A range of treatment options individualizes spasticity management

U.S. Postage
Twin Cities, MN
200 University Ave. E.
Permit No. 5388
St. Paul, MN 55101 Angela Sinner, D.O.
Pediatric Rehabilitation A Pediatric Perspective focuses on
specialized topics in pediatrics, orthopedics, neurology, neurosurgery and rehabilitation A Range of Treatment Options
Angela Sinner, D.O., Individualizes Spasticity
■ The severity of cerebral palsy symptoms To subscribe or unsubscribe from specializes in pediatric A Pediatric Perspective, please send an
rehabilitation medicine with email to [email protected].
varies widely, but most patients who have cerebral palsy will have spasticity.
a special interest in spina Editor-in-Chief – Steven Koop, M.D.
bifida, neurotrauma, and by Angela Sinner, D.O., pediatric rehabilitation medicine specialist
■ Oral medications to control spasticity Editor – Ellen Shriner spasticity management. She and Debbie Song, M.D., pediatric neurosurgeon
will be chosen based on the individual's Designers – Becky Wright, Kim Goodness tone type, other symptoms and received her doctor of osteopathic medicine degree from Photographers – Anna Bittner, Des Moines University's College of Osteopathic Medicine in Des Moines, Iowa. She completed a physical medicine Copyright 2012. Gillette Children's Specialty In the United States, cerebral palsy occurs in approximately two children per 1,000, ■ Botulinum toxin A and phenol and rehabilitation residency at the University of Minnesota Healthcare. All rights reserved.
and as many as 1 million people are affected.1 Cerebral palsy is a motor disorder injections are well-suited for reducing Medical School in Minneapolis, and then completed specialty training at Gillette Children's Specialty Healthcare affecting movement, posture and balance. It may be accompanied by disturbances focal tone issues or if the patient is too through a fellowship in pediatric rehabilitation medicine. of sensation, cognition, communication, perception, behavior and, potentially, seizures. young for more generalized tone She has made numerous professional presentations on The severity of those symptoms varies widely. However, 70 to 80 percent of patients reduction treatments. They can also be used in combination with other topics including pediatric concussion, posterior fossa To make a referral, call 651-325-2200 or
who have cerebral palsy have spasticity.2 spasticity treatments. syndrome, autonomic dysfunction in severe traumatic brain 855-325-2200 (toll-free).
injury, and spinal cord injury evaluation. Her recent research Spasticity is velocity-dependent resistance that affects muscle movement by ■ Intrathecal baclofen therapy is used to has focused on intrathecal baclofen pump management as well as hypercalcemia incidence and treatment in spinal increasing deep tendon reflexes and clonus. Spasticity is caused by a disruption in provide a generalized reduction in tone. cord injury.
N E W S & N O T E S
the baseline inhibitory signals to the stretch reflex, so muscles are stiff and move- The implanted pump is refilled in clinic every few months, depending on the ments are often jerky and awkward. Consequently, even the simplest activities of daily patient's medication requirements.
Gillette Nationally Ranked in Pediatric Orthopedics
living—walking, using hands, talking, swallowing—may be affected. Additionally, the Debbie Song, M.D.
constant stress and abnormal growth forces associated with spasticity may cause ■ Selective dorsal rhizotomy is a Pediatric Neurosurgeon muscle and joint contractures, as well as skeletal deformities. Successfully managing procedure that permanently reduces MedicalStaffBios to learn more about
Gillette Children's Specialty Healthcare is now ranked 12th in the spasticity can increase function and quality of life, while reducing deformity. spasticity by cutting the nerve rootlets nation for pediatric orthopedics and 39th in the nation for pediatric Debbie Song, M.D., is a At Gillette Children's Specialty Healthcare, we provide a range of spasticity that transmit the abnormal signals neurology/neurosurgery in U.S. News Media Group's 2012-2013 associated with spasticity.
pediatric neurosurgeon who Clinical Education
Best Children's Hospitals rankings. Last year, Gillette ranked 25th treatments to meet our patients' varied needs.
treats patients who have Find videos and professional presentations. and 44th in the two areas.
hydrocephalus, cerebral palsy, Visit our website to view a short video of Spectrum of Spasticity Care
spina bifida, and brain and Debbie Song, M.D. performing a selective View the rankings and learn more at www.usnews.com/ spinal cord anomalies. She dorsal rhizotomy surgery.
Our spasticity treatment decisions are based on a variety of factors, include the childrenshospitals has a special interest in following: the patient's age, severity of spasticity and Gross Motor Function ■ Close-up of a selective dorsal Chiari malformations and spinal dysraphism. Song received Classification System (GMFCS) level. We also consider the patient's goals, along her medical degree from the University of Michigan Medical with the family's access to follow-up care and ability to comply with the treatment Center in Ann Arbor, Mich. She also completed a neuro- recommendations. To meet patients' individual needs, we provide a range of ■ Case study - Multiple therapies surgery residency, surgical internship and neurosurgery research fellowship there. Additionally, she completed a treatments, and we may recommend combining treatments to effectively manage used to manage spasticity, P. 3 clinical research fellowship in the surgical neurology branch spasticity (see the case study on P. 3).
of the National Institute of Neurological Disorders and Fourth Biennial Professional and Family Conference for Dravet Spectrum Disorders
Stroke at the National Institutes of Health in Bethesda, Md. August 15 – 19, 2012 The spasticity management options Gillette offers include the following: therapy She finished a fellowship in pediatric neurosurgery at the (physical, occupational and/or speech); bracing and splinting; oral or injected University of Texas Southwestern Children's Medical Center Doubletree by Hilton in Bloomington, Minn.
