Factors associated with surgical approach and outcomes in cerebral palsy scoliosis
Neuromuscular scoliosis is often treated with posterior spinal fusion, with or without anterior release, and either a same-day or staged, 2-day procedure.
We retrospectively reviewed 222 patients from a prospectively collected, multi-center database of patients with cerebral palsy scoliosis with 2-year follow-up. Baseline characteristics, perioperative, radiographic, and HRQoL measures were compared in six sub-analyses: (1) staged versus same-day surgeries, (2) posterior-only fusion (PSF) versus anterior–posterior spinal fusion (APSF), (3) same-day versus staged PSF, (4) staged versus same-day APSF, (5) same-day PSF versus same-day APSF, (6) staged PSF versus staged APSF.
Staged patients had larger curves and more pelvic obliquity, longer anesthesia and surgical times, longer hospital and ICU stays (p < 0.001), and more days intubated (p = 0.021). The staged PSF group had larger curves (p = 0.006), longer anesthesia (p = 0.020) and surgeries (p = 0.007), hospital (p = 0.009) and ICU stays (p = 0.028) compared to same-day PSF. The staged APSF group had longer hospital (p < 0.001) and ICU stays (p = 0.004) and anesthesia and surgeries (p < 0.001). Same-day APSF was associated with larger curves (p < 0.002), longer anesthesia (p = 0.012) and surgeries (p = 0.042), greater residual curves (p = 0.035), and greater absolute correction (p = 0.007) compared to same-day PSF. The staged APSF group had longer anesthesia times (p < 0.001) compared to the staged PSF group. No sub-analysis revealed significant differences in baseline characteristics, complications, or HRQoL.
Staged and circumferential approaches tend to be used for greater deformity, but were not associated with superior deformity correction, and were associated with longer operative time, hospital stays, ICU stays, and days intubated. However, for the most severe deformity, other patient factors may play more important roles in treatment decisions given that patients treated with a staged PSF or an APSF, whether staged or not, were similar at baseline.
Level of evidence
KeywordsCerebral palsy Neuromuscular scoliosis Posterior spinal fusion Anterior spinal fusion Staged fusion
Research grants from DePuy Synthes Spine and from K2M to Setting Scoliosis Straight Foundation for Harms Study Group research efforts were received in support of this work.
Compliance with ethical standards
Conflict of interest
Disclosures relevant to submitted: Grant from the Setting Scoliosis Foundation, with research grants from DePuy Synthes Spine and K2M in support of Harms Study Group research. Disclosures outside of submitted: Consultancy/Personal fee—DePuy Synthes Spine, DePuy Synthes Canada, Cubist, K2M, Ellipse Technologies Inc., NuVasive, Medtronic Inc., Orthopediatrics, Stryker, Globus Medical; Royalties—DePuy Synthes Spine, Thieme Publishing, K2M; Investments/Options—Electrocore; Board membership—Setting Scoliosis Straight Foundation, Rady Children’s Specialists, AAOS, Scoliosis Research Society, International Pediatric Orthopedic Think Tank, Cubist, POSNA; Editorial Boards—JBJS-American, Spine Deformity; Other Financial/Research/Institutional Support—DePuy Synthes Spine, EOS Imaging, NuVasive, Orthopediatrics, K2M, Alphatech, Medtronic Inc. Patents/Product Development—DePuy Synthes Spine, Inc., K2M.
- 5.Tsirikos AI, Chang W-N, Dabney K, Miller F (2003) Comparison of one-stage versus two-stage anteroposterior spinal fusion in pediatric patients with cerebral palsy and neuromuscular scoliosis. Spine 28:1300–1305Google Scholar
- 10.Gum JL, Lenke LG, Bumpass D, Zhao J, Sugrue P, Karikari I, Rahman R, Carreon LY (2016) Does planned staging for posterior-only vertebral column resections in spinal deformity surgery increase perioperative complications? Spine Deform 4:131–137. https://doi.org/10.1016/j.jspd.2015.08.005 CrossRefGoogle Scholar
- 12.Reames DL, Smith JS, Fu K-MG, Polly DW Jr, Ames CP, Berven SH, Perra JH, Glassman SD, McCarthy RE, Knapp RD Jr (2011) Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society Morbidity and Mortality database. Spine 36:1484–1491CrossRefGoogle Scholar
- 13.Keeler KA, Lenke LG, Good CR, Bridwell KH, Sides B, Luhmann SJ (2010) Spinal fusion for spastic neuromuscular scoliosis: is anterior releasing necessary when intraoperative halo-femoral traction is used? Spine (Phila Pa 1976) 35:E427–E433. https://doi.org/10.1097/BRS.0b013e3181d9527e CrossRefGoogle Scholar
- 15.Modi HN, Hong JY, Mehta SS, Srinivasalu S, Suh SW, Yi JW, Yang JH, Song HR (2009) Surgical correction and fusion using posterior-only pedicle screw construct for neuropathic scoliosis in patients with cerebral palsy: a three-year follow-up study. Spine (Phila Pa 1976) 34:1167–1175. https://doi.org/10.1097/BRS.0b013e31819c38b7 CrossRefGoogle Scholar
- 18.Shi Z, Chen J, Wang C, Li M, Li Q, Zhang Y, Li C, Qiao Y, Kaijin G, Xiangyang C, Ran B (2015) Comparison of thoracoscopic anterior release combined with posterior spinal fusion versus posterior-only approach with an all-pedicle screw construct in the treatment of rigid thoracic adolescent idiopathic scoliosis. J Spinal Disord Tech 28:E454–E459. https://doi.org/10.1097/BSD.0b013e3182a2658a CrossRefGoogle Scholar
- 20.Lonstein JE, Koop SE, Novachek TF, Perra JH (2012) Results and complications after spinal fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy using luque galveston instrumentation: experience in 93 patients. Spine (Phila Pa 1976) 37:583–591. https://doi.org/10.1097/BRS.0b013e318225ebd5 CrossRefGoogle Scholar
- 21.Takeshita K, Lenke LG, Bridwell KH, Kim YJ, Sides B, Hensley M (2006) Analysis of patients with nonambulatory neuromuscular scoliosis surgically treated to the pelvis with intraoperative halo-femoral traction. Spine (Phila Pa 1976) 31:2381–2385. https://doi.org/10.1097/01.brs.0000238964.73390.b6 CrossRefGoogle Scholar