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an intrathecal baclofen pump, and older children and teens who are ambulatory and have severe spasticity, according to Dr. Song. Contraindications for selective dorsal rhizotomy include children who have cogni- tive disabilities that may prevent successful completion of a rehabilitative program, as well as children who have significant muscle weakness or dystonia. "We typically advise against rhizotomy in cases where the procedure may make dystonia worse," Dr. Song says. "Similarly, if children have muscle weakness, we counsel patients and their families that if we per- form surgery and take away that tone, they'll have weakness after surgery, which may complicate their postoperative recovery." RESOLVING COMORBID ORTHOPEDIC DEFORMITIES Many children who are candidates for rhizotomy a lso have underly ing bone and joint deformities that require surgi- cal correction. In roughly 90 percent of these cases, selective dorsal rhizotomy is performed first, with orthopedic surgery following at least one year later. Procedures follow this order for several reasons. A f ter or t hopedic surger y, chi ldren may have muscle spa sms. Spa sticit y may worsen these spasms, so reducing spasticity prior to surgery can enhance patients' comfort following orthopedic surgery, according to Dr. Novacheck. Once spasticity is treated, orthopedic surgeons may also need to adjust the surgical plan. For example, if muscle tone is reduced, surgery to resolve soft tissue contracture may no longer be necessary. "If spasticity is managed prior to surgery, we can stay focused on bone deformity cor- rection," Dr. Novacheck says. "Orthopedic surgeons at institutions that don't have tone management and rhizotomy programs have to do more surgery on the soft tissues of the legs." Exceptions to this treatment order include children who have hip dysplasia or other significant torsional deformities that may interfere with the ability to perform rehabilitation prior to rhizotomy. In these cases, orthopedic surger y may be per- formed prior to the rhizotomy procedure. Gi l let te of fers the f u l l spectr um of pediatric orthopedic surgeries. Common procedures performed to resolve bone deformities in children with spasticity and cerebral palsy include femoral derotational osteotomy and reconstructive foot surgery. If children have multiple deformities, orthopedic surgeons at Gillette perform single-event multilevel surgery (SEMLS) during which two teams of orthopedic surgeons work simultaneously to resolve all deformities at the same time. Gillette tea m members a re innovators in this technique, which prevents the need for multiple, painful orthopedic surgeries and rehabilitation. "SEMLS enables us to put children through one single surgery and rehabilita- tion period," Dr. Healy says. "This enhances pain management, limits hospitalizations and leads to better long-term outcomes. This is also where gait analysis helps — we get a comprehensive picture of what we need to do so we can achieve the goal of addressing multiple concerns while performing only one surgery." To refer a patient to Gillette Children's Specialty Healthcare for a spasticity or motor delay evaluation, call 651-325-2200. ■ Advances in Research AT GILLETTE CHILDREN'S Specialty Healthcare, leading edge, evidence-based best practices are constantly being evaluated and integrated into the care of pediatric patients. For term newborns with suspected hypoxic-ischemic encephalopathy, neurologists may recommend therapeutic hypothermia, a therapy that has resulted in dramatic improvements in neurodevelopmental outcomes. Future research endeavors at Gillette will further develop the optimization of this therapy, which may include expanding the indications for its use and deliver - ing it in conjunction with adjunct therapies. For example, the hospital has recently entered a multicenter trial that will examine the use of erythropoietin as an adjunct to therapeutic hypothermia in the pediatric patient population. In the realm of gait analysis, Gillette clinicians are working to develop improved tools for decision-making and to better assess long-term outcomes following rhizotomy, femoral derotational osteotomy and reconstructive foot surgery. "In some instances, we're calling patients eight or 10 years after these interven- tions to see how they're doing in comparison to similar individuals who didn't undergo these procedures," says Tom Novacheck, MD, Director of the James R. Gage Center for Gait and Motion Analysis and pediatric orthopedic surgeon at Gillette. "These studies allow us to see if these procedures are effective at relieving discomfort and disability in the long run or if they only provide short-term results." Michael Healy, MD, orthopedic surgeon, Mark Gormley Jr., MD, pediatrician and rehabilitation specialist, and Debbie Song, MD, neurosurgeon, develop a care plan with a patient and family. M D N E W S .C O M /// M D N E W S M I N N E S O TA ■ 2 017 0 9

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