Back Issues of
medications like botulinum toxin A; and surgical procedures such as implanting in Dallas. She has extensive publications, including profes- A Pediatric Perspective
To register, visit: http://dravet.org/news-events/conference sional journal articles, book chapters and abstracts. She is an intrathecal baclofen pump or performing a selective dorsal rhizotomy. a member of the Congress of Neurological Surgeons and pediatricperspective American Association of Neurological Surgeons.
Some patients will require a combination of treatments to The location of the injection is based on a patient's needs Intrathecal baclofen therapy (ITB) is a drug delivery
The procedure may be done for patients who have spastic Multiple Therapies Used to
effectively manage their spasticity (see the case study on and goals, and the dosage depends on the patient's size and system that consists of a pump implanted in the abdomen diplegic cerebral palsy, are 4 to 10 years old, and are typically P. 3). To relieve spasticity, we may prescribe some or all of prior exposure to the medication. At Gillette, our patients and a catheter whose tip delivers liquid baclofen (Lioresal) at GMFCS levels I, II or III. Usually, children assessed at A female patient has diffuse tone abnor- the treatments below.
typically undergo conscious sedation before botulinum directly to the intrathecal space (where the spinal cord, nerve those levels have impairments affecting their lower malities as a result of schizencephaly. toxin A is injected. Botulinum toxin A has a temporary effect roots and cerebrospinal fluid are contained). Because the extremities, but can walk independently or with the help of Her quadriplegic cerebral palsy is that usually lasts for three or more months.
medication is administered intrathecally, a much smaller a walker or crutches. For more information about patient associated with significant spasticity and Oral medications include benzodiazepines like diazepam
dose is needed to reduce spasticity than is required when the selection for SDR, see Trost J P, Schwartz M H, Krach L E, dystonia of the lower extremities, and (Valium) and muscle relaxants such as dantrolene Phenol neurolysis is another approach to reducing
oral medication is used. ITB therapy is well-suited for Dunn M E, and Novacheck, T F. Comprehensive short-term she has mixed tone in her trunk. Consequently, taking care of her (Dantrium) or baclofen (Lioresal). At times, dopaminergic spasticity and tone. Phenol is dripped directly on the nerve patients who require a generalized reduction in tone or outcome assessment of selective dorsal rhizotomy. (bathing and dressing) is difficult. When she was 2 years old, drugs such as levodopa/carbidopa (Sinemet) and trihexy- to denature the nerve protein and thus damage the myelin whose goals include a focus on functional changes. Developmental Medicine & Child Neurology 2008, 50: she began receiving botulinum toxin A injections. When she was phenidyl (Artane) may be used to treat increased muscle sheath. As a result, the overactive signal is conducted more 4 years old, the decision was made to use a combination of tone. Oral medications are chosen based on the individual's slowly through the nerve to the muscle. The therapy is also helpful for increasing patient comfort, treatments. She would have an intrathecal baclofen pump tone type, other symptoms and tolerance. We begin with low reducing pain and making it easier to manage activities of Rehabilitation and Orthopedic Interventions
implanted to manage the spasticity in her lower extremities. doses and gradually increase them as needed. If a drug must Patients are usually sedated in the operating room to daily living, such as dressing.
Botulinum toxin A or phenol injections could also be used, be discontinued, we taper it off, avoiding the complications ensure their comfort while phenol is being administered. After an SDR reduces spasticity and tone, patients require as needed, to reduce the tone in her upper extremities.
associated with rapid withdrawal. Sedation also helps them lie still, which allows for careful An external programmer is used to set the pump so it intensive rehabilitation so they can relearn muscle patterning. motor stimulation and localization of specific nerves. The delivers the specified dosage of baclofen. The amount can At Gillette , we recommend an extended inpatient rehab- During the baclofen pump implant procedure, the catheter tip Injectable medications like botulinum toxin A (Botox)
effects of phenol typically last for approximately six months. be adjusted to achieve an optimal therapeutic effect. ilitation stay. Children work on stretching, strengthening and was placed in her lower thoracic spine, and flow was established. decrease muscle spasticity, which can allow us to help The pump is refilled with baclofen every few months in an movement. Therapy begins at a basic level: patients work on The pump was pocketed on the right side in the abdominal area, improve range of motion and mobility. This medication is outpatient setting. The timing of the refills depends upon core strength and basic gross motor positions and movement, and the catheter was tunneled between the pump and the best for addressing focal tone issues or if the patient is too Prior to recommending a neurosurgical intervention, a patient's dosage requirements, the concentration of and their therapy is adjusted as they progress. Typically, catheter tip. The pump was filled with baclofen at 500 mcg/ young for more generalized tone reduction treatments. an interdisciplinary team (a neurosurgeon, a pediatric medication used and the size of the pump implanted. patients continue intense outpatient rehabilitation therapy mL concentration. After a priming bolus, it was programmed Botulinum toxin A works at the neuromuscular junction rehabilitation medicine specialist and an orthopedic Because the pump has limited battery life, it must be after discharge. to run at 100 mcg/day with simple continuous flow. The tip, to inhibit acetylcholine release. Once the drug has been surgeon) evaluates the patient. As part of the assessment, surgically explanted and replaced with a new pump after catheter and pump were connected and secured. Both wounds administered into a muscle, the patient can more readily the patient undergoes a physical therapy evaluation and a five to seven years. Approximately one to two years after a rhizotomy, our were closed. The patient did not experience any complications participate in physical or occupational therapy and be fitted gait and motion analysis. The team discusses a course of orthopedic surgeons reassess the child's gait and any postoperatively. The tone in her lower extremities was signifi- with a brace or splint. Note: Botulinum toxin A is widely treatment with the family and may recommend a surgical Selective dorsal rhizotomy (SDR) surgery permanently
orthopedic deformities. If required, our orthopedists may cantly improved. Periodically during the next few years, she also accepted as a treatment for children who have spasticity, reduces spasticity by interrupting abnormal signals being perform a single event multilevel surgery (SEMLS) to correct received botulinum toxin A injections to help reduce the but it is an off-label use for this medication.
