Development and treatment of spinal deformity in patients with cerebral palsy

Reoperation, Readmission, and Postoperative Bleeding in Pediatric Cerebral Palsy Patients Undergoing Spinal Arthrodesis

Background Cerebral palsy (CP) is one of the most common neuromuscular disorders in children, and spinal abnormalities are vastly more common in people with CP compared to the general population. Further investigation is needed to improve our understanding of the perioperative factors that place children with CP at greater risk of postoperative complications. This study aims to investigate (1) whether pediatric CP patients have higher rates of postoperative complications after spinal fusion and (2) risk factors for postoperative bleeding, readmission, and reoperation. Methodology The 2019 American College of Surgeons National Surgical Quality Improvement Program Pediatric database was used for this study. Chi-square tests were used to compare patient demographics, frequency of comorbidities, intraoperative factors, and postoperative complications between CP and non-CP patients. Multivariable logistic regression modeling was conducted to determine if CP was an independent risk factor for the composite variable that included postoperative bleeding, readmission, and reoperation. Results A total of 4,445 patients were included in the study, with 606 CP and 3,839 non-CP patients. Several comorbidities were more prevalent in the CP cohort, most notably asthma, gastrointestinal disease, previous cardiac surgery, and hematologic disorders. Multivariable logistic regression modeling revealed that CP, older age, non-Caucasian race, American Society of Anesthesiologists (ASA) class of 3 or higher, posterior surgical approach, previous cardiac surgery, and ostomy were significantly correlated with higher postoperative complications. Conclusions This study demonstrates that CP, older age, non-Caucasian race, ASA class of 3 or higher, posterior approach, previous cardiac surgery, and ostomy are independent risk factors for postoperative complications, including readmission, reoperation, and postoperative bleeding requiring transfusions. Consequently, there is a pressing need for additional research to establish perioperative strategies that reduce postoperative risks for these patients. Spine surgeons should consider the findings of this study when communicating the potential risks of spinal fusion surgery with patients and their families.

Impact of spinal fusion on severity health status in scoliotic adolescents with polyhandicap

BACKGROUND

Scoliosis constitutes a prevalent comorbidity in adolescents with polyhandicap and frequently leads to other severe impairments, impacting abilities and requiring complex caregiving strategies. Therefore, spinal fusion surgeries are commonly performed to alleviate pain and provide more comfort. However, spine stabilization has not previously been proven to improve the severity health status of adolescents with polyhandicap according to specific clinical scales.

OBJECTIVE

This study describes and compares the severity health status of adolescents with polyhandicap before and after they underwent spinal fusion.

METHODS

A monocentric retrospective observational study was conducted in the university hospital centre of Saint-Etienne, France. We included between 2009 to 2020, 30 scoliotic adolescents with polyhandicap who underwent spinal fusion performed with the same surgical technique and the same surgeon. The main outcome was the variation in the Polyhandicap Severity Scale (PSS) score after surgery. Secondary outcomes were variations in PSS subscores, quality of life scores, fronto-sagittal X-ray parameters, and measures of surgical complication rates and lengths of stay.

RESULTS

Among 30 adolescents, 27 PSS analyses were performed. We found a significant improvement between pre- and postoperative PSS scores, mainly for pain and respiratory, digestive, and skin disabilities. These improvements were accompanied by significant reductions in pelvic obliquity, in frontal and sagittal curves. The mean hospital length of stay was 45 days. During postoperative period, patients received a personalized postoperative rehabilitation procedure with spasticity and pain treatments, physiotherapy, and verticalization (wheelchair sitting and positioning devices such as contoured seat intended to increase postural stability). The mortality rate was estimated at 7%. At least 1 complication per patient occurred.

CONCLUSIONS

We show that spinal fusion surgeries confer a significant improvement in the severity health status in scoliotic adolescents with polyhandicap.

