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To PERCS or Not to PERCS

Posted Oct 04 2009 11:14pm
So many doctors, therapists, parents...so many opinions.   As a parent of a special needs child, you are never too comfortable with the decisions you have made regarding therapies, procedures and surgeries.  You research it ALL, you talk to EVERYONE and you pick and chose...somtimes based soly on your gut feelings.  Well, my gut is changing.  

I HAD decided that they would be NO SURGERIES for at least 2 years and I HAD felt great about that decision.  However, I am very close to deciding the the PERCS procedure (please read more about it below) is just what Grace needs to get her mobile.  I have now seen 4 children, before and after PERCS, and am amazed by the progress.  We will be going to Galveston to see Dr. Yngve very soon and we will do what he says....I think.  Please pray that we will make the right decision.   I'm praying like crazy!

Comment from Dr. Yngve:
I first heard about the Percs (SPML) procedure from a Physical Therapist in the fall of 2005. She had heard about great results with this procedure at a Physical Therapy meeting. I had never heard of the procedure and she urged me to look into it. I found Dr. Nuzzo’s web site (www.pediatric-orthopedics.com) and learned a lot there but still had more questions. In April 2006 I visited Dr. Nuzzo in New Jersey for 2 days started on the process of learning the procedure. I have now done over 100 cases and have been pleased with the results. This procedure does a lot more than Botox, and doesn’t have the long recovery period of surgery with full length incisions.

PERCS (SPML) F.A.Q.
What does Percs (SPML) refer to?
Percs (SPLM) refers to an outpatient surgery usually under a general anesthetic for the treatment of the spasticity and tight tendons that are found in children with cerebral palsy. The name Percs comes from the surgical term “percutaneous” which means using very small skin incisions. The Percs (SPML) method has been developed over the last 20 years by Roy Nuzzo M.D. of Summit NJ. SPML stands for Selective Percutaneous Myofascial Lengthening. I use the term SPML to refer to the specific techniques taught by Dr. Nuzzo.

What is exactly done with the Percs (SPML) procedure?
The Percs (SPML) procedure involves releasing tight bands of tendon. This is done where muscle and tendon overlap. These areas of overlap are areas where a tendon starts to blend into a muscle. The tendon spreads out and is thinner at this location and is called Myofascia. When the myofascia is cut, the muscle under it can easily stretch and lengthen.

What part of the body can be treated with Percs (SPML)?
Some children have tightness and spasticity in many locations in the legs, with the Percs (SPML) procedure, many areas can be addressed during the same procedure.
Common areas for Perc (SPML) surgery are:
n at the back of the ankle for calf / heel cord tightness and spasticity
n behind the knee for hamstring tightness and spasticity
n in the groin area for scissoring gait and groin spasticity

What age can be treated with Percs (SPML)?
Percs (SPML) works well for children of all ages and for adults. Because Percs (SPML) procedure uses micro incisions only about 2 mm long, there is very little scar that forms as a result of the procedure. This is a good feature since scar is known to be associated with recurrent contracture. This allows Percs (SPML) procedure to work well for all ages, including groups that have a reputation for recurrent contracture following conventional tendon lengthening surgery such as very young children and adolescents.

What are the long term results of the Percs (SPML) procedure?
The best data comes from Dr. Nuzzo’s web site where he reports a 5 year review of 278 cases. “Post op admissions were 0.01% (4 cases, single night). Repeat procedures at any location were 10%. Recurrence of operative site contracture occurred in 7%. There were no cases of infection, over lengthening, significant hematoma. All surgeries were performed supine. None required surgical room time in excess of 60 minutes. Parent satisfaction was positive in 100% with similar follow up survey results one year later.” My results have been similar.

Can the Percs (SPML) procedure decrease spasticity?
Yes. Walking on a contracted joint puts a strong pull on the muscle- tendon unit with each step. This stimulates spasticity. Lengthening the muscle- tendon unit decreases the spasticity in that area. The beauty of Percs (SPML) is that since it is practical with the minimal incisions to lengthen muscle- tendon units in many locations in the lower extremities, spasticity can be decreased in many locations.

What is an alcohol nerve block?
The alcohol nerve block is a common procedure that is done at the same time as Percs (SPML) in children who have overactivity of the obturator nerves, which are nerves in the groin that contribute to stiffness of the hips or scissoring gait, in which the legs cross in front of each other in walking. The alcohol nerve block takes the nerve from an overactive spasticity related state to a more normal active state. It does this by dissolving the fatty coating, called the myelin sheath which is wrapped around the nerve. The nerve itself remains intact. The myelin sheath can grow back in about 3 years. The alcohol block is often used to decrease spasticity in the legs when it is associated with groin tightness.

How is the ankle area treated after the Percs (SPLM) procedure?
There will be a cast from below the knee to the ball of the foot. Walking is encouraged. It is best to put a shoe directly over the cast. One type of shoe that may accommodate better to the width is the Vans brand, because of the construction on the tongue and laces.

How is the knee area treated after the Percs (SPML) procedure?
We will put on a knee splint made of cloth and foam with Velcro straps after the procedure. You can take this off for daytime activities. It should be worn every night for a month to prevent sleeping in a curled up position.

How is the groin area treated after the Percs procedure?
Nothing special is needed.

What exercises are recommended after the Percs (SPML) procedure?
Long sitting. This is sitting on the floor with the knees out in front as straight as possible. This helps to keep the backs of the knees stretched out.
Giant steps. Encourage the child to take as big steps as possible. Try counting the number of steps it takes to walk across the room. Then try to walk across the room using giant steps. You should count fewer steps.
Walking on uneven ground. This teaches the ability to deal with the unexpected. It also teaches fast reactions. It helps in learning new ways to use the legs.

How soon can children resume PT following Percs (SPML)?
Children who have the Percs (SPML) procedure are allowed to walk when comfortable, usually the next day. If not walking by the third day, it is time to start! It usually takes 1-2 months to regain the before surgery level of activity, then expect monthly improvement up to 4-5 months from surgery. Physical Therapy can be very beneficial and can be resumed within the week following the procedure.

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