carried through the sensory or dorsal nerve roots to the muscle contractures, bone deformities, weakness, poor motor spasticity in her trunk and extremities.
spinal cord. The concept of SDR is to reduce high muscle control, impaired balance or other problems associated with tone by cutting portions of the nerve roots that carry cerebral palsy. SEMLS will also be followed by rehabilitation When she was 10 years old, a baclofen pump replacement was abnormal signals. planned. Because the patient needed refills at 60-day intervals instead of the more customary 90-day intervals, the pump During SDR, the lumbar nerve roots that transmit infor- battery was depleted faster. She was implanted with a new larger mation to and from the muscles of the lower extremities are Close-up of a Selective Dorsal Rhizotomy
pump (40 mL size), and it was connected to the existing catheter, identified. Each individual sensory nerve root that carries Although most patients who have cerebral palsy also have which was still intact. Postoperatively, she had reduced The edges of the spinal (dural) sac are information from the muscles to the spinal cord is then spasticity, the severity of the spasticity varies widely, and there spasticity in her lower extremities, so she could sit more retracted open with suture (black). Several separated into five to 30 smaller threadlike rootlets, are a number of treatments to reduce spasticity and tone, comfortably in her wheelchair. She will continue to receive nerve roots are exposed (yellow asterisks).  and each of the tiny rootlets is electrically stimulated. enhance comfort and improve function. Having a range of A cotton pad is placed under one dorsal botulinum toxin A or phenol injections as needed to address Rootlets that contribute to a child's increased muscle tone spasticity management options allows us to individualize our nerve root as it enters the spinal sac.  the spasticity in her shoulder and torso.
are identified by the abnormal electrophysiological and/or care and match treatments with each patient's condition and Two hooks hold up a nerve rootlet that has been divided from the bigger nerve clinical response recorded in the muscles of the legs. root. The hooks are used to electrically The rootlets that demonstrate an abnormal response when stimulate the rootlet. If stimulating the stimulated are cut, while the rootlets that trigger normal nerve rootlet results in an abnormal responses when stimulated are not cut. Usually, 20 to 40 electrophysiological or clinical response in percent of the nerve rootlets are cut. the muscles, we cut that nerve rootlet.  Each nerve root is divided into five to 30 rootlets, and 20 to 40 percent of rootlets Some patients will require a combination of treatments to The location of the injection is based on a patient's needs Intrathecal baclofen therapy (ITB) is a drug delivery
The procedure may be done for patients who have spastic Multiple Therapies Used to
effectively manage their spasticity (see the case study on and goals, and the dosage depends on the patient's size and system that consists of a pump implanted in the abdomen diplegic cerebral palsy, are 4 to 10 years old, and are typically P. 3). To relieve spasticity, we may prescribe some or all of prior exposure to the medication. At Gillette, our patients and a catheter whose tip delivers liquid baclofen (Lioresal) at GMFCS levels I, II or III. Usually, children assessed at A female patient has diffuse tone abnor- the treatments below.
typically undergo conscious sedation before botulinum directly to the intrathecal space (where the spinal cord, nerve those levels have impairments affecting their lower malities as a result of schizencephaly. toxin A is injected. Botulinum toxin A has a temporary effect roots and cerebrospinal fluid are contained). Because the extremities, but can walk independently or with the help of Her quadriplegic cerebral palsy is that usually lasts for three or more months.
