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Pelvic fixation is not always necessary in children with cerebral palsy scoliosis treated with growth-friendly instrumentation

Abstract

Purpose

A previous study showed that patients with neuromuscular scoliosis who underwent fusion to L5 had excellent coronal curve correction and improvement in pelvic obliquity (PO) when preoperative L5 tilt was < 15°. Our purpose was to identify indications to exclude the pelvis in children with cerebral palsy (CP) scoliosis treated with growing-friendly instrumentation.

Methods

In a retrospective cohort study, children with CP scoliosis treated with TGR, MCGR, or VEPTR with minimum 2-year follow-up were identified from a multicenter database.

Results

27 patients with distal spine anchors (DSA) and 71 patients with distal pelvic anchors (DPA) placed at the index surgery were analyzed. The DSA group had a lower pre-index PO (9° vs 16°, P = 0.0001). Most recent radiographic data were similar except the DSA patients had a smaller major curve (47° vs 58°, P = 0.038). 6 (22%) DSA patients underwent extension of the instrumentation to the pelvis (DSA-EXT), most commonly at final fusion (5 patients). DSA-EXT patients had a higher pre-index L5 tilt than patients who did not require extension (DSA-NO EXT) (19° vs 10°, P = 0.009). Sub-analysis showed a lower major curve at most recent follow-up in the DSA-EXT group compared to the DPA group (33° vs 58°, P = 0.021). The DSA-EXT group had a higher number of complications per patient compared to the DSA-NO EXT group (2.3 vs 1.1, P = 0.029).

Conclusion

Pre-index L5 tilt ≤ 10° and PO < 10° may be indications to exclude the pelvis in children with CP scoliosis treated with growth-friendly instrumentation. DSA may provide better long-term control of the major curve than DPA.

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Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code availability

The software application and code used for the statistical analysis are available from the corresponding author on reasonable request.

References

  1. Ramo BA, Roberts DW, Tuason D et al (2014) Surgical site infections after posterior spinal fusion for neuromuscular scoliosis: a thirty-year experience at a single institution. J Bone Jt Surg Am 96(24):2038–2048. https://doi.org/10.2106/JBJS.N.00277

    Article  Google Scholar 

  2. Myung KS, Lee C, Skaggs DL (2015) Early pelvic fixation failure in neuromuscular scoliosis. J Pediatr Orthop 35(3):258–265. https://doi.org/10.1097/BPO.0000000000000254

    Article  PubMed  Google Scholar 

  3. Sponseller PD, Zimmerman RM, Ko PS et al (2010) Low profile pelvic fixation with the sacral alar iliac technique in the pediatric population improves results at two-year minimum follow-up. Spine (Phila Pa 1976) 35(20):1887–1892. https://doi.org/10.1097/BRS.0b013e3181e03881

    Article  Google Scholar 

  4. Shabtai L, Andras LM, Portman M et al (2017) Sacral Alar Iliac (SAI) screws fail 75% less frequently than iliac screws in neuromuscular scoliosis. J Pediatr Orthop 37(8):e470–e475. https://doi.org/10.1097/BPO.0000000000000720

    Article  PubMed  Google Scholar 

  5. Brooks JT, Jain A, Sanchez-Perez-Grueso F et al (2016) Outcomes of pelvic fixation in growing rod constructs: an analysis of patients with a minimum of 4 years of follow-up. Spine Deform 4(3):211–216. https://doi.org/10.1016/j.jspd.2015.11.004

    Article  PubMed  Google Scholar 

  6. Chang TL, Sponseller PD, Kebaish KM, Fishman EK (2009) Low profile pelvic fixation: anatomic parameters for sacral alar-iliac fixation versus traditional iliac fixation. Spine (Phila Pa 1976) 34(5):436–440. https://doi.org/10.1097/BRS.0b013e318194128c

    Article  Google Scholar 

  7. Keorochana G, Arirachakaran A, Setrkraising K, Kongtharvonskul J (2019) Comparison of complications and revisions after sacral 2 Alar Iliac screw and iliac screw fixation for sacropelvic fixation in pediatric and adult populations: systematic review and meta-analysis. World Neurosurg 132:408 e1-420 e1. https://doi.org/10.1016/j.wneu.2019.08.104

    Article  Google Scholar 

  8. McCall RE, Hayes B (2005) Long-term outcome in neuromuscular scoliosis fused only to lumbar 5. Spine (Phila Pa 1976) 30(18):2056–2060. https://doi.org/10.1097/01.brs.0000178817.34368.16

    Article  Google Scholar 

  9. Sponseller PD, Yang JS, Thompson GH et al (2009) Pelvic fixation of growing rods: comparison of constructs. Spine (Phila Pa 1976) 34(16):1706–1710. https://doi.org/10.1097/BRS.0b013e3181ab240e

    Article  Google Scholar 

  10. Takaso M, Nakazawa T, Imura T, Fukuda M, Takahashi K, Ohtori S (2018) Segmental pedicle screw instrumentation and fusion only to L5 in the surgical treatment of flaccid neuromuscular scoliosis. Spine (Phila Pa 1976) 43(5):331–338. https://doi.org/10.1097/BRS.0000000000000996

