Scoliosis surgery in cerebral palsy: differences between unit rod and custom rods

Transition of Caregiver Perceptions after Pediatric Neuromuscular Scoliosis Surgery

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.

An intraoperative laterally placed distractor for gradual load sharing correction of severe spastic neuromuscular spinal deformity

PURPOSE

To analyze the overall deformity correction for severe neuromuscular scoliosis using laterally placed intra-operative distraction and compare to those receiving standard surgical technique.

METHODS

This was a retrospective, IRB-approved, cohort study of patients with GMFCS 4 or 5 spastic cerebral palsy with neuromuscular scoliosis, age greater than 10 years, who underwent posterior spinal fusion from 2007 to 2019. All patients had vectored cervical traction with Gardner-Wells tongs, with hips flexed in a relative sitting position. The study cohort underwent intraoperative, laterally placed correction using a distractor placed between two upper ribs and the ipsilateral greater trochanter while the control cohort did not. The 24 study patients were compared to 22 control patients.

RESULTS

Preoperative comparisons identified significant differences in Cobb angle, preoperative flexibility, and pelvic obliquity with the study group having larger, stiffer deformities with greater obliquity. There were no differences in pre-operative sagittal plane deformity. Mean post-operative upright Cobb angle correction was 67.3° ± 14.8° in the study and 55.3° ± 9.9° in the control group, representing a 66% and 60% correction, respectively. No neurological or other complications were noted from the use of this technique.

CONCLUSION

The use of a laterally placed distraction device from upper ribs to ipsilateral greater trochanter allowed gradual lateral un-bending of large stiff neuromuscular spine deformities with greater correction than that of standard technique. In this small series, the technique allowed load-sharing during correction, with hips remaining in a functional sitting position, and without neurological complications.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Variability in length of stay following neuromuscular spinal fusion

BACKGROUND

Patients with neuromuscular scoliosis (NMS) who undergo posterior spinal fusion (PSF) often have long, protracted hospital stays because of numerous comorbidities. Coordinated perioperative pathways can reduce length of hospitalization (LOH) without increasing complications; however, a subset of patients may not be suited to rapid mobilization and early discharge.

METHODS

197 patients with NMS underwent PSF at a single hospital by two surgeons with a post-operative care pathway emphasizing early mobilization, rapid transition to enteral feeds, and discharge prior to first bowel movement. Average LOH was 4.9 days for all patients. Patients were divided into quartiles (< 3 days, 3-5 days, 5-7 days, > 7 days) based on their LOH, and their charts were retrospectively reviewed for preoperative, intraoperative, and postoperative factors associated with their LOH.

RESULTS

Age at surgery, gender, the need for tube feeds, and specific underlying neuromuscular disorder were not significant predictors of LOH; however, severely involved cerebral palsy (CP) patients (GMFCS 4/5) were more likely to have extended stays than GMFCS 1-3 patients (p = 0.02). Radiographic predictors of LOH included major coronal Cobb angle (p = 0.002) and pelvic obliquity (p = 0.02). Intraoperative predictors included longer surgical times, greater numbers of levels fused and need for intraoperative or postoperative blood transfusion (p < 0.05). The need for ICU admission and development of a pulmonary complication were significantly more likely to fall into the extended LOH group (p < 0.05).

CONCLUSIONS

Several variables have been identified as significant predictors of LOH after PSF for NMS in the setting of a standardized discharge pathway. Patients with smaller curves and less complex surgeries were more amenable to accelerated discharge. Conversely, patients with severe CP with large curves and pelvic obliquity requiring longer surgeries with more blood loss may not be ideal candidates. These data can be used to inform providers' and families' post-operative expectations.

LEVEL OF EVIDENCE

Therapeutic Level III.

Pelvic Obliquity Correction in Distraction-Based Growth Friendly Implants

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.

Youth and Experience: The Effect of Surgeon Experience on Outcomes in Cerebral Palsy Scoliosis Surgery

BACKGROUND

Series on the learning curve in spinal deformity surgery have been published, but none has addressed neuromuscular spinal deformity, comprised of arguably the most complex cases. We present the first multi-center analysis of the impact of surgeon experience on neuromuscular spinal deformity surgery.

