Frequently ask question (FAQ) about OSSCS surgical concept & SEMLOSSS in management of Cerebral Palsy –Q. What is the name of the advanced surgical concept in the management of cerebral palsy?A. Orthopedic Selective Spastic Control Surgery (OSSCS).Q. This surgical technique is useful in which type of cerebral palsy?A. this technique is very useful in spastic cerebral palsy and in some children with dystonic & mixed cerebral palsy. It is also claimed to be good for athetoid cerebral palsy but till now it is not proven.
Q. Why does my child need surgery?
A. To correct the deformity and maintain balance.
Q. How soon should surgery take place?
A. Results of surgery are very good if performed in the age group of 6 to 9 year of age
Q. What is the ideal age for surgical intervention
A. Ideal age is 6-9 year because most of the child will develop maturity of gait between 5-6 year of age at it is time when child have peak of functional gain by physiotherapy and they should be give admission to school. surgery should be avoided before the age of 6 year because higher chance of recurrence with too early surgery but it should also not be delayed.
Q. What might happen if I delay or avoid the surgery?
A. Child can develop permanent sequelae which will be irreversible like crouching of gait, genu recurvatum, plano-valgus feet and some time dislocation of joint and torsional deformity of bone.
Q. What results should I expect from the surgery?
A. This surgical technique corrects all contracture and deformity in the affected extremity and body became more balanced so therapy become easier and child expends lesser energy in walking.
Q. Are there any nonsurgical options?
A. Yes, specialized therapy programme is there, but it is useful only up to the age when only Spasticity is there and no contracture has developed. Once child start developing contracture he will not be benefited by therapy which start in most of spastic children at the age of 6- 7 years. Other modalities are botulinum toxin injection and inhibitory plaster application but botulinum toxin is useful only upto the age of 5-6 years in spastic cerebral palsy and it is of no use when child develop fixed contracture and even not useful in athetoid and ataxic cerebral palsy. Inhibitory plaster application has short lasting effect with complication of plaster sore, fracture.
Q. What are traditional methods of surgeries?
A. Traditionally routine orthopaedic surgeries are being performed since long time. They are based on routine assessment of child and does not consider functional status of child and some children even deteriorate after surgeries. Usually they are being done after age of 12 year when child has already develop irreversible deformity and only one or two level are being considered for surgery where child has multilevel problem and child need surgeries many time in his life time
Q. How this new method is different from old method?
A. Concept of OSSCS is based on concept of spastic multiarticular muscle lying by side with antigravity mono-articular muscle in the body. Multiarticular muscles in the body are the hole sole culprit in these children and small mono articular muscle are more advanced developed muscle in the body. So in this technique we perform surgeries only on long bi & multi-articular muscle and leave the smaller muscles. In this concept we perform surgeries in all affected long muscle in a single setting anesthesia so child will not need surgeries in many phase of life. Purpose of the surgery is to balance muscle tone in body.
Q How you will decide that which muscle will need surgery?
A. This need long term experience to decide which muscle will need surgeries. We have to perform gait analysis and thorough musculoskeletal examination of the patient as we know that; to perform a single gait cycle more than 30 muscle will act together to have smooth gait pattern, so to have a balanced gait we have to balance tone in whole body.
Q. Are there any less invasive surgery options?
A. No. We perform multilevel surgery by mini incision (minimal invasive surgery )and perform suture in double layer so that suture line look cosmetically aesthetic with minimal scar (scar less surgery).
Q. What is the next step if this surgery doesn’t work?
A. usually it does not happen because child will go in many phases of assessment and only properly selected children are operated. We have developed certain guidelines for undergoing this surgical procedure. Our aim of surgeries is to correct deformity at all level so that child will have balanced body. We always decide our ultimate goal of surgery.
Q. Can it be done on an outpatient basis?
Q. What is the ideal age for surgery?
A. Ideal age for surgery is 6-9 year age but it can be performed in any elder age group upto 30 year
Q. If I get surgery done after this age then what shall be the effects.
A. surgery at early age gives excellent out come but as age advances child start developing some deformity in extremity that can not be reversible and it has been also proven that hand function will not recover fully if performed after age of 10 years.