Therapeutic positioning to address neuromuscular scoliosis on an adolescent child with Aicardi syndrome: a case study

Among persons with neuromuscular mobility limitations, therapeutic positioning has been implemented to improve body function, avoid secondary complications such as contractures and body shape distortions, and optimize body energy through restorative sleep. This case study describes the application of a 24-hour posture care management intervention for a preadolescent girl with Aicardi syndrome. The intervention was administered by adding therapeutic bed positioning to use of a custom molded wheelchair seating system. Over the 6-year intervention period overlapping with the subject's adolescent years (age 11-17), marked improvement was observed in thoracic shape and symmetry. Moreover, the subject's mother reported regular full-nights of uninterrupted sleep, relaxed muscle tone upon waking, a stronger cough with less audible congestion, more efficient swallowing and zero hospitalizations. The 24-hour posture care management intervention offers an alternative option for families and caregivers of persons with neuromuscular mobility impairments who wish to use a low-risk, noninvasive, locally available approach to improve body symmetry, increase hours of restorative sleep, and ease caregiving routines. Further research in 24-hour posture care management, including positioning for sleep and rest, should be explored in individuals with complex movement limiting disabilities who are at risk of developing neuromuscular scoliosis.

Effect of virtual reality combined with repetitive transcranial magnetic stimulation on musculoskeletal pain and motor development in children with spastic cerebral palsy: a protocol for a randomized controlled clinical trial

PURPOSE

This trial aims to investigate the efficacy and safety of virtual reality (VR) combined with repetitive transcranial magnetic stimulation (rTMS) for improving musculoskeletal pain and motor development in children with unilateral spastic cerebral palsy (CP).

METHODS

This study protocol is for a randomized controlled trial consisting of 2 treatment sessions (3 days/week for 4 weeks in each session, with a 1-week interval between sessions). We will recruit children aged 3-10 years with unilateral spastic CP (Gross Motor Function Classification System level I or II). Participants will be randomly divided into 3 groups: the VR + rTMS group (immersive VR intervention, rTMS and routine rehabilitation therapy), rTMS group (rTMS and routine rehabilitation therapy), and control group (sham rTMS and routine rehabilitation therapy). VR therapy will involve a daily 40-minute movement training session in a fully immersive environment. rTMS will be applied at 1 Hz over the primary motor cortex for 20 min on the contralateral side. The stimulation intensity will be set at 90% of the resting motor threshold, with 1200 pulses applied. A daily 60-minute routine rehabilitation therapy session including motor training and training in activities of daily living will be administered to all participants. The primary outcome will be pain intensity, assessed by the Revised Face, Legs, Activity, Cry, and Consolability Scale (R-FLACC). The secondary outcomes will include motor development, evaluated by the 66-item version of the Gross Motor Function Measure (GMFM-66) and Fine Motor Function Measure (FMFM); balance capacity, measured by the interactive balance system; activities of daily living; and quality of life, measured by the Barthel index and the Chinese version of the Cerebral Palsy Quality of Life scale for Children (C-CP QOL-Child). Safety will be monitored, and adverse events will be recorded during and after treatment.

DISCUSSION

Combined application of VR therapy and rTMS may reveal additive effects on pain management and motor development in children with spastic CP, but further high-quality research is needed. The results of this trial may indicate whether VR therapy combined with rTMS achieves a better analgesic effect and improves the motor development of children with spastic CP.

TRIAL REGISTRATION

Registration number: ChiCTR230069853. Trial registration date: 28 March 2023. Prospectively registered.

