Article

Surgical Correction of Spinal Deformity in Patients With Cerebral Palsy Using Pedicle Screw Instrumentation

Authors:
  • ROYAL HOSPITAL FOR SICK CHILDREN, EDINBURGH, UK
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Abstract

: Retrospective review of a prospectively collected single surgeon's series. : To investigate the efficacy of pedicle screw instrumentation in correcting spinal deformity in patients with quadriplegic cerebral palsy. In addition to assess quality-of-life and functional improvement after deformity correction as perceived by the parents of our patients. : All pedicle screw constructs have been commonly used to correct adolescent idiopathic scoliosis. There is limited information on their effectiveness in treating patients with cerebral palsy and neuromuscular scoliosis. : We reviewed the medical records and serial radiographs of 45 consecutive patients with quadriplegia who underwent spinal arthrodesis using pedicle screw/rod instrumentation and a standardized surgical technique. All patients were wheelchair bound with collapsing thoracolumbar scoliosis and pelvic obliquity. Twenty-eight patients had associated sagittal deformities. A telephone survey was performed by an independent investigator to assess parents' perception on surgical outcome. : Thirty-eight patients underwent posterior-only and 7 staged anteroposterior spinal arthrodesis. Mean age at surgery was 13.4 years (range: 9 to 18.3 y) and mean postoperative follow-up was 3.5 years (range: 2.8 to 5 y). Pedicle screw instrumentation extended from T2/T3 to L5 with bilateral pelvic fixation using iliac bolts. Scoliosis was corrected from mean 82.5 to 21.4 degree (74.1%). Pelvic obliquity was corrected from mean 24 to 4 degree (83.3%). In posterior-only procedures, average blood loss was 0.8 blood volumes, intensive care unit stay 3.5 days, and hospital stay 17.6 days. In anteroposterior procedures, average blood loss was 0.9 blood volumes, intensive care unit stay 8.9 days, and hospital stay 27.4 days. Major complications included 1 deep infection and 1 reoperation to remove prominent implants but no deaths, no neurological deficit, and no detected pseudarthrosis. Parents' survey showed 100% satisfaction rate. : Pedicle screw instrumentation can achieve excellent correction of spinal deformity in quadriplegic cerebral palsy with low complication and re-operation rates and high parent satisfaction.

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... Journal et al. 29 of 38 patients who underwent POA and 7 who had staged anteroposterior spinal arthrodesis reported that scoliosis was corrected from mean 82.5° to 21.4° (74.1%) and PO was corrected from mean 24° to 4° (83.3%). Pelvic Obliquity PO correction is achieved by a balanced pelvis and spine in the coronal plane. ...
... El Banna et al. 6 reported that blood loss in POA was 0.2-1 L (0.5 ± 0.222 L) and blood transfusion was up to 1 L (0.391.4 ± 0.212 L). Study results of Tsirikos et al. 29 revealed a significant difference between POA and APA; that is, the average blood loss was 800 ml in POA, whereas it was 900 ml in APA. ...
... Keeler et al. 9 indicated that the POA approach had a decreased rate of postoperative intubation (38% in POA vs. 81% in APA) and shorter length of mechanical ventilation (2 days in POA vs. 6.5 days in APA). Tsirikos et al. 29 reported that there was a significant difference between APA and POA; that is, ICU stay was 3.5 days in POA, whereas it was 8.9 days in APA. ...
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The Posterior Surgical Approach in Treatment of Neuromuscular Scoliosis Patients: A Systematic Review of Literature Mohamed Fawzy Khattab, MD., Amr Adel Eid, MD., Mohamed Ahmed Maziad, MD. Orthopedic Surgery Department, Faculty of Medicine, Ain shams University, Cairo, Egypt. ABSTRACT Background Data: Neuromuscular scoliosis (NS) causes disorders to the spinal cord, which affects the innervation and tone of the musculoskeletal system. NS can affect the quality of life by causing spinal deformity, sitting difficulties, and back pain. Progression of NS after skeletal maturity is common, and the incidence of surgery in NS is high. Whether posterior surgical strategy in the management of NS results in higher correction and fewer complications than other approaches, either anterior alone or combined, is a controversial issue. Study Design: Systematic review of the literature. Purpose: To determine if the management of NS via the posterior approach has better results and fewer complications or not. Methods: This study was conducted using the PubMed and Cochrane databases; it includes patients treated for NS deformity and the type of surgery, degree of correction achieved, and rate of complications were reported. Results: Our systematic review yielded 104 citations with 9 studies meeting the required criteria. Six studies focused on the comparisons of posterior-only approach (POA) and anteroposterior approach (APA) and three studies on POA only regarding postoperative outcomes and complications such as correction angle of scoliosis (Cobb’s angle), pelvic obliquity, lordosis, kyphosis, amount of blood loss, hospital stay and ICU stay, and operative time. Conclusion: Posterior-only approach has the same results in correction of neuromuscular scoliosis deformity as anterior-posterior approach but with fewer complications. However, the anterior-posterior approach has more advantage in correcting severe rigid neuromuscular scoliosis. (2020ESJ215) Keywords: Systematic review, Neuromuscular scoliosis, Anterior-posterior approach, Posterioronly approach, Surgical complication.
... Descriptive information about participants was often missing. Only nine studies used the GMFCS to describe the sample and in these studies over 75% of the sample were classified as GMFCS level IV to V. 4,[17][18][19][20][21][22][23][24] Twelve studies included posterior approaches to surgery only, 33 studies included posterior approaches or combined/staged anterio-posterior approaches, while approach was not reported, or was not defined for participants with CP, in six studies. Length of follow-up varied greatly among the studies and all except for five studies 18,25-28 did not state measurement time points or they were not standardized. ...
... Thirty-two studies measured scoliosis curve correction, 9,18,20,21,23,24,[27][28][29][30][32][33][34][36][37][38][40][41][42][44][45][46][47][48][49][50][51][52][53][54][55][56] with all studies using the Cobb angle. 57 Studies tended to measure whole group curve correction as mean percentage (%) correction or mean change in Cobb angle. ...
... Fourteen studies reported longer-term (typically >2y) postoperative mean % curve correction. 9,23,24,28,33,37,38,[44][45][46][47]49,50,56 The overall mean longer-term postoperative curve correction was found to be 61.4% mean curve correction, with means ranging from 55% to 78%. Mean whole group preoperative Cobb angles ranged from 65°to 82°and mean postoperative angles from 19°to 37°. ...
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Aim: This study aims (1) to evaluate and synthesize the evidence for the postoperative outcomes after scoliosis surgery for children with cerebral palsy (CP), and (2) to identify preoperative risk factors for adverse outcomes after surgery. Method: Medline, EMBASE, CINAHL, and PubMed were searched for relevant literature. Included studies were assessed for risk of bias using the Cochrane Effective Practice and Organisation of Care tool. Quality of evidence for overall function, quality of life (QoL), gross motor function, caregiver outcomes, deformity correction, and postoperative complications were assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation). Results: Fifty-one studies met inclusion criteria, including 35 case series designs. Risk of bias was high across all studies. On average good deformity correction was achieved, the trend appears positive for caregiver and QoL outcomes, but there was minimal to no change for gross motor or overall function. Inconsistent measurement limited synthesis. A mean overall complication rate of 38.1% (95% confidence interval 27.3-53.3) was found. The quality of evidence was very low across all functional outcomes. Interpretation: Limited high-quality evidence exists for outcomes after scoliosis surgery in children with CP, a procedure associated with a moderately high complication rate. The intervention appears indicated for deformity correction, but currently there is insufficient evidence to make recommendations for this surgery as a way to also improve functional outcomes, caregiver outcomes, and quality of life.
... Spinal deformity remains a highly challenging aspect in the management of children with cerebral palsy [1,2]. The incidence of spinal deformity has been reported to be around 25% and tends to increase in severely involved children with less walking ability [1][2][3]. Scoliosis is the most common deformity with an incidence as high as 74% in children with quadriplegic cerebral palsy who are nonambulatory [3]. Characteristically, the curve extends into the pelvis, causing pelvic obliquity and creating coronal and sagittal imbalance [4,5]. ...
... The incidence of spinal deformity has been reported to be around 25% and tends to increase in severely involved children with less walking ability [1][2][3]. Scoliosis is the most common deformity with an incidence as high as 74% in children with quadriplegic cerebral palsy who are nonambulatory [3]. Characteristically, the curve extends into the pelvis, causing pelvic obliquity and creating coronal and sagittal imbalance [4,5]. ...
... The optimal choice for spinopelvic fixation is still controversial [6]. Many methods have been described in adult and pediatric patients [3,[5][6][7][8][9] and improvements have been made to achieve better results with less complications [8]. The techniques of deformity correction depend highly on a patient's functional status and the curve's structural features [5]. ...
Article
Study Design Single institution cohort data were collected prospectively and reviewed retrospectively. Objectives This study aims to compare outcomes among three different instrumentation types: unit rod, iliac screws, and sacral alar iliac (SAI) screws in terms of pelvic obliquity correction in children with cerebral palsy (CP). Summary of Background Data The optimal choice for spinopelvic fixation in CP scoliosis with pelvic obliquity is controversial. Methods Patients with minimum 2 years' follow-up were divided into three groups according to instrumentation type and matched based on preoperative pelvic obliquity and coronal major curve magnitude. Radiographic measurements included horizontal pelvic obliquity angle (PO), spinopelvic angle (SPA), coronal and sagittal Cobb angles, and T1 pelvic angle. Procedures were performed in one pediatric institution between 2004 and 2012. All measurements were performed by a single independent reviewer who was not involved in the procedures. Results Seventy-seven patients (42 unit rod, 14 iliac screw, and 21 SAI screw) were included. Gender and age distribution was similar across all groups (56% males, 44% females, mean age 13.5 years). Mean follow-up was 3.6 years. Comparing pre- and postoperative measurements, there was a significant decrease (p < .05) in PO, SPA, and coronal major cob angle in all groups. No significant loss of correction occurred during follow-up. Postoperatively, TPA improved in all groups. Nonsymptomatic loosening was noted in 59% of unit rods, 57% of iliac screws, and 52% of SAI screws. One prominent iliac screw needed removal. One nonsymptomatic rod fracture, one infected pseudarthrosis, and one rod malposition occurred in unit rod group. Conclusions This study suggests that for correction of pelvic obliquity in cerebral palsy scoliosis, iliac and SAI screws were similar to the unit rod in comparative effectiveness and implant safety profile.
... Patients with cerebral palsy (CP) commonly have progressive spine deformity involving the thoracic and lumbar spine. Neuromuscular scoliosis ranges from 5 % in diplegia to 64-74 % in spastic quadriplegia [1]. Scoliosis contributes to difficulty in sitting, which typically leads to pain from impingement of the pelvis against the ribs. ...
... Scoliosis contributes to difficulty in sitting, which typically leads to pain from impingement of the pelvis against the ribs. This is associated with pulmonary complications and neurological disorders and can lead to a reduction in the patient's functional capacities and increased need for nursing care [1][2][3][4]. Posterior spinal fusion (PSF) surgery is typically indicated as management of scoliosis since orthotic treatment is not successful in limiting or stopping curve progression [1,2]. Thus, progressive scoliosis induced by CP must be addressed by surgical treatment. ...
... This is associated with pulmonary complications and neurological disorders and can lead to a reduction in the patient's functional capacities and increased need for nursing care [1][2][3][4]. Posterior spinal fusion (PSF) surgery is typically indicated as management of scoliosis since orthotic treatment is not successful in limiting or stopping curve progression [1,2]. Thus, progressive scoliosis induced by CP must be addressed by surgical treatment. ...
Article
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Purpose The purpose of this study was to review the postoperative complications after posterior spinal fusion (PSF) in cerebral palsy (CP) scoliosis and identify the predictive preoperative risk factors. Methods All PSFs consecutively performed for CP scoliosis between 2004 and 2013 were reviewed. Preoperative risk score (ORS) and postoperative complications score (POCS) were used as measures of all recorded preoperative risk factors and postoperative complications, respectively. Results The review included 303 children with a mean age of 14.6 ± 3.0 years. Mean hospitalization was 16 days. Dependence on G-tube feeding was associated with higher POCS (P = 0.027). Postoperative fever, seizures, and septicemia were associated with higher ORS (P < 0.01). Specifically, postoperative pancreatitis and deep wound infections were more common in children with G-tube. Conclusion This study suggests that G-tube dependence is a predictive risk factor of complications after PSF in CP scoliosis. Children with G-tube need special perioperative care. No other specific preoperative risk factor predicted postoperative complications.
... The current trend for deformity correction is through a posterior-only spinal fusion with segmental instrumentation [3,5]. Simultaneous pelvic fixation is frequently utilized to address pelvic obliquity, which is often problematic in nonambulatory patients with neuromuscular scoliosis [3,6,7]. ...
... At that time, the most common fixation technique at our institution was the Luque-Galveston technique with all sublaminar wires (52.0%) or hybrid constructs (46.6%), which included a combination of sublaminar wires, hooks, and/or pedicle screws. Pedicle screw instrumentation is currently the most common instrumentation for posterior spinal fusion due to its ability to achieve stronger segmental fixation and the concept of three-column fixation [6,25]. Thus, our findings may differ from long-term outcomes for present-day patients who receive all-pedicle screw instrumentation. ...
