Single Event Multi Level Surgery for Cerebral Palsy is a concept for doing all needed surgeries for a dip Levi’s case of CP at the age of seven to eight years at one or two sittings.

1. ABC
SEMLS
Single Event Multi Level Surgery
Dr Umesh Prasad Choudhary Suman
MBBS MS DNB(Ortho)

2. SEMLS
CNS development & Gait development
matures
around 7-8 years of age

3. SEMLS
Many ortho surgeons believe that
delaying the surgery until 7-8 years of age
and doing all necessary operations in one or two sittings is the right approach
(earlier surgery might be needed if hips threatens to dislocate)
as against each happy birth day surgery approach
Birth Day Syndrome
all or none
surgery
little or often
surgery

4. SEMLS
Done
-at 7-8 years of age)
-for Diplegia
-affecting hips, knees and ankles
- at one or two go
Diplegia = lower limbs affected more than upper limbs ( CP)
Paraplegia= only lower limbs affected (spinal lesions TB,Tumours,Trauma)
Hemiplegia = one side upper and lower limb affected (CVA)
Monoplegia = one limb affected (Peripheral Nerve Injury)

5. CP
Spastic = hypertonicity of muscle with weakness = Cerebrum
Dyskinetic = abnormal movements tremors, athetosis = Basal Ganglia
Ataxic = incoordination, imbalance, impaired gait = Cerebellum
Gross Motor Function Classification System:
GMFCS I-III = ambulatory
GMFCS IV-V = non-ambulatory (whole body involvement)

6. CP
No deformity at birth
Non-progressive injury to brain in early development that leads to
motor impairment that can impact on function
Positive signs: spasticity, clonus, increased reflexes
Negative signs: weakness, incordination
Diagnosis of CP
• Clinical
• Radiological
• 3D gait analysis
A child unable to walk by 8 years of age is unlikely to walk

7. SEMLS

8. Monoarticular muscle like iliacus, adductors, quadriceps, soleus
are anti gravity muscles: do not cut them rather do sliding operation,
Polyarticular muscles like psoas, gracillis, gastrocnemeus
are propellant muscles , they can be cut
PRINCIPLES OF SEMLS
Hip adduction deformity : if abduction is limited to less than 20 degree then do surgery
obturator neurectomy: 50% of anterior branch of obturator nerve is cut

9. PRINCIPLES OF SEMLS
Surgery for muscle spasm: muscle/tendon lengthening is also a muscle weakening operation
Surgery for bone/ joint deformity correction : to make muscles more effective
Tendon transfer:
-transferred one is weaker, so do only if power transferred muscle is IV orV
-it might cause over-correction due to spasticity
-use gravity in your aid
-surgery for joint dislocation
continued

10. PRINCIPLES OF SEMLS
continued
Equinius with hip flexion deformity > 20 degree and knee flexion deformity >
30 degree :
- do psoas lenghthening
- Then do medial hamstring lengthening sos biceps femoris lengthening
- Equinus correction by itself will increase hip flexion and knee flexion
deformity
Some cases:
Hip flexion deformity more than 20 degree :
- in non-ambulatory child, do tenotomy of psoas at lesser trochanter
- in walking child , do intra-muscular tendon lengthening of psoas tendon at pelvic brim
Gastrocnemeus and hamstrings do
knee extension in stance phase

11. PRINCIPLES OF SEMLS
continued
Tendon transfer: tibialis anterior done after 4 years of age i.e. after appearance of centres of
ossification of cuboid and navicular
- in CTEV, complete tibialis anterior tendon is transferred to cuboid
- in CP, lateral half of tibialis anterior is transferred to cuboid

12. SEMLS
Single Event Multi Level Surgery
at 7 – 8 years of age

13. MY IMMENSE GRATITUDE TO MY TEACHER
DR S S JHA SIR
FOR GIVING ME OPPORTUNITY TO STUDY & LEARN