Multisystem compensations and consequences in spastic quadriplegic cerebral palsy children

Spastic quadriplegic cerebral palsy (CP) is a permanent neuromuscular disorder causing limitation on all four limbs following a lesion on the developing brain. Most children with spastic quadriplegic CP are identified to be Gross Motor Function Classification System (GMFCS) level V, thus they have more comorbidities compared to other types at lower levels. Spastic quadriplegic CP is characterized by weak and inactive postural muscles of the neck and trunk, hence, they will undergo a total body extension as a compensatory mechanism leading to an atypical movement pattern, that give rise to multisystem consequences that reduce their quality of life. The relationship between atypical movement patterns, compensatory strategies, and multisystem consequences have not yet been explored. In fact, these multisystem consequences aggravate their condition and make movement much more atypical, forming a vicious cycle. This review aimed to provide a summary and highlight the mechanism of atypical movement pattern, multisystem compensations, and consequences in spastic quadriplegic CP children. It is true that central nervous system (CNS) lesion in CP is non-progressive, however the multisystem consequences may impair overall function over time. An understanding of how compensatory strategy and multisystem consequences in spastic quadriplegic CP offers the opportunity to intervene as early as possible to improve their quality of life.

Definitive fusions are better than growing rod procedures for juvenile patients with cerebral palsy and scoliosis: a prospective comparative cohort study

PURPOSE

This study compared the outcomes of juvenile patients with cerebral palsy (CP) and scoliosis who underwent spinal fusion (SF) versus growing rod (GR) surgery.

METHODS

Two prospective multicenter registries were queried for patients 8-10 years old with minimum 2-year follow-up who underwent SF or GR surgery (no MCGR). Demographics, radiographs, complications, and outcome scores were recorded.

RESULTS

There were 35 patients in the SF and 15 in the GR group. The mean age at surgery was 10 and 9.3 years in the SF and GR groups, respectively (p = 0.004). In the SF group preoperatively, the major curve measured 86° and 80° in the GR group (p = 0.40). "Definitive" surgery in the GR group consisted of SF in 10, implant retention in three, and implant removal in two. The SF group had 60.8% and the GR group had 45.0% correction following "definitive" surgery (p = 0.03). In the SF group, 8 patients and in the GR group, 9 patients (SF = 22.9%, GR = 60.0%) had a complication (p = 0.01). In the SF group, two patients (5.7%) had reoperations for infection; eight patients (53.3%) in the GR group had reoperations for infection and implant complications (p < 0.001). In the SF group, 23/30 parents (76.6%) noted that the child's life "improved a lot." In the GR group, 3/6 parents (50.0%) noted they were "neutral" about their child's ability to do things, 2/6 (33.3%) were "very dissatisfied."

CONCLUSIONS

SF treatment for juvenile patients with CP and scoliosis resulted in fewer complications and unplanned reoperations and better radiographic outcomes compared with GR. Quality of life improvements were also better in the SF group.

LEVEL OF EVIDENCE

Level III.

In-hospital complications after cervical fusion in cases with versus without cerebral palsy

Background

Patients with cerebral palsy (CP) are at increased risk for cervical spine pathology. Cervical fusion surgery may be considered in this population, but perioperative outcomes relative to patients without CP remains poorly understood. The purpose of this study was to compare in-hospital complications after cervical fusion in patients with versus without cerebral palsy (CP) using a retrospective cohort design.

Methods

Cervical fusion cases with and without CP were identified in the National Inpatient Sample (NIS) database. In-hospital adverse events were tabulated and grouped into any (AAE), serious (SAE), and minor adverse events (MAE). Length of hospital stay (LOS) and mortality were assessed. Multiple logistic regression models with and without 1:1 propensity matching were used to compare outcomes between cases with and without CP, controlling for demographic and preoperative variables.

Results

After weighting, 1,518,012 cases were included in the study population, of which 4,554 (0.30%) had CP. Those with CP were younger, more often male, suffered more comorbidities, more frequently operated on from a posterior or combined approach, and were more frequently addressed at more than one level. By multiple logistic regression after matching, CP cases had higher odds of AAE (OR 1.72; 95% CI 1.05-2.81; p=0.030) and MAE (OR 2.07; 95% CI 1.20-3.57; p=0.009), but no differences in odds of SAE or in-hospital mortality.