Article
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Purpose To describe the incidence of reoperation and factors contributing to surgical revision within a minimum of 10 years after spinal fusion for scoliosis in patients with nonambulatory cerebral palsy (CP). Methods We conducted a retrospective review of consecutive nonambulatory patients with CP who underwent primary spinal fusion at a single specialty care center with a minimum of 10 years from their index surgery (surgery dates 2001–2011). Causes of reoperation were classified as implant failure/pseudoarthrosis, surgical site infection (SSI), proximal junctional kyphosis, prominent/symptomatic implants, and implant removal. Reoperation rates with 95% confidence intervals were calculated for each time interval, and an actuarial survival curve was generated. Results 144 patients met inclusion criteria (mean age = 14.3 ± 2.6 years, 62.5% male); 85.4% had 5 years follow-up data; and 66.0% had 10 years follow-up data. Estimates from the actuarial analysis suggest that 14.9% (95% CI: 10.0–22.0) underwent reoperation by 5 years postsurgery, and 21.7% (95% CI: 15.4–30.1) underwent reoperation by 10 years postsurgery. The most common causes for reoperation were implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. Conclusions To our knowledge, this study is the largest long-term follow-up of nonambulatory patients with CP and neuromuscular scoliosis who underwent spinal fusion. Approximately 22% of these patients required reoperation 10 years after their index surgery, primarily due to implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. Complications and reoperations continued throughout the 10 years period after index surgery, reinforcing the need for long-term follow-up as these patients transition into adulthood. Level of evidence III.
... We have previously investigated the outcomes of pediatric neuromuscular scoliosis surgery and reported a high level of caregiver satisfaction 1) . Although there are many similar reports globally [2][3][4] and the efficacy of surgical treatment has been established, most studies have evaluated the results in a single postoperative survey, and few have assessed the changes in the results over a time period. It will be interesting for surgeons to assess if high level of treatment satisfac-tion is maintained over a period after surgery. ...
... Since the progres-sion of spinal deformity cannot be controlled by brace treatment, spinal fusion has been considered to be the standard treatment [7][8][9] . Although corrective spinal fusion for pediatric neuromuscular scoliosis has a high risk of complications such as postoperative pneumonia 2,[10][11][12][13][14][15][16][17] , massive intraoperative bleeding 10,13,[18][19][20][21][22][23] , and wound infection 2,3,13-18,21-28) , many benefits have been reported including stable sitting position [29][30][31] , improved HRQoL of the child 4,14,15,18,30,[32][33][34] , high caregiver satisfaction [2][3][4]23) , and weight gain 35) . ...
Article
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Introduction: Spinal fusion for children with neuromuscular scoliosis has been known to improve sitting balance and quality of life as well as for high caregiver satisfaction. However, most studies performed were single surveys, and it remains unclear whether high satisfaction levels are maintained. Thus, in this article, we report the short- and medium-term improvements in caregiver standing assessment after neuromuscular scoliosis surgery in children with Gross Motor Function Classification System (GMFCS) level IV or V. Methods: In total, 18 patients with GMFCS levels IV and V were included in this study. The underlying diseases were typical cerebral palsy in 12 cases, chromosomal abnormalities in 5 cases, and congenital myopathy in 1 case. The median age at the time of surgery was 14.5 years. The medians for the first and second follow-up surveys were after 1.4 and 5.9 years, respectively. All the patients had undergone posterior spinal fusion, whereas 12 had undergone pelvic fixation. These patients were assessed using a caregiver questionnaire, in addition to patient demographic data and radiographic assessments. Results: The median BMI was 15.4 kg/m2 preoperatively, 16.6 kg/m2 at the first survey, and 17.1 kg/m2 at the second survey. The main Cobb angles were 97.5°, 36.5°, and 37.0° and the spino-pelvic obliquity angles were 22.5°, 6.0°, and 6.5° preoperatively, at the first survey and at the second survey, respectively. In the questionnaire, most domains were rated similarly in the first and second surveys, but the ratings for the “children's QOL” and “digestion and defecation” domains were noted to increase, while that for the “transfer” and “satisfaction with treatment” domains have decreased. Conclusions: Neuromuscular scoliosis surgery in children has been associated with extremely high treatment satisfaction in the early postoperative period. However, some caregivers showed a decline in the “transfer” and “treatment satisfaction” domains over time.
... Multiple studies have demonstrated acceptable correction of scoliosis deformity in patients with neuromuscular scoliosis using an all-posterior surgical approach, including patients with large and rigid curves. [8][9][10] The addition of an anterior approach, particularly with 3-column pedicle screw fixation, is reserved for patients with very stiff or rigid spinal curves, young patients at risk for crankshaft phenomenon, patients with dysplastic posterior elements, and large spinal curves requiring anterior release or shortening of the anterior column to achieve the deformity correction goals. ...
... [11][12][13][14] However, there is a paucity of literature reporting a comparison of the complication rates, discharge destination, charges, and length of hospital stay for all patients, including adults, with CP undergoing ASF versus PSF versus combined ASF/PSF. In the current CP literature for all age ranges, Tsirikos et al 9 reported increased duration of intensive care unit stays and length of hospitalization for patients with CP undergoing ASF/PSF versus patients undergoing PSF for spinal deformity. However, the study did not report on the outcomes for patients undergoing ASF, which is important given the added aorta-related risk associated with anterior spinal surgical correction of scoliosis. ...
Article
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Background: There is a paucity of literature examining surgical trends and outcomes in both child and adult cerebral palsy (CP) patients. We aimed to evaluate surgical trends, complications, length of stay, and charges for spinal deformity surgery in CP patients. Methods: Using the Nationwide Inpatient Sample (NIS) from 2001 to 2013, patients with CP scoliosis who underwent spinal fusion surgery were identified. Patient characteristics and comorbidities were recorded. Trends in spinal fusion approaches were grouped as anterior (ASF), posterior (PSF), or combined anterior-posterior (ASF/PSF). Complication rates, length of stay, and charges for each approach were analyzed. Bivariate analyses using adjusted Wald tests and multivariate analyses using linear (logarithmic transformation) and logistic regressions were performed. Results: Of the 5191 adult CP patients who underwent spinal fusion the majority underwent PSF (86.5%), followed by the ASF/PSF approach (9.3%). The rate of PSF for cerebral palsy patients with spinal deformity increased significantly per 1 million people in the US population (0.90 to 1.30; P = .048). Complication rate, hospital length of stay, and charges were higher for patients undergoing ASF/PSF (P < .05). The overall complication rate for all surgical approaches was 25.7%. Patient comorbidities and combined ASF/PSF increased the odds of complication. Combined ASF/PSF was also associated with an increased length of stay and charges. Conclusion: Combined ASF/PSF in patients with CP accounted for only 9.3% of surgical cases but was associated with the longest hospital stay, highest charges, and increased complications. Further scrutiny of the surgical indications and preoperative risk stratification should be undertaken to minimize complications, reduce length of stay, and decrease charges for CP patients undergoing spinal fusion. Level of evidence: IV.
... Modular screw-based systems are recommended to decrease morbidity with pelvic screw placement, allow customization, and afford deformity correction. 31 ...
... Tsirikos and Mains demonstrated 72% correction of the major curve with a mean preoperative curve of 76 degrees along with 80% correction of pelvic obliquity from a mean preoperative 22 degrees in a cohort of adolescent CP patients who underwent correction with posterior-only pedicle screw constructs. 31 Pedicle screw-based modular constructs allow for superior Cobb's correction and leveling the pelvic obliquity, but the initial cost of these systems is much greater than the unit rod. However, this is offset in the long term by less implantrelated complications and a lower rate of infection as demonstrated in a multicenter series. ...
Chapter
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Neuromuscular scoliosis is common in children with neuropathic and myopathic disorders, the most common of which is cerebral palsy. The majority of these deformities are progressive, and can interfere with comfort, function (including ambulation, communication, transfers, sitting ability, and postural control), and allowance for daily hygienic and nutritional care. Nonoperative management and observation are reasonable for patients with curves less than 40 degrees, while operative treatment is typically recommended for patients with curves exceeding 50 degrees with concomitant development of symptoms or deterioration in function or 60 degrees with curves lacking flexibility. Curves in patients with remaining growth or flexibility can be observed at biannual intervals and surgery can be delayed until appropriate spinal height has been achieved, or the curve becomes increasingly stiff, preferably before the scoliosis exceeds 90 degrees. Since severe curves before the prepubertal growth spurt present a management dilemma, surgical intervention with growth-friendly spinal implants to control the curves may be an option. A posterior pedicle screw-based construct is the preferred method of instrumentation, as it offers a powerful mechanism of correction in both the coronal and sagittal plane. Extension of instrumentation to the pelvis is typically performed to correct pelvic obliquity and avoid distal progression of deformity. Anterior surgery, associated with increased complications and morbidity, is seldom necessary with modern instrumentation and techniques, but is reserved for large, rigid curves and may be staged when appropriate. The risk of complications in the perioperative and postoperative period is significant, but manageable, and has improved substantially with contemporary care pathways. The most common postoperative complications include infection, implant-related complications, and pulmonary issues. Caregiver satisfaction and long-term outcomes are excellent following surgery for neuromuscular scoliosis.
... Patients with scoliosis, which is defined as having a Cobb angle of more than 20° [4], may need spinal fusion surgery if the curve is greater than 40-50° at skeletal maturity. Otherwise, skeletally immature patients with curve rigidity [1,5], tethered spinal cord, suboptimal sitting balance, patients requiring the use of upper limbs for balance, or patients with deteriorated pulmonary function and marked pelvic obliquity are all candidates for operation [6]. Another indication for operative treatment is rigid lumbar and thoracolumbar kyphosis causing recalcitrant skin ulcerations at the gibbus site [7]. ...
Article
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Purpose To compare the complication rates of two different types of posterior instrumentation in patients with MMC, namely, definitive fusion and fusionless surgery (growing rods). Methods Single-center retrospective study of 30 MMC patients that underwent posterior instrumentation for deformity (scoliosis and/or kyphosis) treatment from 2008 until 2020. The patients were grouped based on whether they received definitive fusion or a growth-accommodating system, whether they had a complication that led to early surgery, osteotomy or non-osteotomy. Number of major operations, Cobb angle correction and perioperative blood loss were the outcomes. Results 18 patients received a growing system and 12 were fused at index surgery. The growing system group underwent a mean of 2.38 (± 1.03) surgeries versus 1.91 (± 2.27) in the fusion group, p = 0.01. If an early revision was necessitated due to a complication, then the number of major surgeries per patient was 3.37 (± 2.44) versus 1.77 (± 0.97) in the group that did not undergo an early revision, p = 0.01. Four patients developed a superficial and six a deep wound infection, while loosening/breakage occurred in 10 patients. The Cobb angle was improved from a mean of 69 to 22 degrees postoperatively. Osteotomy did not lead to an increase in perioperative blood loss or number of major operations. Conclusion Growing systems had more major operations in comparison with fusion surgery and early revision surgery led to higher numbers of major operations per patient; these differences were statistically significant. Definitive fusion at index surgery might be the better option in some MMC patients with a high-risk profile.
... That may explain why in many cases the amount of spinal and pelvic deformity correction obtained by the bipolar technique was higher than with other growing rod techniques and even with arthrodesis in this population of patients [33,34]. ...
Article
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Purpose Posterior spinal fusion (PSF) at skeletal maturity is still the gold standard in children with neuromuscular scoliosis (NMS) who underwent fusionless surgery. The aim of this computed tomography (CT) study was to quantify the spontaneous bone fusion at the end of a lengthening program by minimally invasive fusionless bipolar fixation (MIFBF), that could avoid PSF. Methods NMS operated on with MIFBF from T1 to the pelvis and at final lengthening program were included. CT was performed at least five years postoperatively. The autofusion was classified as completely or not fused at the facets joint (on both coronal and sagittal plane, right and left side, from T1 to L5), and around the rods (axial plane, right and left side, from T5 to L5). Vertebral body heights were assessed. Results Ten patients were included (10.7y ± 2 at initial surgery). Mean Cobb angle was 82 ± 20 preoperatively and 37 ± 13 at last follow-up. CT were performed on average 6.7y ± 1.7 after initial surgery. Mean preoperative and last follow-up thoracic vertebrae height were respectively 13.5 mm ± 1.7 and 17.4 mm ± 1.7 (p < 0.001). 93% facets joints were fused (out of 320 analyzed joints), corresponding to 15/16 vertebral levels. Ossification around the rods was observed in 6.5±2.4 levels out of 13 in the convex side, and 4.2 ± 2.2 in the concave side (p = 0.04). Conclusions This first computed quantitative study showed MIFBF in NMS preserved spinal growth, while it induced 93% of facet joints fusion. This could be is an additional argument when questionning the real need for PSF at skeletal maturity.
