Indian J Pediatr 1989; 56 : 259-265

Intrapelvic Obturator Neurectomy in Cerebral Palsy

S. Sharma, K.S. Mishra, A. Dutta, S.K. Kulkarni and M.N. Nair

Department of Orthopaedic Surgery, Jawaharlal Institute of Post-Graduate Medical Education and Research, Pondicherry

Results of 202 obturator neurectomies including 190 intrapelvic and 8 ex- trapelvic obturator neurectomies in 100 patients were evaluated. Obtura- tor neurectomy, intrapelvic in particular, yielded gratifying results in prop- erly selected patients. It controlled adductor spasticity, scissoring, im- proved perineal care and helped the patients in sitting and early ambula- tion. Pre- and post-operative intensive physiotherapy was necessary to get maximum benefit of the surgery. Poor motor status, low IQ, athetosis and inadequate post-operative care had adverse effect on final outcome.

Key Words : Cerebral palsy; Adductor spasticity; Scissoring" Adductor tenotomy; Obturator neurectomy; Rehabilitation team.

Cerebral palsy is the most crippling dis- ease of childhood. In the absence of specific cure the prognosis remains unpre- dictable. A comprehensive multidiscipli- nary treatment programme is required in- volving an Orthopaedic surgeon, pediatri- cian, neurologisl~, psychiatrist, occupa- tional, physio and speech-therapists.

Inspite of medical advances results of treatment are not gratifying to the patient, the family and the society. This study evalu- ates the results of obturator neurectomy and its role in rehabilitation of these handi- capped patients.

MAa~m~ AND MEa'nODS

The patients of cerebral palsy attending the Department of Orthopaedic Surgery,

I

Reprint requests : Dr. S. Sharma, Professor & Head, Department of Orthopaedic Surgery, Jawaharlal Institute of Post-Graduate Medical Education and Research, Pondicherry 605 006.

Jawaharlal Institute of Post-Graduate Medical Education and Research, Pondi- cherry, during 1970 to 1986 were studied. Clinical details of antenatal and postnatal factors, developmental mUestones, IQ and activities of daily living were elicited in all patients. Relevant laboratory investigations were done. Skiagram of pelvis and skull were taken where applicable.

Conservative treatment consisting of muscle relaxation exercises, gait training, appropriate splint, traction and corrective plaster was tried for about 8 weeks. Those who did not respond well to this regimen were selected for surgery.

For patients with gross scissoring due to adductor spasm, but having good muscle power in the hip abductors obturator neurectomy was performed. Besides this, adductor tenotomy and other surgical pro- cedures were performed in deserving pa- tients. For consideration of surgery factors

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260 THE INDIAN JOURNAL OF PEDIATRICS Vol. 56, No. 2

like hand control, level of intelligence, athetoid movements , pathological reflexes and initiative of the patient were given due weightage.

Transverse Pfannenstiel incision in the distal most transverse abdominal crease just above the-pubic symphsis was employed, for intrapel- vic obturator neurectomy. The obturator nerves on both sides were identified and exposed first on one and then on the other side (Fig 1 a & b). The nerves after being confirmed by stimula- tion, were divided in between two ligatures put on either side, excising a segment of about 1W' on both sides. The wound was closed in layers ~fter complete haemostasis.

The extra pelvic neurectomy was performed through a 3" vertical incision on medial aspect of the thigh overlying adductor longus starting from pubic tubercle. After exposing and divid- ing both anterior and posterior branches of ob- turator nerves the tenotomies of adductor longus, brevis and gracilis were performed if needed.

Post-operatively, if the deformity was cor- :rected on the table in mild cases, lower limbs were kept in wide abduction putting two to three pillows in between the thighs, otherwise light traction with 2-3 kg weight was employed on both sides, keeping both limbs in abduction. Corrective plaster splints or cylinder with trans- verse bar were applied in few severe cases for few days post-operatively. From the second post-operative day active and passive abduction exercises of the hips, and knee were started. This was followed by resisted exercises, standing and gait training after the 10th post-operative day. All the patients had intensive physiother- apy and occupational therapy post-operatively in wards initially, and later on at home and were made to walk with the help of aids initially, and later independently. They were followed up ev- ery month, for one and half years and subse- quently at longer intervals.