medication is administered intrathecally, a much smaller a walker or crutches. For more information about patient associated with significant spasticity and Oral medications include benzodiazepines like diazepam
dose is needed to reduce spasticity than is required when the selection for SDR, see Trost J P, Schwartz M H, Krach L E, dystonia of the lower extremities, and (Valium) and muscle relaxants such as dantrolene Phenol neurolysis is another approach to reducing
oral medication is used. ITB therapy is well-suited for Dunn M E, and Novacheck, T F. Comprehensive short-term she has mixed tone in her trunk. Consequently, taking care of her (Dantrium) or baclofen (Lioresal). At times, dopaminergic spasticity and tone. Phenol is dripped directly on the nerve patients who require a generalized reduction in tone or outcome assessment of selective dorsal rhizotomy. (bathing and dressing) is difficult. When she was 2 years old, drugs such as levodopa/carbidopa (Sinemet) and trihexy- to denature the nerve protein and thus damage the myelin whose goals include a focus on functional changes. Developmental Medicine & Child Neurology 2008, 50: she began receiving botulinum toxin A injections. When she was phenidyl (Artane) may be used to treat increased muscle sheath. As a result, the overactive signal is conducted more 4 years old, the decision was made to use a combination of tone. Oral medications are chosen based on the individual's slowly through the nerve to the muscle. The therapy is also helpful for increasing patient comfort, treatments. She would have an intrathecal baclofen pump tone type, other symptoms and tolerance. We begin with low reducing pain and making it easier to manage activities of Rehabilitation and Orthopedic Interventions
implanted to manage the spasticity in her lower extremities. doses and gradually increase them as needed. If a drug must Patients are usually sedated in the operating room to daily living, such as dressing.
Botulinum toxin A or phenol injections could also be used, be discontinued, we taper it off, avoiding the complications ensure their comfort while phenol is being administered. After an SDR reduces spasticity and tone, patients require as needed, to reduce the tone in her upper extremities.
associated with rapid withdrawal. Sedation also helps them lie still, which allows for careful An external programmer is used to set the pump so it intensive rehabilitation so they can relearn muscle patterning. motor stimulation and localization of specific nerves. The delivers the specified dosage of baclofen. The amount can At Gillette , we recommend an extended inpatient rehab- During the baclofen pump implant procedure, the catheter tip Injectable medications like botulinum toxin A (Botox)
effects of phenol typically last for approximately six months. be adjusted to achieve an optimal therapeutic effect. ilitation stay. Children work on stretching, strengthening and was placed in her lower thoracic spine, and flow was established. decrease muscle spasticity, which can allow us to help The pump is refilled with baclofen every few months in an movement. Therapy begins at a basic level: patients work on The pump was pocketed on the right side in the abdominal area, improve range of motion and mobility. This medication is outpatient setting. The timing of the refills depends upon core strength and basic gross motor positions and movement, and the catheter was tunneled between the pump and the best for addressing focal tone issues or if the patient is too Prior to recommending a neurosurgical intervention, a patient's dosage requirements, the concentration of and their therapy is adjusted as they progress. Typically, catheter tip. The pump was filled with baclofen at 500 mcg/ young for more generalized tone reduction treatments. an interdisciplinary team (a neurosurgeon, a pediatric medication used and the size of the pump implanted. patients continue intense outpatient rehabilitation therapy mL concentration. After a priming bolus, it was programmed Botulinum toxin A works at the neuromuscular junction rehabilitation medicine specialist and an orthopedic Because the pump has limited battery life, it must be after discharge. to run at 100 mcg/day with simple continuous flow. The tip, to inhibit acetylcholine release. Once the drug has been surgeon) evaluates the patient. As part of the assessment, surgically explanted and replaced with a new pump after catheter and pump were connected and secured. Both wounds administered into a muscle, the patient can more readily the patient undergoes a physical therapy evaluation and a five to seven years. Approximately one to two years after a rhizotomy, our were closed. The patient did not experience any complications participate in physical or occupational therapy and be fitted gait and motion analysis. The team discusses a course of orthopedic surgeons reassess the child's gait and any postoperatively. The tone in her lower extremities was signifi- with a brace or splint. Note: Botulinum toxin A is widely treatment with the family and may recommend a surgical Selective dorsal rhizotomy (SDR) surgery permanently
orthopedic deformities. If required, our orthopedists may cantly improved. Periodically during the next few years, she also accepted as a treatment for children who have spasticity, reduces spasticity by interrupting abnormal signals being perform a single event multilevel surgery (SEMLS) to correct received botulinum toxin A injections to help reduce the but it is an off-label use for this medication.
carried through the sensory or dorsal nerve roots to the muscle contractures, bone deformities, weakness, poor motor spasticity in her trunk and extremities.
spinal cord. The concept of SDR is to reduce high muscle control, impaired balance or other problems associated with tone by cutting portions of the nerve roots that carry cerebral palsy. SEMLS will also be followed by rehabilitation When she was 10 years old, a baclofen pump replacement was abnormal signals. planned. Because the patient needed refills at 60-day intervals instead of the more customary 90-day intervals, the pump During SDR, the lumbar nerve roots that transmit infor- battery was depleted faster. She was implanted with a new larger mation to and from the muscles of the lower extremities are Close-up of a Selective Dorsal Rhizotomy
pump (40 mL size), and it was connected to the existing catheter, identified. Each individual sensory nerve root that carries Although most patients who have cerebral palsy also have which was still intact. Postoperatively, she had reduced The edges of the spinal (dural) sac are information from the muscles to the spinal cord is then spasticity, the severity of the spasticity varies widely, and there spasticity in her lower extremities, so she could sit more retracted open with suture (black). Several separated into five to 30 smaller threadlike rootlets, are a number of treatments to reduce spasticity and tone, comfortably in her wheelchair. She will continue to receive nerve roots are exposed (yellow asterisks).  and each of the tiny rootlets is electrically stimulated. enhance comfort and improve function. Having a range of A cotton pad is placed under one dorsal botulinum toxin A or phenol injections as needed to address Rootlets that contribute to a child's increased muscle tone spasticity management options allows us to individualize our nerve root as it enters the spinal sac.  the spasticity in her shoulder and torso.