... 49%-74%) reported in the literature for NMS patients using all pedicle screw constructs and a posterior midline approach. [17][18][19][20] Both groups achieved an equivalent initial pelvic obliquity correction which persisted at final FU and was comparable to the mean pelvic obliquity correction of 56% or 5.2° reported by Modi et al., 18 using a posterior midline approach. ...
Article
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Purpose We present the paraspinal approach use for neuromuscular scoliosis with focus on deformity correction, perioperative (≤30 days) morbidity and outcome at a minimal follow-up length of 2 years. Methods We prospectively collected data of 61 neuromuscular scoliosis patients operated using a paraspinal (Wiltse) approach between 2013 and 2019. We additionally collected data of 104 control cases, operated using a midline approach between 2005 and 2016. Fifteen Wiltse, respectively 37 control patients were excluded due to a short follow-up (<2 years), and 22 controls were excluded secondary to lacking follow-up data. Hence, 46 Wiltse and 45 control patients were compared. Results Wiltse and control patients had comparable follow-up lengths, demographics, deformity corrections, complication rates, number of levels fused, and intensive care unit and hospital lengths of stay. Wiltse cases had a lower estimated blood loss (535 vs 1187 mL; p-value < 0.001), allogenic transfusion rate (48% vs 96%; p-value < 0.001), and operating time (ORT) (337 vs 428 min; p-value < 0.001) than controls. This was also the case when selecting for patients without pelvic fixation (p-values < 0.001). When selecting the cases with pelvic fixation (20 among 91 cases), only the number of levels fused and the ORT differed significantly according to the approach (p-value <0.015 and <0.041). Conclusion The paraspinal approach for neuromuscular scoliosis is safe, associated with significant deformity correction, reduced estimated blood loss, and allogenic transfusion rate. These potential benefits still need to be evaluated, especially for cases with pelvic fixation, with further follow-up of larger cohorts. Level of evidence level III.
... Our group 12 previously described the use of a bipolar construct for neuromuscular scoliosis with a minimally invasive, fusionless technique, which demonstrated a lower rate of complications compared with other TGR series 27,28 . The bipolar, telescopic construct is strong and stable thanks to its proximal fixation with hook-claws 13 and distal fixation using iliosacral screws 14,15 . ...
Article
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Background: Fusionless techniques for the treatment of neuromuscular early-onset scoliosis (EOS) are increasingly used to preserve spinal and thoracic growth and to postpone posterior spinal fusion (PSF). These techniques have greatly improved thanks to magnetically controlled growing rods, which allow the avoidance of repeated surgery. However, the surgery-related complication rate remains high. The objective of the current study was to report the preliminary outcomes of 21 patients with neuromuscular EOS who were treated with a 1-way self-expanding rod (OWSER). This device was designed to avoid repeated surgery and preserve spinal and thoracic growth thanks to its free rod sliding. Methods: Patients with neuromuscular EOS who underwent OWSER fixation were prospectively reviewed; follow-up was a minimum of 3 years. The instrumentation relies on a bipolar construct from T1 to the sacrum, with proximal fixation by double thoracic hook-claws and distal fixation by iliosacral screws. The device comprises a rod with a notched part sliding in 1 direction inside a domino. Changes in Cobb angle, pelvic obliquity, thoracic kyphosis, lumbar lordosis, T1-S1 and T1-T12 length, space available for the lung, and chest width were assessed. Complications were reviewed. Results: The mean age at surgery was 10.5 years. The mean follow-up was 3.9 years. The mean pelvic obliquity improved from 20° preoperatively to 8° postoperatively and to 6° at the latest follow-up. The mean Cobb angle improved from 66° preoperatively to 38° postoperatively and to 32° at the latest follow-up. The mean preoperative kyphosis was reduced from 41° to 26° at the latest follow-up (p = 0.14). The mean lordosis was 34° preoperatively and 38° at the latest follow-up. The mean growth per month was 0.8 mm for the T1-T12 segment and 1.5 mm for T1-S1. The global complication rate was 38% (2 surgical site infections, 3 cases of lack of rod expansion, 1 case of pyelonephritis, and 2 central venous catheter-related infections). No PSF had been performed at the latest follow-up. Conclusions: Use of the OWSER with a minimally invasive bipolar technique for neuromuscular EOS provided satisfactory correction of spinal and pelvic deformities at 3 years of follow-up. A longer follow-up is required. Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
... Previous global studies reported an ICU stay of 3.5-4.9 days in posterior-only procedures, and this period was longer in patients who underwent combined anteroposterior correction surgery [14,15]. In our study group, the interval for ICU stay was 1.9-3.0 ...
Article
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Objective: Postoperative intensive care unit (ICU) admission might be required in adolescent patients following posterior fusion and instrumentation surgery for the treatment of scoliosis. We aimed to evaluate the predictive factors for mechanical ventilation and the characteristics of the patients who required an ICU stay following spinal surgery. Methods: We retrospectively reviewed the records of 85 children undergoing primary scoliosis surgery at a university-affiliated general hospital from January 2010 and June 2020 by the same spinal surgeon. The demographic data, pre- and peritoperative variables were collected and recorded. All patients underwent surgery with a combined anesthesia protocol of fentanyl and remifentanil. Results: There were 31 males (36.5%) and 54 females (63.5%). In the postoperative period, 13 patients (15.3%) were admitted to the ICU, and six of them required mechanical ventilation. Among these, three patients (50%) were extubated within the postoperative 0-12 hours, two (33.3%) within postoperative 12-24 hours, and one (16.7) after postoperative 24 hours. The major complications included acidosis (4.7%), hemodynamic instability (1.2%), hypercapnia (1.2%), hypoxemia (1.2%), and delayed extubation (1.2%). Conclusions: A smaller bodyweight percentile, neuromuscular etiology, abnormal findings in preoperative chest X-ray, additional comorbidities, and preoperative estimated risk for postoperative mechanical ventilation were among the risk factors for postoperative ICU stay. The age, height, weight, degree of the curvature, and the number of operated segments did not have an association with the postoperative outcomes.
... These amounts of correction were similar or better to TGR series 25,26 and even PSF. [27][28][29][30][31] The second one is the strength and the stability of this type of fixation over time allowing PSF avoidance with a reduced mechanical complication rate. The bipolar construct differs from TGR by the stability of the proximal and distal fixations, the frame sliding construct, and the absence of intermediate area damage. ...
Article
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Study design: A prospective study. Objective: The aim was to report the results of an alternative technique to GR for neuromuscular scoliosis using a minimally invasive fusionless surgery with a minimum of 5 years follow-up. Summary of background data: Conservative treatment is not effective in progressive neuromuscular scoliosis. Early surgery using growing rods (GR) are increasingly advocated to control the deformity while preserving spinal and thoracic growth before arthrodesis. These techniques still provide a high rate of complications. Methods: The technique relies on a bilateral double rod sliding instrumentation anchored proximally by 4 hooks claws and distally to the pelvis by ilio-sacral screws through a minimally invasive approach. The clinical and radiological outcomes of 100 consecutive patients with neuromuscular scoliosis who underwent this fusionless surgery with a minimum follow-up of 5 years were reviewed. Results: 6.5 ± 0.7 years after initial surgery, 6 patients were lost of follow-up and 11 died of unrelated raison. Of the 83 remaining patients at latest follow-up, mean Cobb angle was stable to 35.0° which correspond to 61% correction of the initial deformation. Mean pelvic obliquity was 29.6° (0.3° to 80.0°) preoperatively and 7.2 (0.2° to 23.5°) at latest follow-up. Correction of the hyper kyphosis remained stable. Skeletal maturity was reached in 42/ 83 patients (50,6%). None of these patients has required spinal fusion. The global complication rate was 31.3%. Conclusion: The outcomes of this minimally invasive fusionless technique at 5 years follow-up showed a stable correction of spinal deformities and pelvic obliquity over time, with a reduced rate of complication. The arthrodesis was not required for all patient at skeletal maturity. This technique could be a good alternative to arthrodesis for neuromuscular scoliosis.Level of Evidence: 3.
... The innovation of pedicle screw based posterior instrumentation systems has allowed for increased strength and improved deformity correction compared to these previous systems [11,12]. These newer posterior instrumentation systems have been shown to achieve excellent deformity correction in more severe deformity, especially neuromuscular scoliosis such as cerebral palsy, without requiring an additional anterior procedure [10,[13][14][15]. As a result, there are fewer deformity cases requiring combined anterior and posterior spinal fusion procedures. ...
Article
Study designRetrospective case-series study of prospectively collected data. Objective We sought to identify the differences in outcomes between one-stage (single surgical episode) and two­stage (separate day) anterior and posterior spinal fusion and segmental spinal instrumentation surgeries in severe non-idiopathic and idiopathic scoliosis cases.Background Patients with severe pediatric spine deformity may require combined anterior and posterior fusion procedures. Given their increased complexity and morbidity, surgeons may consider staging these procedures on separate days.MethodsA retrospective cohort study was performed on a prospective Pediatric Spine Database. Patients 21 years of age or under with pediatric scoliosis who underwent primary anterior and posterior spinal deformity correction surgery either through a one-stage or planned two-stage sequence with greater than 2-year follow-up were included. Differences in demographics, comorbidities, surgical details, perioperative morbidity, complications, and outcomes were assessed based on scoliosis etiology. Multivariate models were utilized to control for confounders.ResultsThere were 70 non-idiopathic (14 two-stage vs. 56 one-stage) and 65 idiopathic scoliosis (8 two-stage vs. 57 one-stage) patients. Mean follow-up was 90.1 ± 54.7 months.In non-idiopathic scoliosis patients, two-stage surgery was independently associated with a 140-min increased surgical time (95% confidence interval: 52–229 min, p = 0.002) and an 8.2-day (95% confidence interval: 2.3–14.1 days, p = 0.007) increased hospital length of stay.In idiopathic scoliosis patients, two-stage surgery was independently associated with a 2108 ml increase in crystalloid use (95% confidence interval: 834–3381 ml p = 0.002) and a 5.3-day increased hospital length of stay (95% confidence interval: 4.0–6.5 days, p < 0.001).There were no significant differences in blood loss, transfusions, complications, or post-operative curves on multivariate analysis between one-stage and two-stage surgery cohorts in either non-idiopathic or idiopathic scoliosis patient groups.Conclusion Two-stage surgery was associated with increased crystalloid use in idiopathic scoliosis patients and longer operative times in non-idiopathic scoliosis patients, and longer hospital length of stay in both populations, without significant difference in complications or deformity correction. In the appropriate patient, one-stage anterior–posterior scoliosis surgery may be preferable to two-stage surgery.Level of evidenceLevel III Retrospective Comparative Study
... The Cobb angle correction obtained in our series is comparable to the correction achieved in most other series using fusionless surgeries. 30,31 However, we obtained a much better rate of pelvic obliquity correction (83%), thanks to the asymmetric rod lengthening provided by our expandable construct and the pelvic fixation with iliosacral screws. Consequently, the functional status of the patients is improved with a better balance in sitting position. ...
Article
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Study design: A retrospective review. Objectives: To report the results of an alternative technique using a minimally invasive fusionless surgery. The originality is based on the progressive correction of the deformities with proximal and distal fixation and on the reliability of the pelvic fixation using ilio-sacral screws on osteoporotic bones. Summary of background data: Spinal deformities are common in neuromuscular diseases. Conventional treatment involves bracing, followed by spinal instrumented fusion. Growing rod techniques are increasingly advocated but have a high rate of complications. Methods: The technique relies on a bilateral double rod sliding construct anchored proximally by 4 hooks claws and distally to the pelvis by ilio-sacral screws through a minimally invasive approach.100 patients with neuromuscular scoliosis underwent the same fusionless surgery extended from T1 to the pelvis. The average age at initial surgery was 11+6y. Diagnoses included cerebral palsy (61), spinal muscular atrophy (22), muscular dystrophy (10), and other neurological etiologies (7).Cobb angle and pelvic obliquity were measured before and after initial surgery, and at final follow-up. Complications were reviewed. Results: At latest follow-up 3+9 y (range 2y - 6+3y), the mean Cobb angle improved from 89° to 35° which corresponds to 61% correction. Mean pelvic obliquity improved from 29° to 5° which corresponds to 83% correction. Mean T1-S1 length increased from 30.02 cm to 37.28 cm. Mean preoperative hyper kyphosis was reduced from 68.44° to 33.29°. Complications occurred in 22 patients including mechanical complications (12) and wound infections (16). No arthrodesis was required at last follow-up. Conclusion: This original fusionless technique is safe and effective, preserving spinal and thoracic growth. It provides a significant correction of spinal deformities and pelvic obliquity with a reduced complications rate. The strength and stability of this modular construct over time allow the avoidance of final arthrodesis. Level of evidence: xxxxThis is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0.
... Preoperatory SEPs were pathologic in 1 patient and tce-MEPs amplitudes were reduced in 1 patient. Only one patient demonstrated reversible SEPs and tce-MEPs amplitude changes at left lower limb during surgery, with no postoperative sensory-motor or sphincteric deficits [7]. The complications that have been noted are minor type (Table 1) and led to a reoperation in 7 cases (14.5%). ...