METHODS

A multi-center prospective study of spinal deformity surgery for cerebral palsy (CP) with at least 2 years of follow-up provided the dataset for assessment. Surgeons were categorized into one of two groups based on their self-reported first year of practice: an experienced surgeons (ES) group included those with at least 10 years of experience at the time of surgery and a young surgeons (YS) group included those with fewer than 10 years of experience at time of surgery. Groups were compared in multiple pre-operative, operative, and post-operative outcomes.

RESULTS

The YS group had 8 surgeons who performed 59 surgeries; the ES group had 13 surgeons who performed 103 cases, with one surgeon's cases distributed in both groups. The YS group had a greater proportion of patients with severe mental retardation (89.7% vs. 68.6%, p = .01). Duration of surgery was greater in the YS group (456 vs. 344 minutes, p < .001). The mean number of levels fused was greater in the ES group (15.9 vs. 15.6, p = .024), caused by increased variation in the upper level of fusion among the ES group. No significant differences were found between groups for estimated blood loss, length of hospitalization, or in percentage of Cobb correction. Years of experience of the operating surgeon was inversely correlated with duration of surgery (rho = -0.476, p < .001).

CONCLUSIONS

In performing scoliosis surgery on CP patients, surgeons with fewer than ten years of practice experience demonstrate significantly greater average operative time and decreased mean number of levels fused, yet produce similar clinical outcomes to more experienced surgeons.

LEVEL OF EVIDENCE

Level III, therapeutic.

Incidence of and Risk Factors for Loss of 1 Blood Volume During Spinal Fusion Surgery in Patients With Cerebral Palsy

BACKGROUND

Spinal fusion surgery is associated with greater blood loss in patients with cerebral palsy (CP) than in patients with adolescent idiopathic scoliosis. Risk factors for loss of 1 blood volume (LOBV) in patients with CP have not been well studied. We investigated the incidence of and risk factors for LOBV during spinal fusion surgery in young patients with CP.

METHODS

We queried a multicenter registry of CP patients for all patients 21 years or younger who had undergone spinal fusion from 2008 through 2013; 272 patients met these criteria. We analyzed data on patient characteristics, preoperative laboratory values, radiographic measures, and surgical characteristics. For univariate analysis, we used χ tests and logistic regression models. Factors that were significant in the univariate analysis were used to construct a multivariate logistic regression model. Significance was set at P<0.01.

RESULTS

Incidence of LOBV was 39.7%. On multivariate analysis, unit rod construct and coronal curve magnitude were significantly associated with LOBV (P<0.01). The multivariate model accounted for 32.2% of variance in LOBV. Compared with patients with pedicle screw-rod constructs, patients with unit rod constructs had 12.6-fold higher odds of LOBV (P<0.01). For each 1-degree increase in coronal curve magnitude, odds of LOBV increased 1.03-fold (P<0.01).

CONCLUSIONS

In patients with CP, there is a substantial risk of LOBV during spinal fusion surgery. Use of unit rod constructs and greater preoperative coronal curves were significant risk factors for LOBV during surgery.

LEVEL OF EVIDENCE

Level II.

Outcomes after scoliosis surgery for children with cerebral palsy: a systematic review

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.

Surgical correction of scoliosis in patients with severe cerebral palsy

INTRODUCTION

There is a lack of data in the literature on surgical correction of severe neuromuscular scoliosis in patients with serious extent of cerebral palsy. The purpose of this retrospective cohort study was to analyze the radiological and clinical results after posterior-only instrumentation (group P) and combined anterior-posterior instrumentation (group AP) in severe scoliosis in patients with Gross Motor Function Classification System grades IV and V.

MATERIALS AND METHODS

All eligible patients who underwent surgery in one institution between 1997 and 2012 were analyzed, and charts, surgical reports, and radiographs were evaluated with a minimum follow-up period of 2 years.

RESULTS

Fifty-seven patients were included (35 in group P, 22 in group AP), with a median follow-up period of 4.1 years. The preoperative mean Cobb angles were 84° (34 % flexibility) in group P and 109° (27 % flexibility) in group AP. In group P, the Cobb angle was 39° (54 % correction) at discharge and 43° at the final follow-up, while in group AP the figures were 54° (50 % correction) at discharge and 56° at the final follow-up. Major complications occurred in 23 vs. 46 % of the patients, respectively. Preoperative curve flexibility was an important predictor for relative curve correction, independently of the type of surgery.

