Single Event Multilevel Surgery (SEMLS)

Original Editor - Lauren Heydenrych

Top Contributors - Lauren Heydenrych  

Introduction

Single-event multilevel surgery (SEMLS) is a single complex surgical procedure whereby "...correction of all musculoskeletal deformities producing gait abnormalities..." (pg. 1) are addressed. This has replaced older, single-level surgery. A combination of muscle-tendon lengthening, tendon transfers, rotational osteotomies, and joint stabilizations are performed within the procedure. Thus addressing multiple anatomical levels from which gait abnormalities stem. The procedure itself is based on a detailed biomechanical assessment.

Aim of SEMLS

The aim of a SEMLS procedure is to produce functional changes in body structures and function which will create positive changes to the levels of activity, in particular gait, ultimately improving participation.In addition, the ability to perform multiple procedures in a single surgery aims to decrease the rehabilitation period to a single period.

In most studies home, school and community ambulation are assessed. Here parameters such as structural gait analysis, ambulation with or without assistive devices, and long term quality of life are assessed.

History and Development of SEMLS

SEMLS was first described in 1985 by Norlin and Tkaczuk as well as Browne and McManus in 1987.

Initially, follow-up research done by Norlin and Tkaczuk (1992) reported improved gait patterns using video gait analysis. Further studies, performed more recently (between 2013 and 2020), have also found favorable outcomes. These however, have been limited to between 1 and two years post operative follow-up.

In a systematic review performed by McGinley et al. (2011) covering research papers on SEMLS (or similarly described surgical interventions) it was found that the level of research was of poor quality up until 1999. It was in 1999 that Thomas et al. produced a study that included outcome measures of both the GMFCS and gait parameters. In the years following, other studies stood out which included outcomes linking to the ICF model.

Advantages

The advantages in combining multiple procedures into one mean that hospital stay and rehabilitation time is decreased. There is also the possible decrease in complications.

Increase in passive range of movement (PROM), selected gait parameters and overall gait index as well as energy efficiency have been generally reported.

Disadvantages

Complications have generally not been reported to date. Which highlights the need for studies which include this.

To date, no large scale improvement in the GMFCS scores have been noted. This does not necessarily mean there are none, but this aspect has not been reported on.

Considerations

• There is always the possibility of relapses and new biomechanical problems necessitating further surgical intervention.
• The success of the procedure requires intensive post-operative rehabilitation.

• Post operative level of function initially decreases, observed with follow-up 3 and 12 months. Subsequent stabilization of function and then improvement is generally noted 2 years post-operatively
• The older the child, the better the long term benefits appeared to be. These benefits were based on gait kinematics.

Candidates

SEMLS is usually performed on children diagnosed with Cerebral Palsy, with a Gross Motor Function Classification System (GMFCS) of I, II or III. The procedure itself is most commonly performed on candidates with GMFCS level III.

Physiotherapy post SEMLS

Details of rehabilitation are generally poorly reported. In addition, procedures and subsequent rehabilitation protocols tend to vary widely.

The general aim of postoperative rehabilitation tends to focus on:

• Range of motion (ROM)
• Balance
• Strength
• Function (unspecified in literature)

It must be noted that in a systematic review of SEMLS intervention, the predominating aspect in postoperative rehabilitation is dealing with pain in the weeks following surgery.

Initiation and duration of therapy

Again, the initiation of therapy and duration vary. In a retrospective study performed in 2011, mobilisation of patients began 7-10 days after surgery and continued as intensive rehabilitation for some weeks after. In another study performed on a cohort group, an intensive rehabilitative program was initiated 6 weeks after therapy and continued for 12 weeks, or 4 to 6 if treated as in-patients.