... Modi et al. (74) reported a satisfactory decrease in the magnitude of coronal and sagittal curves with a reduced rate of major complications over 3 years follow up. In a retrospective analysis of 45 patients on which pedicle screw instrumentation was performed, a favorable correction of scoliotic curve and pelvic obliquity was reported with a high carer/parent satisfaction rate (75). Although this data is promising, more work is required to assess the long-term efficacy of pedicle screw constructs. ...
Article
Children who suffer with cerebral palsy (CP) have a significant chance of developing scoliosis during their early years and adolescence. The behavior of this scoliosis is closely associated with the severity of the CP disability and unlike idiopathic scoliosis, it continues to progress beyond skeletal maturity. Conservative measures may slow the progression of the curve, however, surgery remains the only definitive management option. Advances in surgical technique over the last 50 years have provided methods to effectively treat the deformity while also reducing complication rates. The increased risk of surgical complications with these complex patients make decisions about treatment challenging, however with careful pre-operative optimization and post-operative care, surgery can offer a significant improvement in quality of life. This review discusses the development of scoliosis in CP patient, evaluates conservative and surgical treatment options and assesses post-operative outcome.
... Elsewhere in the literature, similar trends have been observed in which increased surgeon comfort with posterior-only approaches to the spine combined with the introduction of more advanced instrumentation have resulted in decreased complication rates and blood loss and increases in patient satisfaction associated with the PSF-only approach. 7,23,25,26,41 Patients undergoing NMS surgery typically have more preexisting comorbidities than any other type of spinal deformity surgery. 4,13,22,36,38 Nonetheless, the overall comorbidity burden increased in our surgically treated patient population over time, possibly indicating increasing comfort with deformity correction in more seriously ill patients with NMS, or perhaps reflecting improved coding accuracy of comorbidities. ...
Article
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OBJECTIVE The objective of this study was to determine if the recent changes in technology, surgical techniques, and surgical literature have influenced practice trends in spinal fusion surgery for pediatric neuromuscular scoliosis (NMS). In this study the authors analyzed recent trends in the surgical management of NMS and investigated the effect of various patient and surgical factors on in-hospital complications, outcomes, and costs, using the Nationwide Inpatient Sample (NIS) database. METHODS The NIS was queried from 2002 to 2011 using International Classification of Diseases, Ninth Edition, Clinical Modification codes to identify pediatric cases (age < 18 years) of spinal fusion for NMS. Several patient, surgical, and short-term outcome factors were included in the analyses. Trend analyses of these factors were conducted. Both univariate and multivariable analyses were used to determine the effect of the various patient and surgical factors on short-term outcomes. RESULTS Between 2002 and 2011, a total of 2154 NMS fusion cases were identified, and the volume of spinal fusion procedures increased 93% from 148 in 2002 to 286 in 2011 (p < 0.0001). The mean patient age was 12.8 ± 3.10 years, and 45.6% of the study population was female. The overall complication rate was 40.1% and the respiratory complication rate was 28.2%. From 2002 to 2011, upward trends (p < 0.0001) were demonstrated in Medicaid insurance status (36.5% to 52.8%), presence of ≥ 1 comorbidity (40.2% to 52.1%), and blood transfusions (25.2% to 57.3%). Utilization of posterior-only fusions (PSFs) increased from 66.2% to 90.2% (p < 0.0001) while combined anterior release/fusions and PSF (AR/PSF) decreased from 33.8% to 9.8% (< 0.0001). Intraoperative neurophysiological monitoring (IONM) underwent increasing utilization from 2009 to 2011 (15.5% to 20.3%, p < 0.0001). The use/harvest of autograft underwent a significant upward trend between 2002 and 2011 (31.3% to 59.8%, p < 0.0001). In univariate analysis, IONM use was associated with decreased complications (40.7% to 33.1%, p = 0.049) and length of stay (LOS; 9.21 to 6.70 days, p <0.0001). Inflation-adjusted mean hospital costs increased nearly 75% from 2002 to 2011 (36,805to36,805 to 65,244, p < 0.0001). In the multivariable analysis, nonwhite race, highest quartile of median household income, greater preexisting comorbidity, long-segment fusions, and use of blood transfusions were found to increase the likelihood of complication occurrence (all p < 0.05). In further multivariable analysis, independent predictors of prolonged LOS included older age, increased preexisting comorbidity, the AR/PSF approach, and long-segment fusions (all p < 0.05). Lastly, the likelihood of increased hospital costs (at or above the 90th percentile for LOS, 14 days) was increased by older age, female sex, Medicaid insurance status, highest quartile of median household income, AR/PSF approach, long-segment fusion, and blood transfusion (all p < 0.05). In multivariable analysis, the use of autograft was associated with a lower likelihood of complication occurrence and prolonged LOS (both p < 0.05). CONCLUSIONS Increasing use of IONM and posterior-only approaches may combat the high complication rates in NMS. The trends of increasing comorbidities, blood transfusions, and total costs in spinal fusion surgery for pediatric NMS may indicate an increasingly aggressive approach to these cases.
... They reported an average correction of 74.1%, overall with average blood loss of 0.8 blood volumes, ICU stay of 3.5 days, and hospital stay of 17.6 days in posterior-only group. In anteroposterior group, the average blood loss was 0.9 blood volumes, ICU stay was 8.9 days, and hospital stay was 27.4 days [9]. Tsirikos et al. carried out a retrospective review of 287 patients treated with the unit rod instrumentation with 242 posterior-only and 45 anterior-posterior procedures. ...
Article
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Minimally invasive surgery (MIS) has been described in the treatment of adolescent idiopathic scoliosis (AIS) and adult scoliosis. The advantages of this approach include less blood loss, shorter hospital stay, earlier mobilization, less tissue disruption, and relatively less pain. However, despite these significant benefits, MIS approach has not been reported in neuromuscular scoliosis patients. This is possibly due to concerns with longer surgery time, which is further increased due to more levels fused and instrumented, challenges of pelvic fixation, size and number of incisions, and prolonged anesthesia. We modified the MIS approach utilized in our AIS patients to be implemented in our neuromuscular patients. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, partial/complete facet resection, and all standard reduction maneuvers. Operative time needed to complete this surgery is comparable to the standard procedure and the majority of our patients have been extubated at the end of procedure, spending 1 day in the PICU and 5-6 days in the hospital. We feel that MIS is not only a feasible but also a superior option in patients with neuromuscular scoliosis. Long-term results are unavailable; however, short-term results have shown multiple benefits of this approach and fewer limitations.
... The presented data did not focus on the functional results, as previous studies have documented a high satisfaction rate among parents and caregivers after scoliosis and pelvic imbalance correction [42][43][44]. Further studies, on a larger group of patients, are needed to explore longterm functional results of this technique compared to other procedures. ...
Article
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The primary goal of curve correction in neuromuscular patients is to restore coronal and sagittal trunk balance, including the pelvis, to maximize sitting balance. For several years, it has been a common practice to inject polymeric cement into osteoporotic bone through specially designed, perforated pedicle screws in an effort to enhance screw stability. Therefore, we started using the association of a spinopelvic fixation with S1 pedicle screw augmentation, using bisphenol-a-glycidyl dimethacrylate composite resin in neuromuscular patients with pelvic obliquity, technique in neuromuscular patients to improve pedicle screw stability of our pelvic construct. Ten patients undergoing spinopelvic fixation for a neuromuscular spinal deformity were enrolled in the study. Clinical and radiographic data were analyzed and presented. Minimal follow-up took place at 6 months to assess early complications. Five patients were diagnosed with spastic quadriplegia secondary to cerebral palsy, four had Duchenne's muscular dystrophy, and one had a T5-level traumatic flaccid paraplegia. Preoperative PO ranged from 8° to 34° (mean 19.16°). Postoperative PO ranged from 0° to 6.3° (mean 1.6°). After surgery, all patients returned to a full-time sitting position between days 5 and 12 without the need for additional bracing. No mechanical failure of the construct was noted during follow-up. We used sacral pedicle screw augmentation as a reliable tool to strengthen spinopelvic fixation in neuromuscular scoliosis without increasing the intraoperative morbidity. In our practice, sacral screw augmentation can definitely enhance PO correction obtained by a posterior procedure.
... The presented data did not focus on the functional results, as previous studies have documented a high satisfaction rate among parents and caregivers after scoliosis and pelvic imbalance correction [42][43][44]. Further studies, on a larger group of patients, are needed to explore longterm functional results of this technique compared to other procedures. ...
Article
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Object: Spinopelvic alignment is crucial in assessing an energy-efficient posture in both normal and disease states, such as high-displacement developmental spondylolisthesis (HDDS). The overall effect in patients with HDDS who have undergone local surgical correction of lumbosacral imbalance for the global correction of spinal balance remains unclear. This paper reports the progressive spontaneous improvement of global sagittal balance following surgical correction of lumbosacral imbalance in patients with HDDS. Methods: The records of 15 patients with HDDS who underwent surgery between 2005 and 2010 were reviewed. The treatment consisted of L4-sacrum reduction and fusion via a posterior approach, resulting in complete correction of lumbosacral kyphosis. Preoperative, 6-month postoperative, and final follow-up postoperative angular measurements were taken from full-spine lateral radiographs obtained with the patient in a standard standing position. Radiographic measurements included pelvic incidence, sacral slope, lumbar lordosis, and thoracic kyphosis. The degree of lumbosacral kyphosis was evaluated by the lumbosacral angle. Because of the small number of patients, nonparametric tests were considered for data analysis. Results: Preoperative lumbosacral kyphosis and L-5 anterior slip were corrected by instrumentation. Transient neurological complications were noted in 5 patients. Statistical analysis showed a significant increase of thoracic kyphosis on 6-month postoperative and final follow-up radiographs (p < 0.001). A statistically significant decrease of lumbar lordosis was noted between preoperative and 6-month control radiographs (p < 0.001) and between preoperative and final follow-up radiographs (p < 0.001). Conclusions: Based on the authors' observations, this technique resulted in an effective reduction of L-5 anterior slip and significant reduction of lumbosacral kyphosis (from 69.8° to 105.13°). Due to complete reduction of lumbosacral kyphosis and anterior trunk displacement associated with L-5 anterior slipping, lumbar lordosis progressively decreased and thoracic kyphosis progressively increased postoperatively. Adjusting the sagittal trunk balance produced not only pelvic anteversion, but also reciprocal adjustment of lumbar lordosis and thoracic kyphosis, creating a satisfactory level of compensated global sagittal balance.
Article
Study Design Retrospective Multicenter Study Objective We reviewed 15-year trends in operative factors, radiographic and quality-of-life outcomes, and complication rates in children with cerebral palsy (CP) related scoliosis who underwent spinal fusion. Summary of Background Data Over the past 2 decades, significant efforts have been made to decrease complications and improve outcomes of this population. Methods We retrospectively reviewed a multicenter registry of pediatric CP patients who underwent spinal fusion from 2008 to 2020. We evaluated baseline and operative, hospitalization, and complication data as well as radiographic and quality-of-life outcomes at a minimum 2-year follow-up. Results Mean estimated blood loss and transfusion volume declined from 2.7±2.0 L in 2008 to 0.71±0.34 L in 2020 and 1.0±0.5 L in 2008 to 0.5±0.2 L in 2020, respectively, with a concomitant increase in antifibrinolytic use from 58% to 97% (all, P <0.01). Unit rod and pelvic fusion use declined from 33% in 2008 to 0% in 2020 and 96% in 2008 to 79% in 2020, respectively (both, P <0.05). Mean postoperative intubation time declined from 2.5±2.6 days to 0.42±0.63 days ( P< 0.01). No changes were observed in pre- and post-operative coronal angle and pelvic obliquity, operative time, frequency of anterior/anterior-posterior approach, and durations of hospital and intensive care unit stays. Improvements in the Caregiver Priorities and Child Health Index of Life with Disabilities postoperatively did not change significantly over the study period. Complication rates, including reoperation, superficial and deep surgical site infection, and gastrointestinal and medical complications remained stable over the study period. Conclusions Over the past 15 years of CP-scoliosis surgery, surgical blood loss, transfusion volumes, duration of postoperative intubation, and pelvic fusion rates have decreased. However, the degree of radiographic correction, the rates of surgical and medical complications (including infection), and health-related quality-of-life measures have broadly remained constant. Level of Evidence 3
Chapter
Cerebral palsy (CP) is a common nonprogressive motor impairment syndrome that is subsequent to lesions or abnormalities of the upper motor nervous system that occur in the early perinatal period and affects approximately 2–2.5 children per 1000 live births worldwide [1]. It is described by the type of motor disorder into spastic, ataxic, dystonic, and dyskinetic variants. Based on regional body involvement, it is described as hemiplegia, diplegia, and tetraplegia. Objectively, it is graded into five different classes (Levels I–V) based on the gross motor function classification system (GMFCS) [2, 3]. The presence of spinal deformity in CP has been reported to range between 20 and 25%, 5% of which is seen in spastic diplegia and 74% in spastic quadriplegia. This indicates that the incidence is directly related to the degree of neurological impairment as well as the GMFCS level of the child [4–7].