CONCLUSION

Posterior-only surgery appears to lead to comparable radiological results, with shorter operating times and shorter intensive-care unit and hospital stays than combined surgery. The duration of surgery was a relevant predictor for complications.

Major perioperative complications after spine surgery in patients with cerebral palsy: assessment of risk factors

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 < 0.05) and hospital stays (NC = 7.7 days, YC = 15.6 days, p < 0.05). Variables associated with greater risk of a complication included: increased estimated blood loss (EBL) (p < 0.001), larger preoperative kyphosis (p = 0.05), staged procedures (p < 0.05), a lack of antifibrinolytic use (p < 0.05), and a trend toward lower body mass index (BMI) (p = 0.08). Multivariate regression analysis revealed an increased EBL as independently associated with a major perioperative complication (p < 0.05).

CONCLUSIONS

In this cohort of patients with CP who underwent spinal fusion, 39.4% experienced a major perioperative complication, with pulmonary being the most common. The occurrence of a major perioperative complication lengthened both ICU and hospital stay. Risk factors for major perioperative complications included greater preoperative kyphosis, staged procedures, a lack of antifibrinolytic use, and increased EBL, with the latter being an independent predictor of a major perioperative complication.

LEVEL OF EVIDENCE

2.

Major surgical procedures in children with cerebral palsy

There are 3 surgical procedures that patients with cerebral palsy (CP) undergo that may be considered major procedures: femoral osteotomies combined with pelvic osteotomies, spine fusion, and intrathecal baclofen pump implant for the treatment of spasticity. Many complications are known to occur at a higher rate in this population, and some may be avoided with prior awareness of the preoperative pathophysiology of the patient with CP.

Deep wound infections after spinal fusion in children with cerebral palsy: a prospective cohort study

STUDY DESIGN

Prospective cohort.

OBJECTIVE

To (1) calculate the rate of deep wound infection in children with cerebral palsy (CP) after spinal fusion surgery; (2) identify factors (patient, laboratory, and surgical) associated with deep wound infection development; and (3) report causative organisms.

SUMMARY OF BACKGROUND DATA

Wound infection after spine fusion for CP is more common than after spine fusion for most other diagnoses.

METHODS

We prospectively gathered data on 204 consecutive pediatric patients with CP who underwent surgery at 7 institutions. Univariate and multivariate regression analysis was performed to analyze patient, laboratory, and surgical characteristics to identify factors that were significantly associated with infection development. Statistical significance was set at a value of P less than 0.05.

RESULTS

Deep wound infection developed in 13 (6.4%) children. The mean time to infection development was 34.2 ± 60.2 days. On univariate analysis, older age, larger curve size, presence of gastrostomy/gastrojejunostomy tube, higher preoperative serum white blood cell count, and longer operative time were significantly associated with deep wound infection. On multivariate analysis, only the presence of a gastrostomy/gastrojejunostomy tube remained significant (1.9-fold risk of deep wound infection compared with patients without tubes). Escherichia coli was the most common organism cultured from the wound sites (5 patients). Other infective agents were: Pseudomonas aeruginosa (2), methicillin-susceptible Staphylococcus aureus (1), Proteus mirabilis (1), and polymicrobial organisms (4).

CONCLUSION

Deep wound infection occurred in 6.4% of children with CP after spinal fusion. The presence of a gastrostomy/gastrojejunostomy tube was a significant predictor of infection. Gram-negative organisms were the most common causative agents. Surgeons should be cognizant of these factors when treating children with CP and may consider Gram-negative antibiotic prophylaxis.

Pelvic fixation for neuromuscular scoliosis deformity correction

Pelvic fixation is most frequently indicated in the pediatric population for the treatment of neuromuscular scoliosis with significant pelvic obliquity. Neuromuscular scoliosis surgery is associated with a high risk of complications, and this is further increased by extension of fusion to the sacrum. Numerous techniques have been described for pelvic fixation associated with a long spine fusion each with its own set of specific benefits and risks. This article reviews the contemporary surgical techniques of pelvic fixation used to extend a spine fusion to the sacrum and pelvis focusing on the management of neuromuscular scoliosis, including their biomechanical rationale, results, and complications.