are identified by the abnormal electrophysiological and/or care and match treatments with each patient's condition and Two hooks hold up a nerve rootlet that has been divided from the bigger nerve clinical response recorded in the muscles of the legs. root. The hooks are used to electrically The rootlets that demonstrate an abnormal response when stimulate the rootlet. If stimulating the stimulated are cut, while the rootlets that trigger normal nerve rootlet results in an abnormal responses when stimulated are not cut. Usually, 20 to 40 electrophysiological or clinical response in percent of the nerve rootlets are cut. the muscles, we cut that nerve rootlet.  Each nerve root is divided into five to 30 rootlets, and 20 to 40 percent of rootlets Some patients will require a combination of treatments to The location of the injection is based on a patient's needs Intrathecal baclofen therapy (ITB) is a drug delivery
The procedure may be done for patients who have spastic Multiple Therapies Used to
effectively manage their spasticity (see the case study on and goals, and the dosage depends on the patient's size and system that consists of a pump implanted in the abdomen diplegic cerebral palsy, are 4 to 10 years old, and are typically P. 3). To relieve spasticity, we may prescribe some or all of prior exposure to the medication. At Gillette, our patients and a catheter whose tip delivers liquid baclofen (Lioresal) at GMFCS levels I, II or III. Usually, children assessed at A female patient has diffuse tone abnor- the treatments below.
typically undergo conscious sedation before botulinum directly to the intrathecal space (where the spinal cord, nerve those levels have impairments affecting their lower malities as a result of schizencephaly. toxin A is injected. Botulinum toxin A has a temporary effect roots and cerebrospinal fluid are contained). Because the extremities, but can walk independently or with the help of Her quadriplegic cerebral palsy is that usually lasts for three or more months.
medication is administered intrathecally, a much smaller a walker or crutches. For more information about patient associated with significant spasticity and Oral medications include benzodiazepines like diazepam
dose is needed to reduce spasticity than is required when the selection for SDR, see Trost J P, Schwartz M H, Krach L E, dystonia of the lower extremities, and (Valium) and muscle relaxants such as dantrolene Phenol neurolysis is another approach to reducing
oral medication is used. ITB therapy is well-suited for Dunn M E, and Novacheck, T F. Comprehensive short-term she has mixed tone in her trunk. Consequently, taking care of her (Dantrium) or baclofen (Lioresal). At times, dopaminergic spasticity and tone. Phenol is dripped directly on the nerve patients who require a generalized reduction in tone or outcome assessment of selective dorsal rhizotomy. (bathing and dressing) is difficult. When she was 2 years old, drugs such as levodopa/carbidopa (Sinemet) and trihexy- to denature the nerve protein and thus damage the myelin whose goals include a focus on functional changes. Developmental Medicine & Child Neurology 2008, 50: she began receiving botulinum toxin A injections. When she was phenidyl (Artane) may be used to treat increased muscle sheath. As a result, the overactive signal is conducted more 4 years old, the decision was made to use a combination of tone. Oral medications are chosen based on the individual's slowly through the nerve to the muscle. The therapy is also helpful for increasing patient comfort, treatments. She would have an intrathecal baclofen pump tone type, other symptoms and tolerance. We begin with low reducing pain and making it easier to manage activities of Rehabilitation and Orthopedic Interventions
implanted to manage the spasticity in her lower extremities. doses and gradually increase them as needed. If a drug must Patients are usually sedated in the operating room to daily living, such as dressing.
Botulinum toxin A or phenol injections could also be used, be discontinued, we taper it off, avoiding the complications ensure their comfort while phenol is being administered. After an SDR reduces spasticity and tone, patients require as needed, to reduce the tone in her upper extremities.