Article
PurposeThis study aimed to determine the radiographic outcomes of patients with cerebral palsy (CP) who underwent posterior spinal fusion from T2/3 to L5 at two quaternary hospitals.Methods From January 2010 to January 2020, 167 non-ambulatory patients with CP scoliosis underwent posterior spinal fusion using pedicle screws from T2/3 to L5 in both centers, with a minimum of 2 years follow-up (FU). Radiological measurements and chart reviews were performed.ResultsA total of 106 patients aged 15.6 ± 0.4 years were included. None of the patients was lost to FU. All patients had significant correction of the Cobb angle (MC) and pelvic obliquity (PO), thoracic kyphosis (TK), and lumbar lordosis (LL), without loss of correction at the last FU (LFU). The mean values for preoperative, immediate postoperative, and LFU were MC 93.4°, 37.5°, and 42.8°; PO 25.8°, 9.9°, and 12.7°; TK 52.2°, 44.3°, and 45°; and LL − 40.9°, − 52.4°, and − 52.9°, respectively. Higher residual PO at LFU was associated with more severe MC and PO baselines, lower implant density, and an apex located at L3.ConclusionsCP scoliosis and PO can be corrected, and this correction is maintained over time with posterior spinal fusion using pedicle screws, with L5 as the lowest instrumented vertebra. Larger preoperative MC and PO values associated with the apex at L3 appear to be related to residual PO. Comparative large-scale studies of patient-related clinical outcomes are required to determine whether this intervention is associated with improved surgical outcomes and reduced complication rates.Level of evidenceIV.
Chapter
Scoliosis is a three dimensional deformity of the spine that is one of the most common musculoskeletal conditions in children. This chapter reviews the most common etiologies of scoliosis as well as their respective diagnoses, natural histories and operative and non-operative treatments.
Chapter
The management of early onset scoliosis (EOS) associated with cerebral palsy (CP) is challenging. Children with CP who develop EOS generally have significant medical comorbidities and functional impairments and, therefore, require coordinated, multidisciplinary care in order to optimize outcome. The treatment for mild-to-moderate, flexible curves is generally supportive with adequate seating support and possibly soft orthosis (thoracolumbosacral orthosis (TLSO)) bracing to facilitate transfers. Strict indications for surgery for EOS in CP are not available in the literature; however, the data suggest that a curve approaching 90°, particularly one that is becoming stiff, should be treated with surgery. The literature also only offers limited recommendations for surgical constructs. Definitive spinal fusion is described in this cohort. Certainly, the concern for thoracic insufficiency syndrome (TIS) exists with definitive spinal fusion, but the impact of definitive fusion on pulmonary function is difficult to assess in this patient population as patients have profound intellectual disability and limited ability to participate in pulmonary function tests. Growth friendly techniques continue to evolve. The vertically expandable prosthetic titanium rib (VEPTR) was thought to be an effective tool in managing these complex conditions but may be falling out of favor due to a high complication profile. Traditional growing rods (TGR) and, more recently, magnetically controlled growing rods (MCGR), and growth guidance implants – such as the Shilla™ and modern Luque trolley – are other constructs available for these patients, but the literature supporting their use is at an early stage. While the burden of surgery on the patient and their family is significant, emerging data suggest that the benefit of surgery on health-related quality of life (HRQoL) appears to justify the treatment of EOS in children with CP, but the choice of surgical approach is less clear. More study is required to delineate the optimal surgical approach in this vulnerable group of patients.KeywordsCerebral palsyEarly onset scoliosisGrowth friendly spine surgeryPelvic fixationSpine fusionSurgical site infectionHealth-related quality of life
Article
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The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.
Chapter
Children with cerebral palsy (CP) develop scoliosis as they go through adolescent growth. The most common group of children are those who are not able to walk and are labeled Gross Motor Function Classification System (GMFCS) IV–V. The scoliosis develops between the ages of 8 and 12 years old with progression during the adolescent growth. As the scoliosis curves become more severe, the deformity starts to cause problems with seating. Also as the curve continues to become more severe, it impacts pulmonary function and gastrointestinal motility and often causes pain. The pain develops mostly as the deformity becomes even more severe and the pelvis impinges on the inferior chest wall. Nonoperative treatment options are very limited as there is no evidence that the use of body bracing or orthotics makes an impact on either the magnitude of the scoliosis or the rate of progression of the scoliosis. These body braces or thoracolumbar spinal orthosis (TLSO) can be helpful to improve sitting posture and sitting balance. They should be used for the immediate functional benefit they provide. There is no indication for nighttime bracing, and the complications of the braces have to also be considered which include respiratory restrictions and abdominal restriction which may impact feeding tolerance and pulmonary clearance. Other nonoperative treatments such as physical therapy, postural support, electrical stimulation, and botulinum toxin type A have not demonstrated any benefit to prevent the progression of the deformity.
Chapter
Scoliosis is the most common spinal deformity in cerebral palsy (CP) and is most common in children with greater motor involvement. Most patients present with an unbalanced thoracolumbar or lumbar curvature and pelvic obliquity making it very difficult for the non-ambulatory child to sit in a wheelchair and for the ambulatory child to maintain the head centered over the center of the sacrum for standing balance. Scoliosis may also cause pain, further motor dysfunction, pulmonary compromise, and overall decrease in quality of life. While nonoperative treatment may be temporarily helpful in some children, surgery is the only definitive treatment. The indications for spinal fusion must consider the child’s age, medical condition, scoliosis magnitude, scoliosis flexibility, and the desires of families and caretakers. Posterior spinal fusion with instrumentation is effective in most children with CP with scoliosis; however, very rigid curvatures may require anterior release and/or posterior osteotomy or complete vertebral resection. A multidisciplinary approach to the preoperative and postoperative assessment and medical management is critical to achieve optimum postoperative outcomes. The preoperative management should include preparation for intraoperative bleeding including the use of tranexamic acid, prophylaxis to prevent deep wound infection, maintaining spinal cord integrity, nutritional optimization, and when necessary the management of osteopenic bone. Surgical, functional, and more recent quality of life outcomes have been shown to be favorable in the child with CP undergoing scoliosis surgery.
Article
Objective: Neuromuscular scoliosis (NMS) is often associated with rapid progressive spinal deformities. Indications, when to extend the instrumentation to the pelvis for pelvic obliquity are not generally accepted at this time. This study reports on the indications, surgical technique and results using pedicle screw instrumentation exclusively with or without pelvic fixation for spine fusion in patients with NMS. Patients and methods: Thirty-seven NMS patients were treated with pedicle screw instrumentation (PSI) between 2007 and 2013 with a minimum follow-up of 24 months. The mean age at the time of operation was 14.91 ± 2.03 years (range, 11.17-18.58). Posterior spine fusion (PSF) was conducted in 33 patients; 4 patients underwent a combined anterior spinal release followed by PSF during one-stage surgery. Pelvic fixation was achieved by ilium screws combined with S-1 screws in 4 cases and by sacral-alar-iliac (SAI) technique by Sponseller in 9 cases, respectively. Results: The mean primary Cobb angle was 65.5° (range, 14-103°) and improved significantly to 19.8° (range, 1-50°, p < 0.001) after surgery and 20.5° (range, 3-57, p = 0.47) at 2 years FU, respectively. Besides, an improvement of pelvic obliquity and T1 tilt angle could be detected. Major complications occurred in 19% and minor complications in 32%. Conclusion: Pedicle screw fixation only for spine fusion in patients with NMS can be applied safely with reasonable complication rates. An excellent correction in all planes, a significant improvement of the pelvic obliquity and almost no loss of correction at 2 years FU were observed.
Article
Seizure disorder in cerebral palsy (CP) has been described as a risk factor for postoperative complications after posterior spinal fusion. However, the effect of seizures on the maintenance of curve correction has not been reported. The aim of this study is to investigate associations between seizure history and maintenance of curve correction after posterior spinal fusion in children with CP. We analyzed records of 201 children with CP who underwent posterior spinal fusion with two-year follow-up. Patients were classified as having no seizures (31%); controlled seizures (54%); or poorly controlled seizures (PCS, 15%). Perioperative data, radiographic measurements, and complications were compared between groups. Groups were similar in operative time, estimated blood loss, and rates of deep wound infection and implant-related complications. The PCS group had a higher rate of respiratory complications (27%) than the no seizures (10%; P = 0.03) and controlled seizures (12%; P = 0.04) groups. Controlled seizures and PCS groups had longer ICU stays than the no seizures group (P = 0.02 and P = 0.04). Major coronal curve and pelvic obliquity were corrected significantly in all groups, and correction was maintained at 2 years. Loss of correction during follow-up was similar between groups. Although seizures were associated with longer ICU stays and more respiratory complications, there was no association between seizure history and loss of curve correction at two years of follow-up after CP scoliosis surgery.
Article
Design: Multicenter retrospective review. Objective: To evaluate radiographic outcomes and complication rates of patients treated with distraction based implants and pelvic fixation with either screws (sacral-alar-iliac [SAI] screws or iliac screws) or hooks (S hook iliac fixation). Summary of background data: Multiple options exist for pelvic fixation in distraction-based growing rod systems; however, limited comparative data are available. Methods: Early-onset scoliosis (EOS) patients of all diagnoses with distraction-based implants that had pelvic fixation from 2000 to 2013 were reviewed from two EOS multicenter databases. Patients were divided into two groups by type of pelvic fixation: (1) screw group (SAI screws or iliac screws) or (2) S hooks. Exclusion criteria were as follows: index instrumentation ≥10 years old and follow up <2 years. A total of 153 patients met the inclusion criteria. Mean age at index surgery was 6.1 years (range 1.0-9.9 years) and mean follow-up was 4.9 years. Results: Pelvic fixation in the 153 patients was as follows: screw group = 42 and S hook group = 111. When comparing patients with >20° of initial pelvic obliquity, the screw group had significantly more correction; mean 26° ± 13° for the screw group versus mean 17° ± 7° in the S hook group (p = .039). There was no significant difference in change in T1-S1 length (40 vs. 39 mm, p = .89) or correction of Cobb angle (30° vs. 24°, p = .24). The total complication rate for the screw group was 14% (6/42) versus 25% (28/111) in the S hook group, though this did not achieve significance (p = .25). The most common complications were device migration (13), implant failure (8), and implant prominence (4) for S hooks and implant failure (3), implant prominence (2), and device migration (1) for the screw group. Conclusion: In distraction-based growth-friendly constructs, pelvic fixation with screws achieved better correction of pelvic obliquity than S hooks. Complications were almost twice as common with S hooks than screws, though this did not reach statistical significance.
Article
Study design: A systematic review and meta-analysis OBJECTIVE.: The objective of this study was to investigate the incidence of surgical site infection (SSI) in patients following spine surgery and the rate of microorganisms in these cases. Summary of background data: Many studies have investigated the incidence and risk factors of SSI following spinal surgery, no meta-analysis studies have been conducted regarding the comprehensive epidemiological incidence of SSI after spine surgery. Methods: We searched the PubMed, Embase, and Cochrane Library databases for relevant studies that reported the incidence of SSI after spine surgery, and manually screened reference lists for additional studies. Relevant incidence estimates were calculated. Subgroup analysis, sensitivity analysis and publication bias assessment were also performed. Results: Our meta-analysis included 27 studies, with 603 SSI cases in 22475 patients. The pooled SSI incidence was 3.1%. Subgroup analysis revealed that the incidence of superficial SSI was 1.4% and the incidence of deep SSI was 1.7%. Highest incidence (13.0%) was found in patients with neuromuscular scoliosis among the different indications. The incidences of SSI in cervical, thoracic and lumbar spine were 3.4%, 3.7% and 2.7%, respectively. Compared with posterior approach surgery (5.0%), anterior approach showed a lower incidence (2.3%) of SSI. Instrumented surgery had a higher incidence of SSI than non-instrumented surgery (4.4% versus 1.4%). Patients with minimally invasive surgery (1.5%) had a lower SSI incidence than open surgery (3.8%). Lower incidence of SSI was found when vancomycin powder was applied locally during the surgery (1.9%) compared with those not used (4.8%). In addition, the rates of Staphylococcus aureus, Staphylococcus epidermidis and methicillin-resistant Staphylococci in microbiological culture results were 37.9%, 22.7% and 23.1%, respectively. Conclusions: The pooled incidence of SSI following spine surgery was 3.1%. These figures may be useful in the estimation of the probability of SSI following spine surgery. Level of evidence: 3.