Results and complications after spinal fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy using luque galveston instrumentation: experience in 93 patients

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To evaluate the results of spine fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy, using Luque-Galveston technique, with emphasis on the early and late complications, especially those increasing the hospital stay or requiring additional surgery.

SUMMARY OF BACKGROUND DATA

There are numerous studies in the literature on the treatment of neuromuscular scoliosis using Luque-Galveston instrumentation analyzing the results and complications. Most series are small and evaluate some of the complications, with none evaluating all the early and late complications and none assessing the impact of the complication on length of hospitalization or the need for additional surgical intervention.

METHODS

This was a retrospective review of a consecutive series of patients operated on for neuromuscular scoliosis in cerebral palsy and static encephalopathy with Luque-Galveston instrumentation at 1 institution from January 1997 to December 2003. Ninety-three patients were identified.

RESULTS

The average age at surgery was 14.3 years, with an average age at follow-up of 18.2 years, and an average follow-up of 3.8 years. The mean preoperative scoliosis was 72° with correction postoperatively to a mean of 33°, maintained at 36° at final follow-up. There were 83 early complications in 54 patients, for a complication rate of 58% of patients for the entire study. There were no perioperative deaths or neurological complications. There was only 1 deep wound infection, for an infection rate of 1.1%. Patients with 1 complication had a longer length of stay, 9 versus 7 days, the difference being statistically significant (Mann-Whitney U test, P < 0.001). Two patients required reoperation during the initial hospitalization (1.1%): 1, one for infection and 1 for proximal hook cutout and proximal junction kyphosis. There were a total of 81 late complications in 44 patients, for a late complication rate of 47% of patients for the entire study. The majority of the complications were minor, not requiring additional care or surgery. Seven patients had a pseudarthrosis (7.5%), presenting at an average of 30 months postoperatively. Eight patients underwent 9 procedures for late complications: 5 for repair of a pseudarthrosis, 3 for removal of a prominent iliac screw, and 1 for superior junctional kyphosis. All the pseudarthrosis repairs were solid at follow-up.

CONCLUSION

Spinal fusion in neuromuscular scoliosis with Luque-Galveston technique is a safe and effective procedure. Any early complication increased the length of stay, with a low rate of reoperation during the hospitalization. The majority of late complications were minor, not requiring additional care. Pseudarthroses were detected late and were the main reason for additional surgery.

Surgical site infection after pediatric spinal deformity surgery

The incidence of surgical site infection (SSI) after spinal deformity surgery for adolescent idiopathic scoliosis ranges from 0.5-6.7%. The risk of infection following spinal fusion in patients with neuromuscular scoliosis is greater, with reported rates of 6.1-15.2% for cerebral palsy and 8-41.7% for myelodysplasia. SSIs result in increased patient morbidity, multiple operations, prolonged hospital stays, and significant financial costs. Recent literature has focused on elucidating the most common organisms involved in SSIs, as well as identifying modifiable risk factors and prevention strategies that may decrease the rates of infection. These include malnutrition, positive urine cultures, antibiotic prophylaxis, surgical site antisepsis, antibiotic-loaded allograft, local application of antibiotics, and irrigation solutions. Acute and delayed SSIs are managed differently. Removal of instrumentation is required for effective treatment of delayed SSIs. This review article examines the current literature on the prevention and management of SSIs after pediatric spinal deformity surgery.

Surgical management of spinal deformities in cerebral palsy. A review

Cerebral palsy (CP) spinal deformities encompass a spectrum of deformities that are often initially treated nonoperatively, only to result in progression of scoliotic curves and further morbidity. Various surgical interventions have been devised to address the progressive curvature of the spine. This endeavor cannot be taken lightly and at times can be encumbered by prior treatments such as the use of baclofen pumps or dorsal rhizotomies. Care of these patients requires a multidisciplinary approach and comprehensive preoperative and postoperative management, including nutritional status, orthopedic assessment of functional level with specific emphasis on the hips and pelvic obliquity, and wheelchair modifications. The surgical techniques in CP scoliosis have progressively evolved from the classic Luque-Galveston fixation methods, the use of unit rods, and lately the use of pedicle screws, to modern sacropelvic fixation. With the latter method, the spinal deformity in patients with CP can usually be almost completely corrected.