The results were graded as excellent, good, fair and poor based on the following criteria :

Excellent : This consisted of those who had

no symptoms and had full correctiohs of de- formity could sit comfortably and walk inde- pendently without any support, lurch or scis- soring. Combined abduction graiined more than 60 ~ . Patient became completely independent in activities of daily living.

Good : This category included children who faced no difficulty for toilet, had residual negli- gible deformity, minimal abductor weakness, could sit and walk without any support and from crippled stage had become totally independent in activities of daily living but required some aids for walking long distances. Combined ab- duction not less than 600 .

Fair : Those whose deformities had been corrected and had functional improvement re- garding gain in stability, ambulation and toilet activities to a greater extent belonged to this group. They had moderate abductor weakness, leading to a lurching gait. Patient could sit nor- really and walk with help of appliances but failed to become completely independent in ac- tivities of daily living. Combined abduction less than 60 o .

Poor : Those who had gross residual defor- mity, scissoring, instability or dislocation of hip, had recurrence of symptoms and deformities. Patient had no functional improvement or de- teriorted after surgery.

R~s~Ts

Age incidence. The m a x i m u m age at the t ime of surgery was 24 years and the mini- m u m 3 years in both sexes (Table 1).

Clinical presentation. Clinically 97 cases were spastics, two were a thetoid and one was ataxlc. Ninty cases p resen ted with spastic quadriparesis, 3 with spastic para- plegia and 4 had hemiplegia.

Mental status. Of 100 cases 73 had border line I.Q., and 27 patients though mental ly re tarded were found trainable.

Surgical procedure. On 95 patients, 190 intra-pelvic obtura tor neurec tomies were

performed. One female pat ient who was

SHARMA E T AL : O B T U R A T O R N E U R E C I ' O M Y IN CEREBRAL PALSY 261

FIG. I.

FIG. 2.

(a) Magnified view of obturator nerves just before intra pelvic neureetoa~y (b) Right side obtumtor nerve is exposed and the cut and legated ends of left obturator nerve ~s virdbl�9

(a) Pre-operative photograph showing scissoring and marked adductor s,, asticity. (b) Same patient having good result after intra-pelvic obturator neurecton~y.

262 THE INDIAN JOURNAL OF PEDIATRICS Vol. 56, No. 2

TABLE 1. Age and Sex Distribution

Years Male F e m a l e Total

0-5 23 13 36 6-10 22 12 34

11-15 12 9 21 16-20 5 2 7 21-25 2 2

64 36 100

TABLE 2. Aetiology

No. %

Encephalitis 31 31 Birth asphyxia 21 21 Consanguinity" 20 20 Prematurity 10 10 Assoc. congenital defects 3 3 Trauma 4 4 Epilepsy 6 6 Idiopathic 4 4 Neonatal jaundice 1 1

Total 100 100

subjected to bilateral extra pelvic obturator neurectomy and adductor tenotomy of gra- cilis later on, following the failure of intra pelvic obturator neurectomy performed earlier. Extra pelvic obturator neurecto- mies along-with adductor tenotomy were performed in 4 patients (Table 3). Besides obturator neurectomy, other surgical pro- cedures performed for various associated disabilities and deformities are shown in Table 4.

Complications. Eight cases developed post-operative distension in the first 24 hours and were treated conservatively. Ten patients had superficial wound infection which was controlled with antibiotics and

dressing. Two had recurrence of symp- toms. None of the patients had subluxation or dislocation of the hip or abduction contracture.

Follow up. The follow-up period varied from 6 months to 16 years.

Outcome : The end results of obturator neurectomies performed are shown in Table 5. Only 9 (9%) patients had poor re- suits. Surgery in 6-10 years of age group showed maximum improvement-in both sexes. Out of 34 patients of 6-10 years age group the results were uniformly gratifying of whom 12 were excellent, 17 good, 3 fair. Only 2 patients had poor results. Female

TABLE 3. Obturator Neurectomies

Type No. of No. of patients neurectomy

Intrapelvic 95 190 Extrapelvic 4 8 Intra + Extrapelvic 1 4

Total 100 202

TABLE 4. Associated Surgical Procedures Performed

Procedures No. of cases

Tendo Achilles' lengthening 74 Egger's procedure 21 Steindler's procedure 12 Adductor tenotomy 11 Adductor-Gracile's tenotomy 8 Wilson's release Lateral transfer of tibialis anticus 4 Tibialis posterior lengthening 4 Tibialis posterior transfer to

dorsum of foot 2 Triple arthrodesis 2 Parotid duct transposition 10 Jones Operation 2

SHARMA ET AL : OBTURATOR NEURECTOMY IN CEREBRAL PALSY 263

children improved more than the males. Amongst 64 males the improvement was observed in 89% and in 36 females it was 95%. In cerebral palsy those associated with only prematurity showed excellent re- sults, the encephaiitic group functionally improved more than the anoxia group while the results in athetoid group were disappointing.

