Orthopedic and Mobility Issues in Spina Bifida – Samuel Rosenfeld, MD
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Transcript of Orthopedic and Mobility Issues in Spina Bifida – Samuel Rosenfeld, MD
Interdisciplinary Management of the Child with Spina Bifida 38th SBA
National Conference Samuel R. Rosenfeld, M.D.CHOC Childrens Hospital
Rancho Los Amigos National Rehabilitation Center
University of California, Irvine26 June 2011
Disclosure
Consultant, Zimmer Spine
I have no potential conflicts with this presentation
MyelodysplasiaCongenital defects of the vertebrae with
neural element abnormalities
MyelomenigoceleExposed neural elements
MeningoceleVertebral arch defectsProtrusion of meningesIntact overlying skin
Caudal Regression SyndromeLumbar / sacral agenesisCloacal exstrophyMyelocystocele
complex spinal dysraphism 5% of all covered spina bifida 50% associated with cloacal exstrophy all with hydrocephalus and hydromyelia
Associated Neural Axis DeformitiesArnold Chiari malformationHydrocephalusHydromyeliaSyringomyeliaArachnoid cystDiastematomyeliaSpinal cord tetheringLeptomyelolipoma
Associated Musculoskeletal Deformities
ParalysisPositioningMuscle imbalanceSpasticityMixed tone: spastic and flaccid
Motor Imbalance
AsymmetryAbsence of motorsPosition / gravity
Interdisciplinary TeamNurse practitioner / case managerOrthopaedic surgeonPediatricianNeurosurgeonUrologistPhysical therapistOccupational therapistOrthotistPsychologistSocial workerDietician
Goals of Interdisciplinary Management
Mainstream childrenDevelop independenceCompetence in the communityPersonality developmentTransition into adulthood
Be Aware of Fluctuating CNS PathologyFunctional deteriorationProgressive weaknessSpasticityScoliosis above the dysraphic defectCognitive impairmentFoot deformityIntrinsic hand atrophyNeurogenic bladder changes
Neurosurgical EvaluationCT BrainMRI brain, entire spinal cordCranial ultrasoundShunt surveyShunt O Gram
Neurosurgical InterventionClosure myelomengoceleResection leptomyelolipomaShunting hydrocephalusEndoscopic third ventriculostomyBrainstem decompressionFenestration of syrinxCentral canal subarachnoid shuntRelease spinal cord tethering
Urologic EvaluationRenal ultrasoundVoiding cystourethrogramUrodynamicsUro-flow with pelvic ultrasoundRenal scan
Urologic Intervention Smooth muscle relaxation (anticholinergic /
antispasmodic) oxybutynin (Ditropan) tolterodine (Detrol)
Clean intermittant catheterizationUrinary diversionVesicostomyBladder augmentationUreteral reimplantationContinent stoma
Bowel ManagementCone enemaAntegrade Continence Enema (ACE)
age 4 to 18 years median use every other day must have committed support from specialist nurse major psychological issues
Orthopaedic Surgery EvaluationScoliosis Xrays: sitting, standing, supineCT spineXrays of hips, knees, feet: standing, supineScanogramBone ageDexa bone densitometry
Orthopaedic InterventionCorrection spinal deformityHip managementKnee managementCorrection of foot deformity to facilitate
orthotic managementOrthotic collaboration
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