Conclusions

As there is increasing awareness of potentially cervical pathology in the CP population, the current study suggests that surgical intervention for this population can be appropriately considered without severe in-hospital morbidity or mortality.

Association of Race With Post-operative Complications After Spinal Fusion in Children With Cerebral Palsy

INTRODUCTION

Neuromuscular scoliosis in children with cerebral palsy (CP) can lead to debilitating difficulties with pain, ambulation, sitting, and respiratory or cardiac compromise. Spinal fusion can halt deformity progression, though the decision to undergo surgery involves an individualized risk-benefit assessment. The purpose of this study was to evaluate whether race is a risk factor for patients with CP to experience post-operative complications after spinal fusion.

METHODS

This is a retrospective cohort analysis of a national database. Analyses methods include univariate analyses, multivariate regression models, and other ad-hoc tests.

RESULTS

There were 3,081 pediatric patients with CP who underwent spinal fusion. Black patients had an increased risk of experiencing any post-operative complication compared to Caucasians (OR 1.322, 95% CI 1.099-1.590). Both Caucasian(p=0.005) and Black (p<0.001) races were risk factors for experiencing medical complications; Black patients had an increased risk compared to Caucasians (OR 1.373, 95% CI 1.130-1.667). Other races had a greater length of ICU stay than Caucasians (median {Mdn}=3.00 days vs Mdn=2.00, p=0.029), and longer total hospital stays than Caucasian and Black patients (Mdn=9.00 days vs Mdn=6.00 days vs Mdn=6.00 days, p<0.001).

CONCLUSION

Race is an independent risk factor for pediatric patients with CP to experience medical complications following spinal fusion surgery, with Black patients having an increased risk compared to Caucasians. Further, other races were found to have significantly longer ICU and total hospital length of stay. This study is the first to present race as a risk factor for children with CP to experience increased post-operative complications following spinal fusion and will be valuable in understanding their individualized peri-operative courses and risks.

Feeding tube use is associated with severe scoliosis in patients with cerebral palsy and limited ambulatory ability

PURPOSE

Cerebral palsy (CP) is the most common motor disorder in childhood. Scoliosis is a common complication of CP that can reach clinically severe levels, but predictors for scoliosis in CP are not well understood. Some variables identified in the literature involve the severity of the brain injury and the presence of hip deformity. We aimed to identify associations with developing severe scoliosis in a prospective cohort of patients with cerebral palsy at higher risk for severe curve progression.

METHODS

This study reviewed a prospectively collected database at a tertiary children's hospital. We evaluated a panel of potential associations with severe scoliosis-including age, sex, Gross Motor Function Classification System (GMFCS) class, history of hip surgery, epilepsy, and feeding tube presence-in a population of children with limited ambulatory ability defined as GMFCS level IV or V CP. Univariate analysis and multivariate logistic regression with stepwise selection was used for analysis.

RESULTS

Descriptive analysis showed that female sex, higher GMFCS class, history of hip surgery, non-upright seating, pelvic obliquity, presence of epilepsy, and presence of a feeding tube were associated with an increased risk for scoliosis. Multivariate logistic regression analysis revealed that the presence of a feeding tube was associated with severe scoliosis even when controlling for GMFCS and age.

CONCLUSIONS

Feeding tube use may stratify risk for severe scoliosis progression in patients with GMFCS IV or V CP.

The impact of conservative soft orthotic intervention with strapping on thoracic kyphotic posture and spinal mobility in children with cerebral palsy: a randomized control trial

Background

This study mainly aimed to evaluate the influences of Thera Togs orthotic undergarment with its strapping system on dorsal kyphotic posture and spinal mobility in children with spastic diplegic cerebral palsy. The study also investigated the impact of the modulation of thoracic kyphosis on balance and risk of falls in these children.

Study design

This study was a randomized control trial.

Participants

Forty children with diplegic cerebral palsy, aged from 8 to 10 years were met the inclusion criteria and participated in this study. Only 38 children completed the study.