DISCUSSION

Adduction contracture of hip is the most common deformity in spastic type of cere- bral palsy. Its management has been the subject of wide discussion. Surgery is merely an event in the total care of the pa- tient and the occupational therapist has a vital role in the management. Of 1412 pa- tients with varying degrees of adductor spasticity including 260 with marked scis- soring who had regular exercise and inten- sive physical therapy for few months, only 224 were advised surgery and only 100 pa- tients consented to undergo obturator neurectomy.

Mean age at the time of surgery was 8 yr and 3 mo, similar to that of 8.7 yr reported by Moda and Maini. ~ Surgery in 2 to 10 years of age group has been reported to give good results) The younger children need less extensive procedure, than those in whom surgery is delayed. Moreover, these patients do not develop secondary deformities due to prolonged bad posture and gait.

lntrapelvic obturator neurectomy has the advantage of being performed through a clean area and both the nerves can be dealt with through the same incision. The inconsistency of extra pelvic obturator nerve anatomy also favours the intrapelvic route 3. Intrapelvic obturator neurectomy yielded gratifying results (Table 5 and Fig.

TABLE 5. End Results of Obturator Neurectomy

Results No. of cases %

Excellent 32 32 Good 48 48 Fair i i i i Poor 9 9 Total 100 100

2 a & b) in this series and was sufficient to relieve adductor spasticity and control scis- soring in 91% of cases. Only 10 (10%) patients required additional adductor tenotomy.

Extra-pelvic obturator neurectomy com- bined with adductor tenotomy induding gracilis tenotomy yielded good results in all the 3 cases who had gracilis contracture. McCarroll and Schwartzmann 4 and KeatsS; Banks and Green s expressed satisfaction with a combined obturator neurectomy and adductor tenotomy.

Adductor tenotomy with gracilis tenotomy in particular should be per- formed only in selected cases with severe contracture of gracilis where intrapelvic obturator neurectomy or extrapelvic neurectomy of both divisions of the nerve have failed to give desired result.

Pollock 7 and Phelps 8 reported poor re- suits of obturator neurectomy (57% and 76% respectively), while the results were poor in only 9% in this series. Phelps 9 blamed his failure to regeneration of the nerve where the obturator nerve was sim- ply cut or even where a segment was re- moved. On the contrary, we excised a seg- ment of 1�89 in between two ligatures to avoid any possibility of regeneration. We had only two cases of failure of intrapelvic obturator neurectomy due to faulty tech- nique which led to regeneration of the simply divided nerves.

264 THE INDIAN JOURNAL OF PEDIATRICS Vol. 56, No. 2

Sharrard 2 and Silver et al 1~ condemned intrapelvlc obturator neurectomy or extra pelvic division of both the nerves because of the fear of development of abduction deformity of hip. However, in this series, abduction deformity did not develop in any patient following obturator neurectomy even after a long follow-up period. Adduc- tor magnus and pectineus muscles are sufficient to take care because of dual nerve supply.

Obturator neurectomy forestalls an im- pending subluxation and prevents further deterioration of the condition into a dislo- cation and is therefore recommended as a good initial soft tissue procedure. Besides producing significant .improvement in ab- duction, obturator neurectomy with or without adductor tenotomy had been found to cause acetabular development, n

Unilateral adductor tenotomy or obtu- rator neurectomy should be judiciously avoided, especially in younger children as it can lead to subluxation or dislocation of the contralateral hip. In this series, since all the cases had bilateral procedure no subluxation or dislocation of hip resulted. Adductor tenotomy especially when com- bined with obturator neurectomy should not be done when hip abductors are weak, as this may lead to serious consequences rendering a previously ambulatory patient completely bed ridden. 7

Obturator neurectomy not only con- trolled adductor spasticity and scissoring thus improving the gait in 91 out of 100 pa- tients but also improved perineal care, sit- ting balance and helped in early ambula- tiori. There were 32 excellent results (32%), 48 good (48%) and only 9 (9%) poor results (Table 5).