    Article  Google Scholar 

  11. Whitaker C, Burton DC, Asher M (2000) Treatment of selected neuromuscular patients with posterior instrumentation and arthrodesis ending with lumbar pedicle screw anchorage. Spine (Phila Pa 1976) 25(18):2312–2318. https://doi.org/10.1097/00007632-200009150-00008

    CAS  Article  Google Scholar 

  12. Tondevold N, Lastikka M, Andersen T, Gehrchen M, Helenius I (2020) Should instrumented spinal fusion in nonambulatory children with neuromuscular scoliosis be extended to L5 or the pelvis? Bone Jt J. 102(2-B):261–267. https://doi.org/10.1302/0301-620X.102B2.BJJ-2019-0772.R2

    Article  Google Scholar 

  13. Matsumoto H, Williams B, Park HY et al (2018) The Final 24-Item Early Onset Scoliosis Questionnaires (EOSQ-24): validity, reliability and responsiveness. J Pediatr Orthop 38(3):144–151. https://doi.org/10.1097/BPO.0000000000000799

    Article  PubMed  PubMed Central  Google Scholar 

  14. Nielsen E, Andras LM, Bellaire LL et al (2019) Don’t you wish you had fused to the pelvis the first time: a comparison of reoperation rate and correction of pelvic obliquity. Spine (Phila Pa 1976) 44(8):E465–E469. https://doi.org/10.1097/BRS.0000000000002888

    Article  Google Scholar 

  15. Li Y, Swallow J, Gagnier J et al (2021) Growth-friendly surgery results in more growth but a higher complication rate and unplanned returns to the operating room compared to single fusion in neuromuscular early-onset scoliosis: a multicenter retrospective cohort study. Spine Deform 9(3):851–858. https://doi.org/10.1007/s43390-020-00270-7

    Article  PubMed  Google Scholar 

  16. Anari JB, Flynn JM, Cahill PJ et al (2020) Unplanned return to OR (UPROR) for children with early onset scoliosis (EOS): a comprehensive evaluation of all diagnoses and instrumentation strategies. Spine Deform 8(2):295–302. https://doi.org/10.1007/s43390-019-00024-0

    Article  PubMed  Google Scholar 

  17. Hell AK, Braunschweig L, Behrend J et al (2019) Health-related quality of life in early-onset-scoliosis patients treated with growth-friendly implants is influenced by etiology, complication rate and ambulatory ability. BMC Musculoskelet Disord 20(1):588. https://doi.org/10.1186/s12891-019-2969-2

    CAS  Article  PubMed  PubMed Central  Google Scholar 

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Funding

The study was funded by departmental resources.

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YL: made substantial contributions to the conception or design of the work; performed acquisition, analysis, and interpretation of data; drafted the work; approved the version to be published; agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JS: performed acquisition of data; revised the work critically for important intellectual content; approved the version to be published; agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JG: performed data analysis; revised the work critically for important intellectual content; approved the version to be published; agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JTS: performed interpretation of data; revised the work critically for important intellectual content; approved the version to be published; agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. RFM: performed interpretation of data; revised the work critically for important intellectual content; approved the version to be published; agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. PDS: performed interpretation of data; revised the work critically for important intellectual content; approved the version to be published; agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. PJC: performed interpretation of data; revised the work critically for important intellectual content; approved the version to be published; agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Pediatric Spine Study Group: Performed acquisition of data; revised the work critically for important intellectual content; approved the version to be published; agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Ying Li.

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Conflict of interest

Dr. Li has received a research grant from the Scoliosis Research Society, personal fees from Medtronic, and non-financial support from Zimmer. Dr. Smith has received royalties from Globus and personal fees from Stryker. Dr. Murphy has received personal fees from Globus Medical. Dr. Sponseller has received personal fees from Journal of Bone and Joint Surgery, Depuy Synthes Spine, Globus, and OrthoPediatrics. Dr. Cahill has received research grants from the Setting Scoliosis Straight Foundation and the Children’s Spine Study Group, and has received personal fees from Biogen and NuVasive. The Pediatric Spine Study Group has received research grants from Depuy Synthes Spine, NuVasive, Zimmer Biomet, OrthoPediatrics, Medtronic, Globus Medical, Stryker, and the Pediatric Spine Foundation. The remaining authors declare that they have no conflicts of interest.

Ethics approval

IRB approval, University of Michigan, HUM 00082789, 1/7/14.

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Informed consent to participate in this study was obtained from the parent or legal guardian of all participants.

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Not applicable.

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Li, Y., Swallow, J., Gagnier, J. et al. Pelvic fixation is not always necessary in children with cerebral palsy scoliosis treated with growth-friendly instrumentation. Spine Deform 10, 925–932 (2022). https://doi.org/10.1007/s43390-022-00474-z

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  • DOI: https://doi.org/10.1007/s43390-022-00474-z

Keywords

  • Cerebral palsy
  • Early-onset scoliosis
  • Pelvic fixation
  • Growing rods
  • VEPTR
  • Pelvic obliquity