Article
Study design: Retrospective review. Objective: To assess correction of pelvic obliquity in children with cerebral palsy (CP) scoliosis postoperatively and 5 years after posterior spinal fusion with pelvic fixation using unit rods, sacral-alar-iliac (SAI) screws, or iliac screws. Summary of background data: There are multiple options for pelvic fixation in children with scoliosis secondary to CP. The long-term differences in outcomes between these fixation methods are still unclear. Methods: A multicenter review identified records of 70 children with CP who underwent posterior spinal fusion for scoliosis using unit rods (n = 9), SAI screws (n = 19), or iliac screws (n = 42). Patients younger than 18 years with 5-year follow-up were included. Pelvic obliquity and major coronal curve measurements were compared using preoperative, (first erect) postoperative, and 5-year follow-up radiographs. Implant-related complications were noted. Alpha = 0.05. Results: For all groups, there was a significant difference between preoperative and postoperative pelvic obliquity that was maintained at 5 years. At 5-year follow-up, pelvic obliquity was significantly higher in the IS group (12°) compared with the unit rod group (4°, p = 0.001) and SAI screw group (6°) (p = 0.006). Implant-related complications were as follows: unit rod group, 1 patient (reoperation); SAI screw group, none; iliac screw group, 6 patients, including 3 cases of loss of connection between the rod and the iliac screw, 2 prominent screws, and 1 loose screw. Conclusion: Correction of pelvic obliquity for children with CP-related scoliosis was achieved postoperatively using unit rods, SAI screws, and iliac screws. Implant-related complications and reoperations were most common in the iliac screw group. At 5-year follow-up, the iliac screw group had loss of major curve correction and less correction of pelvic obliquity than the unit rod and SAI screw groups. Level of evidence: 3.
Chapter
Scoliosis commonly occurs in children with cerebral palsy. This spine deformity is much more common in non-ambulators (GMFCS Levels IV and V) and can be progressive with negative consequences on quality of life, including increased pain, difficulty seating, progressive restrictive lung disease, and a potential shortened lifespan. Spine fusion is a reliable method of treating progressive scoliosis in these children, but the complication and infection rate is high. However, spine fusion has been demonstrated to improve the quality of life of these patients and their family or caretakers.
Article
Study design: Retrospective analysis. Objective: The aim of this study is to compare the safety and efficacy of the apical pedicle subtraction osteotomy (PSO) technique with multiple posterior column osteotomies (PCO) in non-ambulatory patients with severe, rigid neuromuscular scoliosis. Summary of background data: Neuromuscular scoliosis frequently causes intolerance to sitting due to pelvic obliquity, trunk decompensation and associated back and rib impingement pain which diminish the patient's functional capacity. In the case of rigid curves, spinal osteotomy techniques are occasionally required for effective correction. Methods: We retrospectively reviewed our patients with severe and rigid neuromuscular scoliosis with associated pelvic obliquity whom were treated with posterior instrumented fusion extending to pelvis with >1-year postoperative follow-up. We compared radiological and clinical results of PSO and multiple PCO techniques in severe rigid neuromuscular scoliosis with pelvic obliquity >15° in traction radiograph under general anesthesia (TRUGA). Hospital records were also reviewed for operative time, intraoperative blood loss, amount of blood transfusion, duration of hospital stay and complications. Results: There were 12 patients in the PSO group and 10 patients in the PCO group. There was no significant difference between groups in terms of major curve magnitude, sagittal parameters or pelvic obliquity. Although not statistically significant, PSO technique did trend toward better scoliosis correction (Post-op Cobb angle 56.1° vs 66.7° [p = 0.415]). PSO technique provided a significantly better correction in pelvic obliquity (59% vs 84%) (p = 0.001). There was no significant difference in average intraoperative blood loss, transfusion, operative times including anesthesia time, hospital stay or complications. Conclusion: PSO may be an option in correction of severe and rigid neuromuscular scoliosis. It provides better correction of pelvic obliquity without increasing operative time, need for transfusion or duration of hospitalization as compared to multiple apical PCO technique. TRUGA is a valuable tool in surgical decision-making. Level of evidence: 4.
Article
Study Design Retrospective, chart review. Objectives The objective of this study is to investigate the impact of using two surgeons for posterior spinal fusion (PSF) in patients with AIS with large-magnitude curves (greater than 70°). Summary of Background Data Previous studies have shown that intraoperative risk factors can be reduced by having two surgeons operate simultaneously. Methods A retrospective chart review identified 47 patients between January 1, 2009, and December 31, 2014, who underwent a posterior spinal fusion (PSF) with AIS with large-magnitude curves (greater than 70°). Patients with large-magnitude curves due to neuromuscular diseases or any defined pathology other than idiopathic scoliosis were excluded, as well as patients with kyphotic or kyphoscoliotic curves. Results There was no statistical difference between the total operative time, anesthesia time, estimated blood loss (EBL), %EBL, and blood transfusion units. Total operative time for the two-surgeon group and single-surgeon group was 212.11 and 238.07 minutes, respectively (p = .078). The two-surgeon group averaged 0.26 blood transfusion units versus 0.39 units for the single-surgeon group (p = .50). Average hospital length of stay was decreased in the two-surgeon group (5.16 vs. 6.82 days, p = .002). Conclusions The use of two surgeons for PSF for AIS has previously been shown to decrease operative time and blood loss, factors that are correlated with prolonged hospital stay and increased risk of both neurologic and nonneurologic complications. However, in this study, the technique of having two experienced orthopedic spine surgeons work simultaneously to perform pedicle screw–only posterior spinal fusion on large-magnitude AIS curves greater than 70° did not improve blood loss or operative time. Further study needs to continue to identify ways to minimize complications for patients who undergo spinal fusion. Level of Evidence Level III, retrospective, comparative study.
Article
This prospective cohort study investigated radiographic outcomes and complications over time in patients with rigid neuromuscular scoliosis treated with sublaminar bands and Ponte osteotomies. Twenty consecutive patients with neuromuscular scoliosis were treated with sublaminar bands in addition to Ponte osteotomies at and around the apex of the deformity and prospectively included. All curves were rigid, with less than 30% reduction on preoperative bending films. Cobb angle, pelvic obliquity, and shoulder obliquity were significantly corrected (P<0.01). Normal thoracic kyphosis was achieved for 85% of patients at the last follow-up. No intraoperative complications were observed. The association between Ponte osteotomies and sublaminar bands appears to be efficient for the management of rigid neuromuscular deformities in children and adolescents. No death and no permanent neurological impairment, as well as no sublaminar bands associated events were recorded.
Article
Cerebral palsy patients who undergo posterior spinal instrumentation for scoliosis are at a greater risk of surgical site infection compared to adolescents with idiopathic scoliosis. Many infecting organisms are reported. Risk factors include patients’ specific factors, nutritional status as well as surgery related factors. Although surgical management is still controversial, it is always based on irrigation and debridement followed or not by implant removal. The purpose of this paper is to review the pathophysiology of surgical site infection in this patient population and to propose a treatment algorithm, based on a thorough review of the current literature and personal experience.
Article
Objectives: We designed a novel surgical strategy named one-stage selective discectomy combined with expansive hemilaminectomy (OSDEHL) which might theoretically reduce the postoperative complications of Cervical Spondylotic Myelopathy (CSM). The objectives of this study is to evaluate its efficacy and safety. Methods: 62 patients with CSM were enrolled in this study. The procedure includes selective discectomy with fusion at 1 or 2 segments of maximal cord compression and expansive hemilaminectomy on the symptomatic or severe side of the body. The neurological function was evaluated using the Japanese Orthopedics Association score (JOAs) before and after the surgery. Mid-sagittal dural sac diameter, dural sac transverse area at segments of discetomy on MRI, and the lordosis of C-spine on lateral plain film were measured. All patients were followed up more than one year. Results: 88 discs and 272 hemilaminas were resected from 62 patients. JOAs was found to be improved from 8.7 ± 1.76 preoperatively to 13.4 ± 1.61 at one year follow-up (P<0.001). The mean mid-sagittal dural sac diameter, dural sac area and lordotic angle were also increased from 0.45 ± 0.10cm, 0.83 ± 0.14cm(2) and 7.9 ± 2.60° to 0.81 ± 0.08cm, 0.96 ± 0.14cm(2) and 11.7 ± 3.06° respectively (P<0.05). No case of postoperative axial pain, C5 palsy, nonunion, or kyphosis was reported. Conclusions: OSDEHL is an effective surgical approach for treatment of CSM in patients whose neurological function, mid-sagittal dura sac diameter, and dura transverse area can be improved actually with few complications postoperatively.
Article
Neuromuscular scoliosis (NMS) is the second most prevalent spinal deformity (after idiopathic scoliosis) and is usually first identified during early childhood. Cerebral palsy (CP) is the most common cause of NMS, followed by Duchenne muscular dystrophy (DMD). Progressive spinal deformity causes difficulty with daily care, walking and sitting, and can lead to back and rib pain, cardiac and pulmonary complications, altered seizure thresholds, and skin compromise. Early referral to specialist spinal services and early diagnosis of NMS is essential to ensure appropriate multidisciplinary patient management. The most important goals for patients are preservation of function, facilitation of daily care, and alleviation of pain. Non-operative management includes observation or bracing for less severe and flexible deformity in young patients as a temporising measure to provide postural support. Surgical correction and stabilisation of NMS is considered for patients with a deformity >40-50°, but may be performed for less severe deformity in patients with DMD. Post-operative intensive care, and early mobilisation and nutritional supplementation aim to minimise the rate of post-surgical complications, which are relatively common in this patient group. However, surgical management of NMS is associated with good long-term outcomes and high satisfaction rates for patients, their relatives and carers.
Chapter
Fixed knee flexion in cerebral palsy patients is a severe condition that may not only interfere with gait but also affect standing and daily-life activities. When conservative management fails, surgical correction is required. Several surgical options have been described, such as a posterior knee capsulotomy and a supracondylar femoral extension osteotomy, but they are invasive and characterized by potentially severe complications. Recently, guided growth of the distal femur was proposed as a minimally invasive, safe and reliable technique for correcting fixed knee deformities in cerebral palsy patients. In this chapter, we will describe this technique and discuss its effect on the function of cerebral palsy patients and its advantages with respect to the other surgical procedures.
Chapter
Spinal deformity in cerebral palsy (CP) presents significant challenges to care providers and is one of the most common types of neuromuscular spinal disorders. This chapter details the natural history, clinical presentation, clinical evaluation, non-operative care, and operative care in patients with CP. The rationale and considerations needed in the operative care including surgical indications, levels of instrumentation, early-onset scoliosis in CP, sagittal plane deformities, pelvic and infra-pelvic coronal plane deformities, intraoperative neuromonitoring, need for anterior release, intraoperative halofemoral traction, and intrathecal baclofen pump are discussed. Patients with cerebral palsy and spinal deformity tend to be medically complex. Strategies to optimize patients’ medical conditions pre-, peri-, and postoperatively are reviewed. Surgical technique, outcomes, and complications including authors’ preferred methods are discussed.
Article
Study design: Multicenter prospective database review of patients with cerebral palsy (CP) and spinal deformity. Objective: To determine if the type of distal fixation is associated with improved correction of coronal deformity or pelvic obliquity (PO) at 2 years in long posterior fusions to the sacrum. Summary of background data: Multiple techniques are utilized for distal fixation in patients with CP. Although there is emerging evidence that the augmentation of iliac screws with S1 screws may be beneficial, this remains controversial. Methods: A prospective, multicenter database was used to identify patients with CP who underwent long posterior fusions to the sacrum. Eighty-eight patients were included, 52 with iliac screws (I) and 36 with iliac and S1 screws (IS) for distal fixation. Preoperative, first erect, and 2-year follow-up radiographs and complications were analyzed. Statistical analysis was performed using ANOVA and repeated measures ANOVA with significance set at P < 0.05. Results: Scoliosis was the primary deformity in greater than 90% of patients in both groups (P=0.84). Preoperative coronal deformity was similar (I = 83°, IS = 87°, P = 0.49), but correction was better with the use of S1 screws on the first erect radiograph and at 2 years (I = 35°, IS = 22°, P = 0.001), reflecting correction of 58% and 74% for iliac and iliac-S1 screws, respectively (P < 0.001). Preoperative PO was similar (I = 29°, IS = 30°, P = 0.71) and was noted to improve more in the iliac-S1 group by 2 years (I = 11°, IS = 5°, P = 0.004), representing correction of 60% and 77% for the iliac and iliac-S1 groups, respectively (P = 0.018). There was no difference in the rate of major (P = 0.27) or minor (P = 0.65) complications in either group. Conclusion: Bilateral S1 and iliac screws are associated with improved spinal deformity and PO correction at 2 years in the CP population. Two points of distal fixation, S1, and ilium should be considered for this population. Level of evidence: 3.