Methods

The children in the control group received 2 h of conventional exercise protocol aiming for modulating thoracic kyphotic posture. The treatment program was conducted 3 times/week, for 12 successive weeks. Children in the study group wore TheraTogs orthoses with the strapping system for 8 h every day in combination with the conventional exercise program.

Outcome measures

For both groups, the primary outcome measures (thoracic kyphotic angle, and thoracic flexion and extension range of motion), and the secondary outcomes (the overall stability index of fall risk test, and the pediatric balance scale score) were recorded at baseline and after completion of the treatment. T test was used to compare the changes within-and between-groups in all measured variables, at baseline and immediately after 12 weeks of treatment.

Results

Children in the study group showed significant improvements in the scores of all primary and secondary measures post-treatment compared to the control group (P < 0.05).

Conclusion

Conservative treatment composed of TheraTogs orthotic system with conventional exercise treatment is effective in modulating thoracic kyphosis and improving dorsal range of motion in children with spastic diplegic cerebral palsy. This improvement has a positive influence on postural balance performance and reduces the risk of fall in these children.

Trial registration

The ClinicalTrial.gov PRS (NCT05063175). 30 September 2021—retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05063175

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.

Efficacy of TheraTogs orthotic undergarment on modulation of spinal geometry in children with diplegic cerebral palsy

Background

The use of TheraTogs orthotic undergarments has been suggested to improve the ability to stabilize the posture, to correct or prevent deformities, to improve functionality, and to enable the user a more appropriate functional pattern. The aim of this study was to investigate the efficacy of TheraTogs orthotic undergarment on modulation of spinal geometry in children with diplegic cerebral palsy. Forty children with diplegic cerebral palsy, with ages ranging from 6 to 9 years, were selected for this randomized controlled study. They were randomly assigned to (1) an experimental group that received TheraTogs orthotic undergarment (12 h/day, 3 days/week) plus traditional physical therapy for 3 successive months and (2) a control group that received only traditional physical therapy program for the same time period. Spinal geometry was measured at baseline and after 3 months of intervention using the Formetric system.

Results

Children in both groups showed significant improvements in the spinal geometry (P < 0.05), with significantly greater improvements in the experimental group than the control group. The post-treatment mean values of lateral deviation (mm), pelvic tilt (mm), trunk imbalance (mm), and surface rotation (mm) were 5.45, 6.35, 8.8, and 3.65 and 8, 8.9, 11.2, and 5.9 for the experimental and control group, respectively.

Conclusions

TheraTogs orthotic undergarment may be a useful tool for improving spinal geometry in children with diplegic cerebral palsy.

Trial registration

This study was registered in the ClinicalTrial.gov PRS (NCT04271618).

The effect of a flexible thoracolumbar brace on neuromuscular scoliosis: A prospective observational study

Neuromuscular scoliosis is a common deformity seen in patients with neuromuscular diseases. Although rigid thoracolumbosacral orthosis is the most frequently used brace, it has low compliance rates and can lead to complications including skin ulcers. Thus, alternative methods for treating neuromuscular scoliosis are needed. The purpose of this study is to evaluate the clinical effects of a novel flexible brace to prevent the progression of neuromuscular scoliosis.This study is a prospective observational study. Twenty-three patients with neuromuscular scoliosis were enrolled in the study. Among patients diagnosed with neuromuscular disease, spine radiographs were checked for a neuromuscular scoliosis diagnosis. The participants were treated with a novel flexible brace for 6 months. The control group (n = 46) was selected using propensity score matching method from a clinical data warehouse. The Cobb angle was measured and compared between the study and control groups.In the study group, the average Cobb's angle significantly decreased from 47.22 ± 18.9° to 31.8 ± 20.0 when wearing the flexible brace (P < .001). Thus, the correction rate was 36.9%. The annual progression rate was significantly lower in the study group than in the control group (P  < .05).The flexible brace showed a significant correction rate of scoliosis in patients with severe neuromuscular diseases. The flexible brace is an alternative treatment modality for patients with neuromuscular scoliosis. Daily application of the flexible brace during the growing period can reduce the degree of fixed deformity in the long term.

