required to ensure that the best care is provided to these children. This review summarizes multi-organ dysfunction in children with CP whilst highlighting emerging research and gaps in our knowledge. We identify some potential organ-specific biomarkers which may prove useful in developing guidelines for follow-up and management of these children throughout their lifespan.
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Affiliation(s)
- John Allen
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland.,Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | | | - Samantha Doyle
- Department of Clinical Genetics, Birmingham Women's Hospital, Birmingham, United Kingdom
| | - Laura Whitla
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Zainab Afzal
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Maria Stack
- Children's Health Ireland at Crumlin, Dublin, Ireland.,Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Orla Franklin
- Children's Health Ireland at Crumlin, Dublin, Ireland.,Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Andrew Green
- Children's Health Ireland at Crumlin, Dublin, Ireland.,Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Adam James
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland.,Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Timothy Ronan Leahy
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Shoana Quinn
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Basil Elnazir
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - John Russell
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Sri Paran
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Patrick Kiely
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Edna Frances Roche
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland.,Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Ciara McDonnell
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland.,Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland.,Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Louise Baker
- Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | | | - Louise Gibson
- Department of Paediatrics, Cork University Hospital, Cork, Ireland
| | - Stephanie Kelly
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Denise McDonald
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Eleanor J Molloy
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland.,Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland.,Children's Health Ireland at Crumlin, Dublin, Ireland.,Department of Neonatology, The Coombe Women and Infants University Hospital, Dublin, Ireland
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Skalsky AJ, Dalal P, Le J, Ewing E, Yaszay B. Screening Intrathecal Baclofen Pump Systems for Catheter Patency via Catheter Access Port Aspiration. Neuromodulation 2020; 23:1003-1008. [PMID: 32027431 DOI: 10.1111/ner.13106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/10/2019] [Accepted: 01/02/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To screen all of our patients being treated with intrathecal baclofen (ITB) therapy for catheter patency. METHOD Catheter patency was examined by performing a catheter access port study in 91 pediatric and adult patients undergoing ITB therapy at our institution. RESULTS Despite no preoperative clinical suspicion of a problem with the ITB system in all but one case, 16.5% of the catheters in our patient population were not patent. After replacement, prerevision and stable postrevision dosage was examined to determine the impact system replacement had on the daily dosage. There was a significant 65% reduction in the daily ITB dosage from before catheter exploration (M = 823.8 mcg/day, SD = 390.51) to stable post replacement/revision dosage after catheter replacement or revision (M = 289.43 mcg/day, SD = 187.76), t11 = 4.09, p = .002, 95% CI [246.80, 822.00]. CONCLUSIONS These results suggest that catheters need to be routinely screened for patency. Routine maintenance and screening can minimize or more quickly detect nonpatent systems and ensure proper functioning of the ITB system.
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Affiliation(s)
- Andrew J Skalsky
- Division of Pediatric Rehabilitation Medicine, Rady Children's Hospital San Diego, 3020 Children's Way MC 5096, San Diego, CA, USA.,Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Pritha Dalal
- Division of Pediatric Rehabilitation Medicine, Rady Children's Hospital San Diego, 3020 Children's Way MC 5096, San Diego, CA, USA.,Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Joan Le
- Division of Pediatric Rehabilitation Medicine, Rady Children's Hospital San Diego, 3020 Children's Way MC 5096, San Diego, CA, USA.,Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Emily Ewing
- Division of Pediatric Rehabilitation Medicine, Rady Children's Hospital San Diego, 3020 Children's Way MC 5096, San Diego, CA, USA
| | - Burt Yaszay
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA.,Division of Orthopaedic Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
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Mohan R, Unnikrishnan PN, George H, Bass A, Dhotare SVR, Sampath JS. Is ferritin estimation and optimisation important in cerebral palsy children undergoing single event multilevel surgery? J Orthop 2018; 16:1-4. [PMID: 30568342 DOI: 10.1016/j.jor.2018.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Rahul Mohan
- St Helens and Knowsley NHS Trust, Whiston, United Kingdom
| | | | - Harvey George
- Alder Hey Children's NHS Foundation Trust, United Kingdom
| | - Alfie Bass
- Alder Hey Children's NHS Foundation Trust, United Kingdom
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Abousamra O, Nishnianidze T, Rogers KJ, Er MS, Sees JP, Dabney KW, Miller F. Risk factors for pancreatitis after posterior spinal fusion in children with cerebral palsy. J Pediatr Orthop B 2018; 27:163-7. [PMID: 27509481 DOI: 10.1097/BPB.0000000000000376] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This study reports on the prevalence and risk factors of acute pancreatitis after posterior spinal fusion for cerebral palsy scoliosis. Pancreatitis diagnosis was based on elevated amylase or lipase above three times the upper normal limit. Perioperative data were compared between patients with and without pancreatitis. We included 300 patients; 55% developed acute pancreatitis. Gastrostomy dependence was more common in the pancreatitis group (P=0.048). Perioperative data were similar between groups. Patients with pancreatitis had longer duration of hospitalization (19 vs. 13 days, P<0.001). Acute pancreatitis is common after cerebral palsy scoliosis surgery. Gastrostomy dependence increases its risk. Although no mortality was reported, hospital stay was longer.