Article
Purpose A prospective, longitudinal cohort was studied to determine the incidence, consequences, and risk factors of major perioperative complications in patients with cerebral palsy (CP) treated with spinal fusion. There is a wide variety of data available on the complications of spine surgery; however, little exists on the perioperative complications in patients with CP. Methods A prospective multicenter dataset of consecutive patients with CP treated with spinal fusion was evaluated. All major perioperative complications were identified and stratified into categories: pulmonary, gastrointestinal, other medical, wound infection, neurological, instrumentation related, and unplanned staged surgery. Univariate and multivariate analyses were performed to identify various risk factors for major perioperative complications. Results 127 patients were identified with a mean age of 14.3 ± 2.6 years. Overall, 39.4 % of the patients had a major perioperative complication. Occurrence of a complication [no complication (NC), yes complication (YC)] resulted in significantly increased intensive care unit (ICU) (NC = 3.2 days, YC = 7.8 days, p
Article
The aim of this article was to summarize current literature on surgical treatment of pediatric and adult spinal deformity with regard to clinical outcomes and surgical complications. When surgery is considered for treatment of spinal deformity, it is important for both the physician and patient to appreciate the outcome objectives, have reasonable expectations, and understand the potential for adverse events. We conducted a comprehensive search of the English literature from the years 2000–2011 using Medline for articles related to the surgical treatment of spinal deformity, using selected terms. We reviewed abstracts and restricted them to those focused on surgical treatment of spinal deformity. We included clinical outcomes measures and overall complications rates, and reviewed corresponding manuscripts. For pediatric and adult spinal deformity, we identified 8 and 17 manuscripts, respectively, that included preoperative and postoperative assessments of outcomes measures. The vast majority of reported studies demonstrated that operative treatment has the potential to produce significant improvement of health-related quality of life. Surgical treatment of pediatric scoliosis, including idiopathic, neuromuscular, and congenital, had reported complication rates ranging from 4.4% to 15.4%, 17.9% to 48.1%, and 8.3% to 31%, respectively. Surgical treatment of adult scoliosis had reported overall complication rates ranging from 10.5% to 96%. The number of high-quality studies that provide assessment of the outcomes of surgery for pediatric and adult scoliosis remains limited; further study is needed. Available studies suggest that in selected patients, surgical treatment offers potential for improvement of health-related quality of life. The current literature also demonstrates the risks that accompany surgical procedures for the correction of spinal deformity. It is important that spinal deformity patients considering surgical treatment have appropriate expectations not only of the potential benefits it may offer, but also of the risks inherent to such procedures.
Article
Full-text available
Scoliosis is a common deformity in children and adolescents with cerebral palsy. This is usually associated with pelvic obliquity due to extension of the curve to the sacrum. Sagittal plane deformity is less common and often develops along with scoliosis. Spinal deformity in patients with severe neurological handicaps can affect their ability to sit and cause significant back pain or pain due to rib impingement against the elevated side of the pelvis on the concavity of the curvature. Surgical correction followed by spinal arthrodesis is indicated in patients with progressive deformities which interfere with their level of function and quality of life. Spinal deformity correction is a major task in children with multiple medical co-morbidities and can be associated with a high risk of complications including death. A well-coordinated multidisciplinary approach is required in the assessment and treatment of this group of patients with the aim to minimize the complication rate and secure a satisfactory surgical outcome. Good knowledge of the surgical and instrumentation techniques, as well as the principles of management is needed to achieve optimum correction of the deformity and balancing of the spine and pelvis. Spinal fusion has a well-documented positive impact even in children with quadriplegia or total body involvement and is the only surgical procedure which has such a high satisfaction rate among parents and caregivers.
Article
The aim of this study was to document the rate of survival among 288 severely affected pediatric patients (154 females, 134 males) with spasticity and neuromuscular scoliosis who underwent spinal fusion (mean age at surgery 13 years 11 months, SD 3 years 4 months), and to identify exposure variables that could significantly predict survival times. Kaplan-Meier survival analysis was performed demonstrating a mean predicted survival of 11 years 2 months after spinal surgery for this group of globally involved children with cerebral palsy (CP). Cox's proportional hazards model was used to evaluate predictive efficacy of exposure variables, such as sex, age at surgery, level of ambulation, cognitive ability, degree of coronal and sagittal plane spinal deformity, intraoperative blood loss, surgical time, days in hospital, and days in the intensive care unit. Number of days in intensive care unit after surgery and the presence of severe preoperative thoracic hyperkyphosis were the only factors affecting survival rates. This demonstrated statistically significant predictability for decreased life expectancy after spinal fusion in children with CP.
Article
It is a retrospective study of 52 neuromuscular scoliosis patients with cerebral palsy (CP). To determine the effectiveness and amount of correction using posterior-only pedicle screw construct. Although there have been many reports in literature supporting the use of pedicle screw-only constructs for the correction of adolescent idiopathic scoliosis, similar studies have not been reported in patients with CP. We retrospectively evaluated outcomes of 52 neuropathic scoliosis patients (28 males and 24 females) with CP over minimum 2 years of follow-up. All patients underwent pedicle screw fixation without any anterior procedure for the correction. Pelvic fixation was done in 10 patients who had pelvis obliquity more than 15 degrees . All coronal and sagittal parameters were noted after surgery and at final follow-up. Patient's functional outcome was measured using modified Rancho Los Amigos Hospital system criteria. Complications were recorded from record sheets and any change in the ambulatory status was also recorded. Mean age was 22 years at the time of operation and average follow-up was 36.1 month. Cobb's angle was improved to 62.9% (P < 0.0001) from 76.8 degrees to 30.1 degrees after surgery and 31.5 degrees at final follow-up. This correction of scoliosis (41% approximately 92%) was found to be statistically significant (P < 0.0001). Overall correction in pelvic obliquity was 56.2% from 9.2 degrees before surgery to 4.0 degrees after surgery which was 43.1% at final follow-up to 5.2 degrees. Twenty-one patients (42%) improved their functional ability by grade 1 with 2 patients by grade 2. After the operation parent or caretakers of patients exhibited better sitting balance and nursing care. There were 32% complications in the series major being pulmonary. There were 2 perioperative deaths and 1 patient developed neurologic deficit due to screw impingement in canal, which was resolved after removal. We reported satisfactory coronal and sagittal correction with posterior-only pedicle screw fixation without higher complication rate in CP patients. Further long-term study is recommended to evaluate the success of pedicle screw in this population.
Article
Of 294 patients with cerebral palsy seen from 1960 to 1972, forty-two had clinically significant lumbar and thoracolumbar scoliosis (31 to 135 degrees) and thirty-three were treated by spine surgery: ten by Harrington instrumentation and posterior spine fusion, eighteen by the Dwyer procedure and anterior fusion, and five by a two-stage combined anterior and posterior fusion. Evaluation of the results after eighteen to sixty-eight months showed: relief of pain in seventeen cases, improved sitting tolerance in seventeen, less nursing care needed in three, less equipment required in six, ability to use equipment providing more function in three, placement in a facility where less care was required in two, and improved eating patterns in two. Only the combined procedure appeared to give adequate correction and a low incidence of pseudarthrosis.
Article
Sixty-eight patients with neuromuscular spine deformity were treated by posterior spine fusion with Luque-Galveston instrumentation between 1982 and 1986. The minimum follow-up was 4 years. Diagnoses included cerebral palsy in 34 patients and other neuromuscular diseases in another 34 patients. The average age was 14 years. Twenty patients also had anterior spine fusion without instrumentation. Preoperatively the average scoliosis was 73 degrees and this was corrected to 33 degrees at final follow-up. The subgroup having anterior discectomy and fusion had a more severe scoliosis and pelvic obliquity, but the percent of correction was similar to that of the group with posterior reconstruction only. Twenty-four patients who had an associated significant sagittal plane deformity were corrected to a physiologic curvature. A postoperative thoracolumbosacral orthosis was used in 27 patients, and a molded seating orthosis was used in 18. Although the rate of complications was high (62%), most of them were minor. Instrumentation problems occurred in 14 patients (21%), only 4 of them having broken rods. There were no broken wires. Pseudarthrosis occurred in seven patients (10%). Three patients had minor neurologic deficits, all transient. The "windshield-wiper" sign was defined as any radiolucency of 2 mm or greater. Twenty-six patients had this sign at follow-up, and this group had a higher percentage of complications, but the existence of this sign did not necessarily indicate a problem.
Article
Thirty-four nonambulatory patients with progressive neuromuscular spinal deformity were surgically managed using a 1/4" U-shaped double rod construct with segmental instrumentation from T2 to the pelvis accompanied by posterior spinal fusion. Diagnoses included 17 patients with cerebral palsy, six with spinal bifida, and 11 with other diseases (spinal muscular atrophy, Friedreich's ataxia, polyneuropathy, nemaline myopathy, and polio). Twenty-three patients had single uncompensated thoracolumbar curves, and 11 had a double curve pattern. The mean preoperative major curve was 66 degrees (range, 22-132 degrees), the secondary curve 58 degrees (range, 23-84 degrees). No postoperative spinal support was used. Mean curve correction was 36 degrees or 54.6%. There were four major complications, including two implant failures requiring revision and two patients sustaining excessive intraoperative blood loss necessitating completion of the procedure in a second stage. There were two neurologic complications including one case of postoperative seizures and an L4 monoradicular neuropathy in a spina bifida patient. Four patients had temporary postoperative ileus, one gastroesophageal reflex, and four had urinary tract infections. There were no significant postoperative pulmonary complications. Excluding the patients with rod failure, mean loss of correction at mean follow-up of 21.3 months was 6.5%. The stability and curve correction obtained using this system supports its continued use in patients with progressive neuromuscular scoliosis.
Article
Ninety-six children and adolescents, born in 1959-78, with spastic tetraplegic cerebral palsy (TPL) were studied in terms of impairments and disabilities. The series was population-based and derived from 15 Swedish counties, and the city of Gothenburg, a population of 4.5 million people in all. All the patients had a pronounced motor disability with severe spastic pareses of all four limbs, and all of them were severely mentally retarded. None of them could speak. Ninety-four percent had epilepsy, 47% were severely impaired visually. Additional impairments were hip luxation(s) in 75%, severe contractures in 73% and scoliosis in 72%. Sixty-eight percent of cases had secondary microcephaly; 13% were born microcephalic. - The general uniformity of the severity and multiplicity of the impairment and disability pattern is emphasized - making the TPL group suitable for scientific care load studies on the basic requirements for the care of the profoundly retarded with maximum multi-handicaps.
Article
To study the natural history of scoliosis in institutionalized adults who have cerebral palsy, we reviewed retrospectively the cases of fifty-one patients. The patients were followed for at least four years (mean, 16.3 years; range, four to forty years) after they had reached skeletal maturity. The individuals in whom the curve eventually progressed the most had had the largest curves at the time of skeletal maturity. The rate of progression was 0.8 degree each year in the patients in whom the curve was less than 50 degrees at the time of skeletal maturity and 1.4 degrees in those in whom the curve was more than 50 degrees (p less than 0.04). The patients who had the largest curves at the time of skeletal maturity had spastic quadriplegia and either a thoracolumbar or a lumbar curve, and they were bedridden.
Article
Many controversial areas exist in the treatment of spinal deformities in patients with cerebral palsy or mental retardation, including the benefits of surgery, the use of traction for preoperative curve correction, the need for a combined anterior and posterior approach, the need to fuse to the sacrum, and the moral question of operating on these severely handicapped patients. To help to clarify these questions, the surgical treatment of spinal deformities in patients with cerebral palsy or mental retardation was analyzed in 109 patients who were treated from May 1948 through December 1979 at the Twin Cities Scoliosis Center, Minneapolis and St. Paul, Minnesota. Seventy-seven (71 per cent) of the patients had cerebral palsy and thirty-two (29 per cent) had only mental retardation. One patient had lordosis only and one had kyphosis only. Of the 107 patients with scoliosis, forty-four had Group-I (double balanced) curves and sixty-three had Group-II (large unbalanced lumbar or thoracolumbar) curves. The incidence of the two curve types was found to differ in those patients with only mental retardation, in ambulatory patients, in patients who lived at home, and in patients with pelvic obliquity. The treatment programs in use during the thirty-one years that are covered by this study were: cast correction and posterior fusion followed by a long post-operative supine period; posterior fusion and Harrington instrumentation; and a two-stage combined anterior and posterior fusion and instrumentation with a very short postoperative supine period. The indications for surgery were curve progression (63 per cent), loss of function (35 per cent) and the magnitude of the curve (77 per cent). Traction was found to be of no use for correcting the curve, but was very useful in controlling the uncooperative patient. The length of follow-up averaged 4.5 years (range, two to twenty-nine years). All but ten of the patients achieved a solid spine fusion. Eight of the ten had painless pseudarthroses without loss of correction and two had pseudarthroses with loss of correction. The Group-II curves were better treated by the two-stage combined approach, which gave better correction of the scoliosis and a lower rate of pseudarthrosis compared with posterior fusion and instrumentation alone. The improvement in the results using the combined approach caused us to use this approach also in selected Group-I curves in the presence of a significant lumbar component. Fusion to the sacrum was necessary only when pelvic obliquity was present or sitting balance was absent. One patient was functionally worse post-operatively, eighty-two showed no change, and twenty-four showed improvement. The complication rate was high (81 per cent). The most frequent complications were pressure scores, wound problems, instrumentation problems, and an increase in the length of the curve. Pseudarthroses occurred in 17 per cent and infection, in 5 per cent of the patients. Three patients died and one became paraplegic. In our opinion, surgery can be of benefit in this group of severely handicapped patients.
Article
Sixty-five consecutive scoliosis patients, 25 with idiopathic deformities and 40 with postpoliomyelitis deformities, were treated by preoperative correction, segmental spinal instrumentation with arthrodesis, and no postoperative immobilization. The follow-up ranged from 12 to 25 months (average, 18 months); no patients was lost to follow-up. The initial deformity varied from 35 degrees to 140 degrees (average, 69 degrees), and the final correction varied from 53% to 93% (average, 72%). The average loss of correction was 1.5 degrees, or 2%. The complications in this group were two infections and two pseudoarthroses. The author believes that segmental spinal instrumentation gives a planned maximum correction of scoliotic deformities, provides a satisfactory method of rigid internal fixation of the spine that needs no external fixation, and leads to rapid efficient arthrodesis.