associated with rapid withdrawal. Sedation also helps them lie still, which allows for careful An external programmer is used to set the pump so it intensive rehabilitation so they can relearn muscle patterning. motor stimulation and localization of specific nerves. The delivers the specified dosage of baclofen. The amount can At Gillette , we recommend an extended inpatient rehab- During the baclofen pump implant procedure, the catheter tip Injectable medications like botulinum toxin A (Botox)
effects of phenol typically last for approximately six months. be adjusted to achieve an optimal therapeutic effect. ilitation stay. Children work on stretching, strengthening and was placed in her lower thoracic spine, and flow was established. decrease muscle spasticity, which can allow us to help The pump is refilled with baclofen every few months in an movement. Therapy begins at a basic level: patients work on The pump was pocketed on the right side in the abdominal area, improve range of motion and mobility. This medication is outpatient setting. The timing of the refills depends upon core strength and basic gross motor positions and movement, and the catheter was tunneled between the pump and the best for addressing focal tone issues or if the patient is too Prior to recommending a neurosurgical intervention, a patient's dosage requirements, the concentration of and their therapy is adjusted as they progress. Typically, catheter tip. The pump was filled with baclofen at 500 mcg/ young for more generalized tone reduction treatments. an interdisciplinary team (a neurosurgeon, a pediatric medication used and the size of the pump implanted. patients continue intense outpatient rehabilitation therapy mL concentration. After a priming bolus, it was programmed Botulinum toxin A works at the neuromuscular junction rehabilitation medicine specialist and an orthopedic Because the pump has limited battery life, it must be after discharge. to run at 100 mcg/day with simple continuous flow. The tip, to inhibit acetylcholine release. Once the drug has been surgeon) evaluates the patient. As part of the assessment, surgically explanted and replaced with a new pump after catheter and pump were connected and secured. Both wounds administered into a muscle, the patient can more readily the patient undergoes a physical therapy evaluation and a five to seven years. Approximately one to two years after a rhizotomy, our were closed. The patient did not experience any complications participate in physical or occupational therapy and be fitted gait and motion analysis. The team discusses a course of orthopedic surgeons reassess the child's gait and any postoperatively. The tone in her lower extremities was signifi- with a brace or splint. Note: Botulinum toxin A is widely treatment with the family and may recommend a surgical Selective dorsal rhizotomy (SDR) surgery permanently
orthopedic deformities. If required, our orthopedists may cantly improved. Periodically during the next few years, she also accepted as a treatment for children who have spasticity, reduces spasticity by interrupting abnormal signals being perform a single event multilevel surgery (SEMLS) to correct received botulinum toxin A injections to help reduce the but it is an off-label use for this medication.
carried through the sensory or dorsal nerve roots to the muscle contractures, bone deformities, weakness, poor motor spasticity in her trunk and extremities.
spinal cord. The concept of SDR is to reduce high muscle control, impaired balance or other problems associated with tone by cutting portions of the nerve roots that carry cerebral palsy. SEMLS will also be followed by rehabilitation When she was 10 years old, a baclofen pump replacement was abnormal signals. planned. Because the patient needed refills at 60-day intervals instead of the more customary 90-day intervals, the pump During SDR, the lumbar nerve roots that transmit infor- battery was depleted faster. She was implanted with a new larger mation to and from the muscles of the lower extremities are Close-up of a Selective Dorsal Rhizotomy
pump (40 mL size), and it was connected to the existing catheter, identified. Each individual sensory nerve root that carries Although most patients who have cerebral palsy also have which was still intact. Postoperatively, she had reduced The edges of the spinal (dural) sac are information from the muscles to the spinal cord is then spasticity, the severity of the spasticity varies widely, and there spasticity in her lower extremities, so she could sit more retracted open with suture (black). Several separated into five to 30 smaller threadlike rootlets, are a number of treatments to reduce spasticity and tone, comfortably in her wheelchair. She will continue to receive nerve roots are exposed (yellow asterisks).  and each of the tiny rootlets is electrically stimulated. enhance comfort and improve function. Having a range of A cotton pad is placed under one dorsal botulinum toxin A or phenol injections as needed to address Rootlets that contribute to a child's increased muscle tone spasticity management options allows us to individualize our nerve root as it enters the spinal sac.  the spasticity in her shoulder and torso.
are identified by the abnormal electrophysiological and/or care and match treatments with each patient's condition and Two hooks hold up a nerve rootlet that has been divided from the bigger nerve clinical response recorded in the muscles of the legs. root. The hooks are used to electrically The rootlets that demonstrate an abnormal response when stimulate the rootlet. If stimulating the stimulated are cut, while the rootlets that trigger normal nerve rootlet results in an abnormal responses when stimulated are not cut. Usually, 20 to 40 electrophysiological or clinical response in percent of the nerve rootlets are cut. the muscles, we cut that nerve rootlet.  Each nerve root is divided into five to 30 rootlets, and 20 to 40 percent of rootlets U.S. Postage
Twin Cities, MN
200 University Ave. E.
Permit No. 5388
St. Paul, MN 55101 Angela Sinner, D.O.
Pediatric Rehabilitation A Pediatric Perspective focuses on
specialized topics in pediatrics, orthopedics, neurology, neurosurgery and rehabilitation A Range of Treatment Options
Angela Sinner, D.O., Individualizes Spasticity
■ The severity of cerebral palsy symptoms To subscribe or unsubscribe from specializes in pediatric A Pediatric Perspective, please send an
rehabilitation medicine with email to [email protected].
varies widely, but most patients who have cerebral palsy will have spasticity.
a special interest in spina Editor-in-Chief – Steven Koop, M.D.
bifida, neurotrauma, and by Angela Sinner, D.O., pediatric rehabilitation medicine specialist
■ Oral medications to control spasticity Editor – Ellen Shriner spasticity management. She and Debbie Song, M.D., pediatric neurosurgeon
will be chosen based on the individual's Designers – Becky Wright, Kim Goodness tone type, other symptoms and received her doctor of osteopathic medicine degree from Photographers – Anna Bittner, Des Moines University's College of Osteopathic Medicine in Des Moines, Iowa. She completed a physical medicine Copyright 2012. Gillette Children's Specialty In the United States, cerebral palsy occurs in approximately two children per 1,000, ■ Botulinum toxin A and phenol and rehabilitation residency at the University of Minnesota Healthcare. All rights reserved.