Management of spinal deformity in cerebral palsy

An understanding of the three-dimensional components of spinal deformity in children with cerebral palsy is necessary to recommend treatments that will positively affect these patients' quality of life. Management of these deformities can be challenging and orthopedic surgeons should be familiar with the different treatments available for this patient population. This article discusses the incidence, causes, natural history, and treatment of patients with scoliosis.

Low profile pelvic fixation with the sacral alar iliac technique in the pediatric population improves results at two-year minimum follow-up

STUDY DESIGN

Retrospective review.

OBJECTIVE

Anchor stability and prominence are problems with pelvic fixation in pediatric spinal deformity surgery. We compared the new sacral alar iliac (SAI) fixation technique (with a starting point in the sacral ala and in-line anchors deep under the midline muscle flap) with other methods of screw fixation.

SUMMARY OF BACKGROUND DATA

Iliac anchors have been shown to provide the best form of pelvic fixation. A trajectory from the posterior sacral surface to the iliac wings has recently been described. To our knowledge, no clinical series has compared this method of pelvic fixation in children to others.

METHODS

Of 32 consecutive pediatric patients who underwent SAI fixation, 2 died and 26 returned for follow-up (>2 years). Mean age at surgery was 14 years. Average screw size was 67 mm long and 7 to 9 mm in diameter. Clinical examinations, radiographs, and computed tomography scans were analyzed. Outcomes included pain over the implants, screw placement, implant prominence, radiographic lucency, need for revision, and infection. SAI patients were compared with 27 previous patients who had pelvic fixation via other screw techniques.

RESULTS

For SAI fixation, correction of pelvic obliquity and Cobb angles were 20° ± 11° (70%) and 42° ± 25° (67%), respectively. For other pelvic fixation methods, those values were 10° ± 9° (50%), and 46° ± 16° (60%), respectively. Compared with other screws, SAI screws provided significantly better pelvic obliquity correction (P = 0.002) but no difference in Cobb correction. There were 2 lucencies adjacent to screws in both groups. Computed tomography scans of 18 SAI patients showed no intrapelvic protrusion, but 1 screw extended laterally (<5 mm). One early SAI patient required revision with larger screws, which relieved pain; there was 1 revision in the comparison group. SAI patients had no deep infections, implant prominence, late skin breakdown, or anchor migration; traditional patients had 3 deep infections (P = 0.09) and 3 instances of implant prominence, skin breakdown, or anchor migration.

CONCLUSION

SAI pelvic fixation produces better correction of pelvic obliquity than do previous techniques. Radiographic and clinical anchor stability is satisfactory at 2-year follow-up.

Surgical management of spasticity in persons with cerebral palsy

Cerebral palsy is a disorder that primarily affects the neurologic system but secondarily affects the musculoskeletal system through the effects of spasticity, dystonia, and other movement disorders. The treatment of cerebral palsy requires a multidisciplinary approach with treatment aimed at modulating the movement disorder through oral medication, injectable drugs (phenol, botulinum toxin), and physical and occupational therapy. Treatment of the neurologic effects of the central movement disorders include selective dorsal rhizotomy, intrathecal baclofen pump placement, and potentially deep brain stimulation. Although any effect on tone is temporary, orthopedic surgery has an important role in the treatment of the musculoskeletal deformities and contractures present in the child with cerebral palsy. Orthopedic surgery improves function by lengthening the musculotendinous structures, transferring tendons, performing osteotomies to reduce dislocated joints, and normalizing rotation and fusion of selected joints to improve stability. Neurosurgical techniques are not as widely used, but may reduce spasticity in select individuals. The combined approach of managing tone and normalizing the biomechanics of the spine and upper and lower extremities through orthopedic surgery and neurosurgery and subsequent rehabilitation is the cornerstone of treatment of the child and adult with cerebral palsy.