Poor motor status, low IQ, atlietosis, inadequate post-operative care, lack of co-

operation on part of patients, parents and lack of education and poverty had adverse effects on final outcome. 'The over all results were more encouraging and rewarding mainly due to an energetic reha- bilitation team which played a vital role in the entire treatment programme.

ACKNOWLEDGEMENTS

The authors are grateful to Professor O.P. Bhargava, Director, JIPMER and Medical Superintendent for permitting us to use h6spital records and permission for publication of this study.

REFEm~NCES

1. Moda SK, Maini PS, Chaddha NS. Reconstructive surgery in spastic lower limbs. Indian J Orthop 1979; 13 : 1-9.

2. Sharrard WJW. Orthopaedic surgery in cerebral palsy. In : Recent Advances in Orthopaedics; Ed A Graham Apley, London : J & A Churchill Ltd., 1969; 269.

3. Baker LD, Dodelin RA, Bassett FH. Pathological changes in the hip in cerebral palsy incidence, pathogenesis and treatment, l Bone Joint Surg 1962; 44-A : 1331-1342.

4. Mc Carroll HR, Schwartzmann JR : Spastic paralysis and allied disorders. 1 Bone Joint Surg 1943; 25 : 745-767.

5. Keats S. Combined adductor gracilis tenotomy and selective obturator nerve resection for correction of adduction deformity: of the hip in children with cerebral palsy. J Bone Joint Surg 1957; 39A : 1087-1090.

6. Banks HH, Green WT. Adductor myotomy and obturator neurectomy for correction of adduction contracture of the hip in cerebral palsy, l Bone Joint Surg 1960; 42A : 111-120.

7. Pollock GA. Surgical treatment of cerebral palsy. J Bone Joh~t Surg i962; 44-B : 68-81.

8. Phelps WM. Long term results of

SHARMA ET AL : OBTURATOR NEURECTOMY IN CEREBRAL PALSY 265

orthopaedic surgery in cerebral palsy. J Bone 1oint Surg 1957; 39-A : 53-59.

9. Phelps WM. Treatment and care of cerebral palsies. Clin Orthop 1943; 2 : 987-991.

10. Silver CM, Simon SD, Litchman HM. The

11.

use and abuse of obturator neurectomy. Dev Med Child Neurol 1966; 201-203. Wheeler ME, Weinstein SL. Adductor tenotomy and obturator neurectomy. ] Pediatr Orthop 1984; 4 : 48-51.

TREATMENT OF BRAIN ABSCESS

Abscesses of sinusitic origin, predominantly caused by anaerobic streptococci, should be treated with peniciltm and chloromphenicol or matronidazole. Otitic abscesses frequently yield mixed cultures, including Bacteroides and Proteus spp. A similar regimen with the possible addition of ampicillin or gentamicin, has been recommended. Traumatic and postoperative abscesses, nearly always due to S. aureus, are best treated with fusidic acid. If an additional agent seems desirable the choice should fall on erythromycin, lincomycin, or clindamycin as flucloxacillin penetrates brain abscesses poorly. Abscesses of metastatic origin may be caused by steptococci or a mixture of bacteria. Multiple broad-spectrum therapy including penicillin should be used until culture results are available.

Preferred method of surgical treatment has been burr hole aspiration of pus combined with instillation of antibiotics. Subsequent excision of the shrunken abscess capsule has been preferred by some surgeons to prevent recrudescence, which in an early series occurred in 8% of patients from 3 months to 13 years later. Operative removal of the acute abscess as the initial treatment is controversial. Many neurosurgeons who prefer initial burr hole aspiration for supratentorial abscesses settle for primary excision when the abscess is in the cerebellum.

There has been a substantial improvement in the outcome of the treatment, for brain abscess with a mortality rate now in the order of 10%. This improvement has largely been due to three factors : the development of the CT scan, the introduction of more appropriate antibiotic regimens, and the.use of steroids which so effectively reduce the localised cerebral oedema around the abscess capsule.

Abstracted from : Lancet 1988; i : 219-220.