Serebral Palsi Hastalarındaki Alt Ekstremite Patolojilerine Ortopedik Yaklaşım
Özet
Serebral palsi (SP), gelişmekte olan merkezi sinir sisteminin hasarı sonucu ortaya çıkan, ilerleyici olmayan motor bozukluk sendromudur ve bu duruma sıklıkla spastisite, eklem kontraktürleri ile sekonder kas-iskelet sistemi patolojileri eşlik etmektedir. Alt ekstremite tutulumlarında ambulasyon kapasitesini ve kaba motor fonksiyonlarını tanımlamak için GMFCS-ER sınıflandırma sistemi kullanılır ve tedaviler bu seviyeye göre planlanır. Yürüyebilen SP hastalarında en sık cerrahi gerektiren deformite ekinus olup, hastanın durumuna göre botulinum toksin enjeksiyonları, ortezler veya aşil z-plasti gibi cerrahi prosedürler uygulanmaktadır. Ayrıca tibialis anterior ve posterior spastisitesine bağlı ekinovarus, gastroksoleus ve peroneus brevis spastisitesine bağlı ekinovalgus deformiteleri ile anormal popliteal açıya yol açan hamstring gerginliği sıkça görülmekte; bu patolojiler yumuşak doku uzatmaları, tendon transferleri veya kemik prosedürleri ile tedavi edilmektedir. Diplejik ve kuadriplejik hastalarda kalça fleksiyon kontraktürleri ve makaslama yürüyüşüne yol açan addüktör spastisitesi yaygındır. SP hastalarında kalça displazisi insidansı yaklaşık %30 olup, kas dengesizliği nedeniyle zamanla posterosuperior subluksasyon ve çıkık gelişebilir; teşhiste Reimer'in indeksi kullanılır ve dejenerasyon başlamadan önce femoral veya pelvik osteotomiler planlanmalıdır. Düşük kemik mineral yoğunluğu, yetersiz beslenme ve antikonvülzan kullanımı gibi faktörler nedeniyle orta-ağır SP hastalarında özellikle diz çevresi ve femurda düşük enerjili kırıklar ciddi bir problem oluşturur ve tedaviler hastanın ambulasyon durumuna göre bireyselleştirilmelidir. Sonuç olarak, tek bir eklemdeki patoloji diğerlerini de etkileyebileceğinden, alt ekstremite yönetimi detaylı bir fizik muayene ile hastaya özgü ve multidisipliner şekilde planlanmalıdır.
Cerebral palsy (CP) is a non-progressive motor disorder syndrome resulting from damage to the developing central nervous system, frequently accompanied by spasticity, joint contractures, and secondary musculoskeletal pathologies. The GMFCS-ER classification system is utilized to define ambulation capacity and gross motor functions in lower extremity involvement, and treatments are planned according to this level. Equinus is the most common deformity requiring surgery in ambulatory CP patients, managed with botulinum toxin injections, orthoses, or surgical procedures like achilles z-plasty depending on the patient's status. Additionally, equinovarus due to tibialis anterior and posterior spasticity, equinovalgus due to gastrosoleus and peroneus brevis spasticity, and hamstring tightness causing an abnormal popliteal angle are frequently observed, treated with soft tissue lengthenings, tendon transfers, or bony procedures. Hip flexion contractures and adductor spasticity leading to scissoring gait are common in diplegic and quadriplegic patients. The incidence of hip dysplasia in CP patients is approximately 30%, where muscle imbalance can lead to posterosuperior subluxation and dislocation over time; Reimer's index is used for diagnosis, and femoral or pelvic osteotomies should be planned before degeneration occurs. Due to factors such as low bone mineral density, malnutrition, and anticonvulsant use, low-energy fractures, particularly around the knee joint and femur, pose a serious problem in moderate-to-severe CP patients, and treatments must be individualized based on the patient's ambulatory status. Consequently, since a pathology in a single joint can exacerbate symptoms in others, lower extremity management must be tailored to the patient and planned multidisciplinarily through a detailed physical examination.
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