Abstract
The higher the functional impairment, the more likely patients with cerebral palsy (cP) are to develop a scoliotic deformity. This is usually long-sweeping, C-shaped, and progressive in nature, since the causes of the deformity, such as muscular weakness, imbalance, and osteoporosis, persist through adulthood. In contrast to idiopathic scoliosis, not only is the spine deformed, the patient is also sick. This multimorbidity warrants a multidisciplinary approach with close involvement of the caregivers from the beginning. Brace treatment is usually ineffective or intolerable in light of the mostly stiff and severe deformities and the poor nutritional status. The pros and cons of surgical correction need to weighed up when pelvic obliquity, subsequent loss of sitting balance, pressure sores, and pain due to impingement of the rib cage on the ileum become issues. General risks of, for example, pulmonary or urogenital infections, pulmonary failure, the need for a tracheostoma, permanent home ventilation, and death add to the particular surgery-related hazards, such as excessive bleeding, surgical site infections, pseudarthrosis, implant failure, and dural tears with leakage of cerebrospinal fluid. The overall complication rate averages around 25 %. From an orthopedic perspective, stiffness, marked deformities including sagittal profile disturbances and pelvic obliquity, as well as osteoporosis are the main challenges. In nonambulatory patients, long fusions from T2/T3 with forces distributed over all segments, low-profile anchors in areas of poor soft tissue coverage (sublaminar bands, wires), and strong lumbosacropelvic modern screw fixation in combination with meticulous fusion techniques (facetectomies, laminar decortication, use of local autologous bone) and hemostasis can be employed to keep the rate of surgical and implant-related complications at an acceptably low level. Excessive posterior release techniques, osteotomies, or even vertebrectomies in cases of very severe short-angled deformity mostly prevent anterior one- or two-stage releases. Despite improved operative techniques and implants with predictable and satisfactory deformity corrections, the comorbidities and quality-of-life related issues demand a thorough preoperative, multidisciplinary decision-making process that takes ethical and economic aspects into consideration.
Similar content being viewed by others
References
Reames DL, Smith JS, Fu KM et al (2011) Complications in the surgical treatment of 19,360 cases of paediatric scoliosis: a review of the Scoliosis Research Society Morbidity and Mortality Database. Spine (Phila Pa 1976) 36:1484–1491
Lonstein JE, Koop SE, Novachek TF, et al (2012) Results and complications following spinal fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy using Luque–Galveston instrumentation: experience in 93 patients. Spine (Phila Pa 1976) 37(7):583–591
Piazzolla A, Solarino G, De Giorgi S et al (2011) Cotrel–Dubousset instrumentation in neuromuscular scoliosis. Eur Spine J 20(Suppl 1):S75–S84
White AA 3rd, Panjabi MM (1976) The clinical biomechanics of scoliosis. Clin Orthop Relat Res 118:100–112
Watanabe K, Lenke LG, Daubs MD et al (2009) Is spine deformity surgery in patients with spastic cerebral palsy truly beneficial? A patient/parent evaluation. Spine (Phila Pa 1976) 34:2222–2232
Bemer P, Corvec S, Tariel S et al (2008) Significance of Propioni bacterium acnes-positive samples in spinal instrumentation. Spine (Phila Pa 1976) 33:E971–E976
Hahn F, Zbinden R, Min K (2005) Late implant infections caused by Propioni bacterium acnes in scoliosis surgery. Eur Spine J 14:783–788
Jhaveri SN, Zeller R, Miller S et al (2009) The effect of intra-operative skeletal (skull femoral) traction on apical vertebral rotation. Eur Spine J 18:352–356
Sponseller PD, Zimmerman RM, Ko PS et al (2010) Low profile pelvic fixation with the sacral alar iliac technique in the paediatric population improves results at two-year minimum follow-up. Spine (Phila Pa 1976) 35:1887–1892
Sponseller PD, Jain A, Lenke LG, et al (2012) Vertebral column resection in children with neuromuscular spine deformity. Spine (Phila Pa 1976) 37(11):E655–E661
Wang X, Aubin CE, Crandall D et al (2011) Biomechanical comparison of force levels in spinal instrumentation using monoaxial versus multi degree of freedom postloading pedicle screws. Spine (Phila Pa 1976) 36:E95–E104
La Rosa G, Giglio G, Oggiano L (2011) Surgical treatment of neurological scoliosis using hybrid construct (lumbar transpedicular screws plus thoracic sub-laminar acrylic loops). Eur Spine J 20(Suppl 1):S90–S94
Ko PS, Jameson PG 2nd, Chang TL et al (2011) Transverse-plane pelvic asymmetry in patients with cerebral palsy and scoliosis. J Pediatr Orthop 31:277–283
Phillips JH, Gutheil JP, Knapp DR Jr (2007) Iliac screw fixation in neuromuscular scoliosis. Spine (Phila Pa 1976) 32:1566–1570
Chechik O, Fishkin M, Wientroub S et al (2011) A new pelvic rod system for the surgical correction and fixation of pelvic obliquity in paediatric neuromuscular scoliosis. J Child Orthop 5:41–48
Modi HN, Hong JY, Mehta SS et al (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
Master DL, Connie PK, Jochen SH et al (2011) Wound infections after surgery for neuromuscular scoliosis: risk factors and treatment outcomes. Spine (Phila Pa 1976) 36:E179–E185
Jones-Quaidoo SM, Yang S, Arlet V (2010) Surgical management of spinal deformities in cerebral palsy. A review. J Neurosurg Spine 13:672–685
Acknowledgments
I have not received funds for this study.
Author information
Authors and Affiliations
Corresponding author
About this article
Cite this article
Hasler, C.C. Operative treatment for spinal deformities in cerebral palsy. J Child Orthop 7, 419–423 (2013). https://doi.org/10.1007/s11832-013-0517-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11832-013-0517-4