| Treatment |
- Nonoperative
- observation, custom seat and/or bracing, botox injections
- indications
- nonprogressive curves < 50°
- early stages in patients < 10 years of age
- goal is to delay surgery until an older age
- outcomes
- custom seat orthosis
- helpful with seating but does not affect natural course of disease
- bracing
- TLSO is helpful to improve sitting balance but does not affect natural course of disease
- some studies have supported use as a palliative measure to slow progression in skeletally immature patients only
- botox
- competitive inhibitor of presynaptic cholinergic receptor with a finite lifetime (usually last 2-3 months)
- provide some short term benefit in patients with spinal deformity
- Operative
- goals of surgery
- obtain painless solid fusion with well corrected, well balanced spine with level pelvis
- decision to proceed with surgery must include careful assessment of family's goals and careful risk-benefit analysis
- PSF with/without extension to the pelvis
- indications
- Group I curves 50° to 90° in ambulators that is progressive or interfering with sitting position
- patient > 10 yrs of age
- adequate hip range of motion
- stable nutritional and medical status
- technique
- treated as idiopathic scoliosis with selective fusion
- can result in worsening pelvic obliquity and sitting imbalance
- PSF +/- ASF with/without extension to pelvis
- indicated for
- Group I curves >90° and in non-ambulators
- Group II curves
- children who have not yet reached skeletal maturity (avoid crankshaft phenomenon)
- extension to pelvis
- indications
- pelvic obliquity > 15°
- required due to increased pseudoarthosis rate if you do not do it
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| Preoperative Assessment & Planning |
- Overview
- treatment of cerebral palsy spine disorders is complicated by medical comorbidities
- all patients should have a thorough multidisciplinary approach
- Nutritional status
- increase complications (infection, length of intubation, longer hospital stays)
- associated with poor nutritional status (weight less than fifth percentile)
- be sure patient has adequate nutrition before surgery (serum albumin > 3.5 g/dL, consider gastrostomy tube if not)
- Respiratory status
- difficult to do formal pulmonary functional capacity testing
- can use respiratory history, clinical evaluation, and chest radiographs
- GI evaluation
- preoperative management of GERD is important in prevention of aspiration pneumonia
- Neurologic function
- if patients have seizure disorder (common) be sure it is under control
- if patient taking valproic acid, obtain bleeding time as these patients may have increased risk of bleeding
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| Surgical Techniques |
- Fusion levels
- proximal fusion should extend to T1 or T2 (otherwise risk of proximal thoracic kyphosis)
- distal fusion depends on curve pattern
- due to long curves in CP often extends to L4 or L5
- extend to pelvis whenever pelvic obliquity is > 15°
- Posterior fixation techniques
- Luque rod with subliminar wires technique
- Unit rod with sublaminar wires technique
- Pedicle screw fixation technique
- may provide better correction and eliminate need for anterior surgery
- Pelvic fixation techniques
- Galveston Technique
- technique to fuse to pelvis with goal of a stability and truncal balance and a level pelvis
- caudal ends of rods are bent from lamina of S1 to pass into the posterosuperior iliac spine and between the tables of the ileum just anterior to the sciatic notch
- bilatral sacral screws
- iliosacral screws
- spinopelvic transiliac fixation
- Dunn-McCarthy technique (S-contoured rod that wraps over sacral ala)
- Anterior and Posterior Techniques
- use of anterior procedures decreasing with improved posterior constructs
- higher complication rate in anterior surgery in CP spinal deformity than idiopathic scoliosis
- decrease complication rate if A/P done on same day verses staging procedure (improved nutritional status, decreased blood loss, short length of hospitalization)
- Preoperative traction
- may be option in severe and rigid curve
- Postoperative bracing
- usually not required
- may be used in patients with osteoporosis or tenuous fixation
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| Complications |
- Implant failure
- sometimes may be asymptomatic and not require treatment
- includes penetration of pelvic limb of unit rod into pelvis
- Pulmonary complications
- chronic aspiration
- pulmonary insufficiency most common complication in recent study
- pneumonia
- GI complications
- GERD
- poor nutrition and delayed growth
- Neurologic complications
- Wound infection
- more common in CP than idiopathic scoliosis
- occurs in 3-5% and usually can be treated with local wound debridement alone
- Death (0-7%)
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