Q. What is SEMLOSSS
A. SEMLOSSS is Single Event Multi Level Orthopedic Selective Spasticity control Surgery . Basic concept of OSSCS give rise to excellent outcome if surgery has been performed in younger children (6-9 year). but elder age children with pubertal growth their deformity increase at great pace and child develop lots of bony deformity and torsion that can not be corrected by basic OSSCS so we have included bony alignment surgery by corrective Osteotomy with some modification in OSSCS. Even after these procedure some children left with some weakness in group of muscle and unbalanced muscle forces that is being working . Most of the time we come out with vigorous therapy and faradic stimulation but in hands and feet, therapy does not help a lot so we use tendon transfer but it is being utilized only in spastic variety of cerebral palsy. So in SEMLOSSS we have included all useful modality of surgical modality for getting good functional recovery.
Q. how much tendon transfer is effective and which places it is required ?
A. tendon transfer is very useful in few cases with spastic cerebral palsy where muscle on one side of joint are weak or too spastic & other side have strnger muscle or not able to perform at normal pace like in foot (partial tendon transfer of tibalis post & tibialis ant ) & in hand . but it is not so much useful in athetoid CP.
Q. How much tendon transfer is effective in hands muscle weakness
A. Tendon transfer is much more effective in children with spastic & week hands function . tendon transfer can only be performs in the hands with good power in some muscle group & transferred tendon can be spared without compromising from other important function of the hand . We use tendon with good power to replace other important function. it give rise to excellent outcome in function if properly executed.
Q. What will be protocol after surgery?
A. Role of surgeries is to correct the deformity and to get functional outcome. Child will need good therapeutic intervention based specifically on requirement of each child. We start therapy just after two weeks of surgeries. Some time we need plaster application to correct residual deformity and to protect lengthen tendon and muscle but we usually up-to 2-3 week only.Therapy session is of 45 minute twice a day 6 days week.First 2 week we concentrate on light massage, relaxation exercise, confidence building exercise, then after ward we put the child on vigorous strength training exercise for 4-6 weeks, then as child start showing response we put them on ADL (activity of daily life).We also give training to parents in therapeutic technique so that they can carry out therapy at their home after completion of therapy at center. Usually in most of the cases therapy programme go up to 4-6 months post surgery, then we ask the parents to continue therapy programme at their home. Some time child may need therapy for long duration up-to 1-2 years.
Q. How this treatment will affect my child’s education.
A. If you are cautious then it may not affect your child education and you can plan surgery just before your child holiday and your child can continue all his education at house during therapy period.
Q Will my child require any other surgical procedure?
A. usually in this concept we do multilevel surgery by OSSCS concept so that child is saved from repeated surgeries at different age group. but rarely he may develop contracture of some muscle then he may require minimal surgery after completion of growth (14-15 year age)
Q Do you provide in house therapy programme?
A. We provide Residential facility at our CP home, along with in house therapy programme and transportation facility for one time therapy at rehab center of Samvedna. By this concept we have got much better response in most of our children.
Q. What kind of preparation is needed for surgery?
A. Only routine blood investigation and some time x-ray of pelvis is require to rule out hip joint problem. Some time non-ambulatory children have osteomalacia that should be treated before going for surgery. When hemoglobin level is normal then blood is not required.
Q.What kind of anesthesia will be used (general, local, or regional)?
A. Usually we perform surgery in regional anesthesia like spinal, epidural, brachial anesthesia. General anesthesia is rarely required so child an take fluid and semisolid with in 2-3 hour of surgery.
Q. How long will the procedure take?
A. Surgery on both lower limbs takes 4- 5 hours and on one upper limb takes 2 hours
Q.How successful is this procedure?
A. Till now we have got excellent outcome in more than 90 % patients with this procedure. Deformity correction & tone balancing is achieved in most of the patient.
Q. What are the risks associated with this surgery?
A. We have more than 800 patients in follow up for nine years . till now we have one patients with myositis ossification, 3 patients with plaster sore and 4 patients with minor stitch infection. All these complication were treated successfully. No Major complication has been reported so far.
Q. How long will I have to stay after surgery?
A. You will have to stay in hospital only for 3-4 days and 3-4 month in early age surgery and upto 1 year in elder age surgery at Allahabad for therapy .
Q. How will I feel after surgery?
A. Usually surgeries in lower limb are being performed in spinal/ epidural anesthesia and upper limb in scalene block, so child can start taking liquid just after coming from Operation Theater and patient will be pain free.You can also give regular meal in the evening of the surgery.
Q. What kind of care will my child need after surgery?
A. Your child will not need any special precaution and can be given side turn and even he can sit on the bed.
For any query you are free to contact on —
Dr Jitendra Kumar Jain
Consultant Pediatric Orthopedic Surgeon
Secretary Samvedna Trust
Ph No. 0532-2468989, Mobile Number-9415014994, 9453039213
E-mail – firstname.lastname@example.org