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Abstract
Intrathecal baclofen (ITB) has been known to reduce spasticity which did not respond to oral medications and botulinum toxin treatment. However, few results have been reported comparing the effects of ITB therapy in patients with cerebral palsy (CP) and acquired brain injury. This study aimed to investigate beneficial and adverse effects of ITB bolus injection and pump therapy in patients with CP and to compare outcomes to patients with acquired brain injury such as traumatic brain injury and hypoxic brain injury. ITB test trials were performed in 37 patients (19 CP and 18 acquired brain injury). Based on ambulatory function, CP patients were divided into 2 groups: 11 patients with nonambulatory CP and 8 patients with ambulatory CP. Change of spasticity was evaluated using the Modified Ashworth Scale. Additional positive or negative effects were also evaluated after ITB bolus injection. In patients who received ITB pump implantation, outcomes of spasticity, subjective satisfaction and adverse events were evaluated until 12 months post-treatment. After ITB bolus injection, 32 patients (86.5%) (CP 84.2% versus acquired brain injury 88.9%) showed a positive response of reducing spasticity. However, 8 patients with CP had negative adverse effects. Particularly, 3 ambulatory CP patients showed standing impairment and 1 ambulatory CP patient showed impaired gait pattern such as foot drop because of excessive reduction of lower extremity muscle tone. Ambulatory CP patients received ITB pump implantation less than patients with acquired brain injury after ITB test trials (P = .003 by a chi-squared test). After the pump implantation, spasticity was significantly reduced within 1 month and the effect maintained for 12 months. Seventeen patients or their caregivers (73.9%) were very satisfied, whereas 5 patients (21.7%) suffered from adverse events showed no subjective satisfaction. In conclusion, ITB therapy was effective in reducing spasticity in patients with CP and acquired brain injury. Before ITB pump implantation, it seems necessary to perform the ITB bolus injection to verify beneficial effects and adverse effects especially in ambulatory CP.
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Affiliation(s)
- Young Kwon Yoon
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine Department of Medicine, The Graduate School of Yonsei University Rehabilitation Institute of Neuromuscular Disease Department of Neurosurgery and Brain Research Institute, Yonsei University College of Medicine Brain Korea 21 PLUS Project for Medical Science, Yonsei University Yonsei Stem Cell Research Center, Avison Biomedical Research Center, Seoul, Korea
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DiCindio S, Arai L, McCulloch M, Sadacharam K, Shah SA, Gabos P, Dabney K, Theroux MC. Clinical relevance of echocardiogram in patients with cerebral palsy undergoing posterior spinal fusion. Paediatr Anaesth 2015; 25:840-845. [PMID: 25958933 DOI: 10.1111/pan.12676] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Spinal deformity is one of the secondary musculoskeletal problems that occur with cerebral palsy (CP). Of the co morbidities associated with CP and spinal deformity, cardiac function is of theoretical concern. OBJECTIVE The goal of our study was to determine the clinical relevance of routine preoperative cardiology evaluation via echocardiogram for patients with CP presenting for posterior spine fusion (PSF) surgery. METHODS A retrospective chart review was performed of CP patients presenting for scoliosis surgery. The data collected for each patient included: age, sex, height, weight, Cobb angle, and medical history. All patients had a preoperative cardiac evaluation. RESULTS Seventy-two patients were included. The mean age was 13.6 ± 3.4 years. Left ventricular systolic function was normal in all patients; the mean shortening fraction was 39.3 ± 6.2%. No patient had more than mild insufficiency of either the semilunar or atrioventricular valve. One patient was diagnosed with aortic root dilation as well as aortic valve insufficiency. All patients had PSF surgery without changes in anesthetic or surgical plans, and no patient experienced complications attributable to a cardiac origin. CONCLUSION The results suggest that routine preoperative cardiology evaluation via echocardiogram for children with CP in the absence of clinical history or physical examination findings suggestive of cardiac disease is not necessary.
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Affiliation(s)
- Sabina DiCindio
- Department of Anesthesiology and Critical Care Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Anesthesiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lynda Arai
- Department of Anesthesiology and Critical Care Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Anesthesiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael McCulloch
- Department of Cardiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kesavan Sadacharam
- Department of Anesthesiology and Critical Care Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Suken A Shah
- Department of Orthopedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Orthopedics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Peter Gabos
- Department of Orthopedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Orthopedics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kirk Dabney
- Department of Orthopedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Orthopedics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mary C Theroux
- Department of Anesthesiology and Critical Care Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Anesthesiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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