Article
From April 1977 through September 1980 at the University of Texas Medical Branch, 10 cerebral palsied individuals with total body involvement were surgically treated for their scoliosis. Each underwent L-rod instrumentation either as a definitive procedure or as the second surgery in a two-staged correction and arthrodesis. The average age of the group was 15.6 years and the average curve severity 70.8 degrees. An average correction of 59.9% or 41.5 degrees was obtained; two-stage procedures averaged 7.2 degrees correction per segment as contrasted with 5.4 degrees for single stage surgery. Most patients had regained their preoperative level of function within 2 weeks after L-rod instrumentation. At an average follow-up interval of 2.73 years, all have a solid spinal arthrodesis. On the basis of this experience, we feel that L-rod instrumentation is a more effective adjunct in the surgical management of cerebral palsy scoliosis than combined Harrington-Dwyer instrumentations.
Article
A nonrandomized descriptive case series. To analyze the results of spinal fusion in patients with total-body-involvement cerebral palsy to determine early and late outcomes, including caregiver satisfaction. Data from 79 to 100 patients with total-body-involvement spastic cerebral palsy who underwent posterior Luque instrumentation, or anterior spinal fusion, or both, were adequate to be included in the study. Functional status was evaluated by physical examination, and a personal interview was conducted with the patient, parents, and primary caregiver. Median follow-up was 4 years (range, 2-14 years). Late progression of scoliosis (> 10 degrees), pelvic obliquity (> 5 degrees), and decompensation (> 4cm ) were noted in more than 30% of the patients. More than 75% of patients with late progression were skeletally immature at the time of surgery and underwent a posterior procedure only. Twenty-one percent of the patients required a revision procedure because of disease progression. Progression was not noted in any patient who underwent anterior fusion (with or without anterior instrumentation) plus posterior instrumentation from the upper thoracic spine to the pelvis. Eighty-five percent of parents or caregivers were very satisfied with the results of surgery and noted a beneficial impact of the patient's sitting ability, physical appearance, ease of care, and comfort. To avoid late progression of trunk deformity in skeletally immature patients, anterior spinal release and fusion combined with posterior segmental spinal instrumentation and fusion from the upper thoracic spine to the pelvis are recommended. Skeletally mature patients with good curve flexibility can be treated with posterior instrumentation and fusion only. Skeletally mature patients with large fixed curves benefit from an anterior-posterior procedure for better correction of the scoliosis and pelvis obliquity. Despite the surgical complexity and expected complications, the overall good surgical results and high patient and caregiver satisfaction confirm that corrective spinal surgery is indicated and is beneficial for most patients with total-body-involvement cerebral palsy and scoliosis.
Article
A retrospective review of 107 patients with cerebral palsy who had undergone a posterior spinal fusion with unit rod instrumentation by the same two surgeons was done to determine what factors cause complications that lead to delayed recovery time and a longer than average hospital stay. The operative risk score was developed with scores for the child's ability to walk and talk, oral feeding ability, cognitive ability, and medical problems within the year prior to surgery. Operative risk score is primarily a measure of degree of neurologic involvement. The postoperative complication score (POCS) is a combined measure of all postoperative complications including factors for prolonged intubation, intensive care unit stay, hospital stay, and delayed feeding. The mean age at surgery was 14.3 years. The mean weight was 29.5 kg, with 89 of 107 patients below the fifth percentile for weight compared with age. The mean degree of spinal deformity was 75.2 degrees (range 43-120 degrees ). The mean weight for age was -1.96 SD below the normal. The mean operative time was 4.3 h, with estimated blood loss of 1.2 blood volumes. The mean length of hospitalization was 23 days 2 h, with 5 days 2 h in the intensive care unit. The operative risk score and weight for chronological age below the fifth percentile showed statistical significance (p = 0.05) in regard to increased POCS. The weight for height-age and deficient total lymphocyte count, both factors that measure nutritional status, showed no statistical significance (p > 0.05) compared with POCS. Curves with deformity of >70 degrees had statistically significant high POCS (p = 0.03). Complications for patients having a posterior and an anterior surgery versus those who had a posterior fusion alone were not statistically different (p > 0.05). The factors that led to a greater rate of complications were the severity of neurologic involvement, severity of recent history of significant medical problems, and severity of scoliosis.
Article
A retrospective study investigated 24 ambulatory pediatric patients with spastic cerebral palsy and neuromuscular scoliosis. To evaluate the effect of spinal fusion from T1-T2 to the sacrum with pelvic fixation using unit rod instrumentation on the ambulatory potential of these patients. Spinal deformities in patients with cerebral palsy and good ambulatory capacity are infrequently associated with pelvic obliquity, so instrumented spinal fusions traditionally do not extend to the pelvis. The medical charts and radiographs were reviewed, and the patients' ambulatory ability was assessed clinically with videotape or complete gait analysis. A questionnaire assessing patients' functional improvement was given to the caretakers. The study group included 17 female and 7 male patients, among whom were 19 quadriplegics and 5 diplegics. The mean age at surgery was 15.4 years. Of the 24 patients, 20 underwent posterior spinal fusion and 4 had combined anteroposterior procedures. The patients were evaluated clinically before surgery and after surgery. Follow-up evaluations of ambulatory function occurred at a mean of 2.86 years after surgery. No alteration in the ambulatory status of the patients was found, except in one patient who experienced bilateral hip heterotopic ossification and gradually lost her ability to ambulate. Preoperative and postoperative gait analysis was performed for 12 patients, showing no change in their ambulatory function. The surgical outcome survey demonstrated significant improvement in the patients' physical appearance, head and trunk balance, sitting ability, and respiration, with no change in ambulatory capacity. Spine surgery with fusion extending to the pelvis in ambulatory patients with cerebral palsy provided excellent deformity correction and preserved their ambulatory function.
Article
A retrospective study was performed including 45 pediatric patients with spastic quadriplegic cerebral palsy and neuromuscular scoliosis who underwent anteroposterior spinal fusion. To evaluate the outcomes and complications of one-stage and two-stage combined anteroposterior spine fusion and to document which procedure is more efficacious and provides better results. Circumferential spinal arthrodesis has been proven to achieve better scoliotic curve correction, decreasing significantly the risk of pseudarthrosis and progression of the deformity. There have been a few studies comparing same-day versus staged anteroposterior spinal surgery in mixed populations with neuromuscular scoliosis, but not in an isolated group of pediatric patients with spastic cerebral palsy. The medical records and radiographs of all patients were reviewed, and the results were statistically analyzed. The complications were divided into medical, subcategorized into major and minor, and technical. There was no statistically significant difference (P > 0.05) between one-stage (Group 1) and two-stage (Group 2) patients, considering age at surgery, preoperative scoliosis angle, pelvic obliquity, kyphosis angle, lordosis angle, levels of anterior release, percentage of scoliosis correction, radiographic follow-up, hospitalization time, and intensive care unit stay. Sequentially performed spinal procedures (Group 1) were associated with increased intraoperative blood loss, prolonged operative time, and a considerably higher incidence of medical and technical complications, including two perioperative deaths. Two-stage anteroposterior spinal fusion provides safer and more consistent results with several advantages over the single-stage procedure in the management of patients with cerebral palsy and neuromuscular scoliosis.
Article
The aim of this study was to document the rate of survival among 288 severely affected pediatric patients (154 females, 134 males) with spasticity and neuromuscular scoliosis who underwent spinal fusion (mean age at surgery 13 years 11 months, SD 3 years 4 months), and to identify exposure variables that could significantly predict survival times. Kaplan-Meier survival analysis was performed demonstrating a mean predicted survival of 11 years 2 months after spinal surgery for this group of globally involved children with cerebral palsy (CP). Cox's proportional hazards model was used to evaluate predictive efficacy of exposure variables, such as sex, age at surgery, level of ambulation, cognitive ability, degree of coronal and sagittal plane spinal deformity, intraoperative blood loss, surgical time, days in hospital, and days in the intensive care unit. Number of days in intensive care unit after surgery and the presence of severe preoperative thoracic hyperkyphosis were the only factors affecting survival rates. This demonstrated statistically significant predictability for decreased life expectancy after spinal fusion in children with CP.
Article
The purpose of this study was to delineate parents' and professional caretakers' satisfaction after spinal fusion in children with spasticity and to determine differences in their perceptions. A questionnaire assessing patients' functional improvement after spinal arthrodesis for correcting scoliosis was addressed to 190 parents. An expanded questionnaire was also addressed to 122 educators and therapists working in the care of children with cerebral palsy. Caretakers did not recognize effects of the scoliotic deformity on patients' head control, hand use, and feeding ability. Most of parents and caregivers reported a very positive impact of the surgery on patients' overall function, quality of life, and ease of care. Parents had more appreciation of the benefits in the children's appearance, whereas educators and therapists acknowledged more improvement in gross and oral motor function. Considering that the benefits from scoliosis correction clearly outweigh the increased risk of surgical complications, most parents (95.8%) and caretakers (84.3%) would recommend spine surgery.
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We aimed to investigate whether the outcome and complications of surgical treatment of neuromuscular curves with segmental third-generation instrumentation could compare with those reported with standard second-generation instrumentation. The clinical and radiologic data of a single surgeon's consecutive series of patients with neuromuscular scoliosis treated with two types of newer-generation instrumentation and posterior or anteroposterior approaches were retrospectively and independently reviewed. The results of this study support the concept that third-generation instrumentation is able to provide at least as good results as second-generation instrumentation in the treatment of neuromuscular scoliosis patients, at the expense of a lower complication rate.
Article
Retrospective. To report on the treatment of patients with cerebral palsy and neuropathic scoliosis with third-generation instrumented spinal fusion by Cotrel-Dubousset instrumentation. Second-generation instrumented spinal fusion is considered the standard for progressive neuropathic scoliosis in cerebral palsy, despite high complication rates. Evidence is needed to evaluate the increasing use of third-generation instrumented spinal fusion in similar patients. Patients with cerebral palsy and spinal deformity treated consecutively by 1 surgeon with Cotrel-Dubousset instrumentation and minimum 2-year follow-up were reviewed. An outcome questionnaire was administered at final follow-up. A total of 60 patients were included. Mean age was 15 years at surgery. Mean follow-up was 79 months. There were 26 anteroposterior and 34 posterior-only procedures. Correction of coronal deformity and pelvic obliquity averaged 60% and 40%, respectively. Major complications affected 13.5% of patients, and included implant loosening, deep infection, and pseudarthrosis. Minor complications affected 10% of patients. Outcome questionnaires showed marked improvements in the areas of satisfaction, function, and quality of life after surgery. Segmental, third-generation instrumented spinal fusion provides lasting correction of spinal deformity and improved quality of life in patients with cerebral palsy and neuropathic scoliosis, with a lower pseudarthrosis rate compared to reports on second-generation instrumented spinal fusion.
Article
Retrospective clinical and radiographic consecutive case series of 2 surgeons. The purpose of this study was to present a large consecutive series of patients with cerebral palsy who were treated with the Unit rod instrumentation at a single institution. The goal was to report the incidence of surgical complications, degree of deformity correction, reoperation rate, prevalence of pseudarthrosis, and the caretakers' perceived outcome. Children with cerebral palsy frequently develop scoliosis that requires surgical correction. Segmental instrumentation has been the primary mode of treatment. There are no reported large series with long-term follow up. This study was a retrospective review of 287 children treated with the Unit rod instrumentation. This instrumentation with fusion included the whole spine (between C7 and T3 into the pelvis) with 242 posterior-only and 45 anterior-posterior procedures. Of this group, 241 patients were observed for more than 2 years. This review focused on the rate of complications and radiographic outcome of the treatment. Parent and caretaker interviews were conducted to define perceived functional outcome after surgery. Scoliosis was corrected from a mean of 76 degrees to 25 degrees (68%). Pelvic obliquity was corrected from a mean of 17 degrees to 5 degrees (71%). In posterior-only procedures the average blood loss was 2.8 L, ICU stay was 4.9 days, and the hospital stay was 19.6 days. In combined procedures, the average blood loss was 3.4 L, ICU stay was 6.7 days, and the hospital stay was 24.5 days. Major complications included 3 perioperative deaths, 18 deep wound infections [12 early deep infections in a total of 287 patients (4.2%); 6 late deep infections in a total of 236 patients (2.5%)], and 2 patients with septicemia who recovered after prolonged antibiotic management. Caretakers' survey reported a 96% satisfaction rate. The Unit rod instrumentation is a common standard technique and the primary instrumentation system for the treatment of pediatric patients with cerebral palsy and neuromuscular scoliosis because it is simple to use, it is considerably less expensive than most other systems, and can achieve good deformity correction with a low loss of correction, as well as a low prevalence of associated complications and a low reoperation rate.
Luque-Galveston procedure for correction and stabilization of neuromuscular scoliosis and pelvic obliquity: a review of 68 patients.
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Comparison of parents and caregivers satisfaction after spinal fusion in children with cerebral palsy.
  • Tsirikos