and as many as 1 million people are affected.1 Cerebral palsy is a motor disorder injections are well-suited for reducing Medical School in Minneapolis, and then completed specialty training at Gillette Children's Specialty Healthcare affecting movement, posture and balance. It may be accompanied by disturbances focal tone issues or if the patient is too through a fellowship in pediatric rehabilitation medicine. of sensation, cognition, communication, perception, behavior and, potentially, seizures. young for more generalized tone She has made numerous professional presentations on The severity of those symptoms varies widely. However, 70 to 80 percent of patients reduction treatments. They can also be used in combination with other topics including pediatric concussion, posterior fossa To make a referral, call 651-325-2200 or
who have cerebral palsy have spasticity.2 spasticity treatments. syndrome, autonomic dysfunction in severe traumatic brain 855-325-2200 (toll-free).
injury, and spinal cord injury evaluation. Her recent research Spasticity is velocity-dependent resistance that affects muscle movement by ■ Intrathecal baclofen therapy is used to has focused on intrathecal baclofen pump management as well as hypercalcemia incidence and treatment in spinal increasing deep tendon reflexes and clonus. Spasticity is caused by a disruption in provide a generalized reduction in tone. cord injury.
N E W S & N O T E S
the baseline inhibitory signals to the stretch reflex, so muscles are stiff and move- The implanted pump is refilled in clinic every few months, depending on the ments are often jerky and awkward. Consequently, even the simplest activities of daily patient's medication requirements.
Gillette Nationally Ranked in Pediatric Orthopedics
living—walking, using hands, talking, swallowing—may be affected. Additionally, the Debbie Song, M.D.
constant stress and abnormal growth forces associated with spasticity may cause ■ Selective dorsal rhizotomy is a Pediatric Neurosurgeon muscle and joint contractures, as well as skeletal deformities. Successfully managing procedure that permanently reduces MedicalStaffBios to learn more about
Gillette Children's Specialty Healthcare is now ranked 12th in the spasticity can increase function and quality of life, while reducing deformity. spasticity by cutting the nerve rootlets nation for pediatric orthopedics and 39th in the nation for pediatric Debbie Song, M.D., is a At Gillette Children's Specialty Healthcare, we provide a range of spasticity that transmit the abnormal signals neurology/neurosurgery in U.S. News Media Group's 2012-2013 associated with spasticity.
pediatric neurosurgeon who Clinical Education
Best Children's Hospitals rankings. Last year, Gillette ranked 25th treatments to meet our patients' varied needs.
treats patients who have Find videos and professional presentations. and 44th in the two areas.
hydrocephalus, cerebral palsy, Visit our website to view a short video of Spectrum of Spasticity Care
spina bifida, and brain and Debbie Song, M.D. performing a selective View the rankings and learn more at www.usnews.com/ spinal cord anomalies. She dorsal rhizotomy surgery.
Our spasticity treatment decisions are based on a variety of factors, include the childrenshospitals has a special interest in following: the patient's age, severity of spasticity and Gross Motor Function ■ Close-up of a selective dorsal Chiari malformations and spinal dysraphism. Song received Classification System (GMFCS) level. We also consider the patient's goals, along her medical degree from the University of Michigan Medical with the family's access to follow-up care and ability to comply with the treatment Center in Ann Arbor, Mich. She also completed a neuro- recommendations. To meet patients' individual needs, we provide a range of ■ Case study - Multiple therapies surgery residency, surgical internship and neurosurgery research fellowship there. Additionally, she completed a treatments, and we may recommend combining treatments to effectively manage used to manage spasticity, P. 3 clinical research fellowship in the surgical neurology branch spasticity (see the case study on P. 3).
of the National Institute of Neurological Disorders and Fourth Biennial Professional and Family Conference for Dravet Spectrum Disorders
Stroke at the National Institutes of Health in Bethesda, Md. August 15 – 19, 2012 The spasticity management options Gillette offers include the following: therapy She finished a fellowship in pediatric neurosurgery at the (physical, occupational and/or speech); bracing and splinting; oral or injected University of Texas Southwestern Children's Medical Center Doubletree by Hilton in Bloomington, Minn.
Back Issues of
medications like botulinum toxin A; and surgical procedures such as implanting in Dallas. She has extensive publications, including profes- A Pediatric Perspective
To register, visit: http://dravet.org/news-events/conference sional journal articles, book chapters and abstracts. She is an intrathecal baclofen pump or performing a selective dorsal rhizotomy. a member of the Congress of Neurological Surgeons and pediatricperspective American Association of Neurological Surgeons.
U.S. Postage
Twin Cities, MN
200 University Ave. E.
Permit No. 5388
St. Paul, MN 55101 Angela Sinner, D.O.
Pediatric Rehabilitation A Pediatric Perspective focuses on
specialized topics in pediatrics, orthopedics, neurology, neurosurgery and rehabilitation A Range of Treatment Options
Angela Sinner, D.O., Individualizes Spasticity
■ The severity of cerebral palsy symptoms To subscribe or unsubscribe from specializes in pediatric A Pediatric Perspective, please send an
rehabilitation medicine with email to [email protected].
varies widely, but most patients who have cerebral palsy will have spasticity.
a special interest in spina Editor-in-Chief – Steven Koop, M.D.
bifida, neurotrauma, and by Angela Sinner, D.O., pediatric rehabilitation medicine specialist
■ Oral medications to control spasticity Editor – Ellen Shriner spasticity management. She and Debbie Song, M.D., pediatric neurosurgeon
will be chosen based on the individual's Designers – Becky Wright, Kim Goodness tone type, other symptoms and received her doctor of osteopathic medicine degree from Photographers – Anna Bittner, Des Moines University's College of Osteopathic Medicine in Des Moines, Iowa. She completed a physical medicine Copyright 2012. Gillette Children's Specialty In the United States, cerebral palsy occurs in approximately two children per 1,000, ■ Botulinum toxin A and phenol and rehabilitation residency at the University of Minnesota Healthcare. All rights reserved.
and as many as 1 million people are affected.1 Cerebral palsy is a motor disorder injections are well-suited for reducing Medical School in Minneapolis, and then completed specialty training at Gillette Children's Specialty Healthcare affecting movement, posture and balance. It may be accompanied by disturbances focal tone issues or if the patient is too through a fellowship in pediatric rehabilitation medicine. of sensation, cognition, communication, perception, behavior and, potentially, seizures. young for more generalized tone She has made numerous professional presentations on The severity of those symptoms varies widely. However, 70 to 80 percent of patients reduction treatments. They can also be used in combination with other topics including pediatric concussion, posterior fossa To make a referral, call 651-325-2200 or
who have cerebral palsy have spasticity.2 spasticity treatments. syndrome, autonomic dysfunction in severe traumatic brain 855-325-2200 (toll-free).
injury, and spinal cord injury evaluation. Her recent research Spasticity is velocity-dependent resistance that affects muscle movement by ■ Intrathecal baclofen therapy is used to has focused on intrathecal baclofen pump management as well as hypercalcemia incidence and treatment in spinal increasing deep tendon reflexes and clonus. Spasticity is caused by a disruption in provide a generalized reduction in tone. cord injury.
N E W S & N O T E S
the baseline inhibitory signals to the stretch reflex, so muscles are stiff and move- The implanted pump is refilled in clinic every few months, depending on the ments are often jerky and awkward. Consequently, even the simplest activities of daily patient's medication requirements.
Gillette Nationally Ranked in Pediatric Orthopedics
living—walking, using hands, talking, swallowing—may be affected. Additionally, the Debbie Song, M.D.
constant stress and abnormal growth forces associated with spasticity may cause ■ Selective dorsal rhizotomy is a Pediatric Neurosurgeon muscle and joint contractures, as well as skeletal deformities. Successfully managing procedure that permanently reduces MedicalStaffBios to learn more about
Gillette Children's Specialty Healthcare is now ranked 12th in the spasticity can increase function and quality of life, while reducing deformity. spasticity by cutting the nerve rootlets nation for pediatric orthopedics and 39th in the nation for pediatric Debbie Song, M.D., is a At Gillette Children's Specialty Healthcare, we provide a range of spasticity that transmit the abnormal signals neurology/neurosurgery in U.S. News Media Group's 2012-2013 associated with spasticity.
pediatric neurosurgeon who Clinical Education
Best Children's Hospitals rankings. Last year, Gillette ranked 25th treatments to meet our patients' varied needs.
treats patients who have Find videos and professional presentations. and 44th in the two areas.
hydrocephalus, cerebral palsy, Visit our website to view a short video of Spectrum of Spasticity Care
spina bifida, and brain and Debbie Song, M.D. performing a selective View the rankings and learn more at www.usnews.com/ spinal cord anomalies. She dorsal rhizotomy surgery.
Our spasticity treatment decisions are based on a variety of factors, include the childrenshospitals has a special interest in following: the patient's age, severity of spasticity and Gross Motor Function ■ Close-up of a selective dorsal Chiari malformations and spinal dysraphism. Song received Classification System (GMFCS) level. We also consider the patient's goals, along her medical degree from the University of Michigan Medical with the family's access to follow-up care and ability to comply with the treatment Center in Ann Arbor, Mich. She also completed a neuro- recommendations. To meet patients' individual needs, we provide a range of ■ Case study - Multiple therapies surgery residency, surgical internship and neurosurgery research fellowship there. Additionally, she completed a treatments, and we may recommend combining treatments to effectively manage used to manage spasticity, P. 3 clinical research fellowship in the surgical neurology branch spasticity (see the case study on P. 3).
of the National Institute of Neurological Disorders and Fourth Biennial Professional and Family Conference for Dravet Spectrum Disorders
Stroke at the National Institutes of Health in Bethesda, Md. August 15 – 19, 2012 The spasticity management options Gillette offers include the following: therapy She finished a fellowship in pediatric neurosurgery at the (physical, occupational and/or speech); bracing and splinting; oral or injected University of Texas Southwestern Children's Medical Center Doubletree by Hilton in Bloomington, Minn.
Back Issues of
medications like botulinum toxin A; and surgical procedures such as implanting in Dallas. She has extensive publications, including profes- A Pediatric Perspective
To register, visit: http://dravet.org/news-events/conference sional journal articles, book chapters and abstracts. She is an intrathecal baclofen pump or performing a selective dorsal rhizotomy. a member of the Congress of Neurological Surgeons and pediatricperspective American Association of Neurological Surgeons.

Source: https://www.gillettechildrens.org/uploads/general/Newsletter_PDFs/Vol21No2.pdf