Hip-Spine Relationship: Thoracolumbar Deformation in a Patient with Limited Hip Flexion: A Case Report

CASE

We describe thoracolumbar kyphosis with severe vertebral deformation in a 13-year-old boy with cerebral palsy, hip extension contractures, and history of hip flexion-adduction releases.

CONCLUSION

Patients with cerebral palsy and hip extension contractures may develop thoracolumbar kyphosis to maintain sitting balance. It is important to recognize hip extension contractures as the underlying cause of the compensatory kyphosis and to be familiar with treatment options that address the hips and the spine.

How Do Complications Within the First 30 days after Spinal Deformity Surgery in Children with Cerebral Palsy Affect Length of Stay?

BACKGROUND

Surgery for spinal deformity in patients with cerebral palsy is reported to have high perioperative complication rates. However, minor complications are not generally reported and the influence of the varied severity of complications on length of stay is not known. Understanding the risk factors for both minor and major perioperative complications and their effect on length of stay is important information for clinicians who seek to improve care for this group of children.

QUESTIONS/PURPOSES

(1) What is the prevalence of postoperative complications in the first 30 days after surgery for spinal deformity in a New Zealand national cohort of children with cerebral palsy using the Clavien-Dindo classification? (2) What are the patient and operative predictive risk factors for minor and major perioperative complications? (3) What is the effect of year of operation on risk of minor and major perioperative complications? (4) What is the effect of perioperative complications on length of stay?

METHODS

We conducted a retrospective cohort study, identifying all children in New Zealand with a confirmed diagnosis of cerebral palsy who had surgery for a spinal deformity from January 1997 to January 2018. Two hundred-three patients with cerebral palsy (102 boys) were surgically treated for a spinal deformity, at a mean age of 14 ± 3 years, at one of three centers in New Zealand. Six children had Gross Motor Function Classification System Level II or III, 66 had Gross Motor Function Classification System Level IV, and 131 had Gross Motor Function Classification System Level V. Thirty-day perioperative complications were extracted from the patients' health records and classified according to the Clavien-Dindo system. Univariate and multivariate analyses were performed to identify patient and operative risk factors for complications, and the effect on length of stay.

RESULTS

In all, 85% of patients experienced at least one perioperative complication. There were 300 Clavien-Dindo Grade I complications in 141 patients, 156 Clavien-Dindo Grade II complications in 102 patients, 25 Clavien-Dindo Grade III complications in 22 patients, 29 Clavien-Dindo Grade IV complications in 28 patients, and one Clavien-Dindo Grade V complication (death; 0.5%). Univariate analysis showed that multiple independent factors, Gross Motor Function Classification System Level V ability (odds ratio 2.13 [95% confidence interval 1.15 to 3.95]; p = 0.02), seizure disorder (OR 2.27 [95% CI 1.20 to 4.32]; p < 0.01), preoperative Cobb angle of greater than 70° (OR 2.40 [95% CI 1.20 to 4.78]; p < 0.01), and anterior approach to surgery (OR 3.29 [95% CI 1.21 to 8.90]; p = 0.02), were associated with Grade I complications but, of these factors, only the presence of a seizure disorder (OR 2.27 [95% CI 1.20 to 4.32]; p < 0.01) was associated with Grade I complications on multivariate analysis. Previous recurrent respiratory infections predicted an increased risk of Clavien-Dindo Grade II complications (OR 3.6 [95% CI 1.81 to 7.0]; p = 0.03). The presence of a feeding gastrostomy was associated with an increased risk of Clavien-Dindo Grade IV complications (OR 2.6 [95% CI 1.19 to 5.87]; p = 0.02). The year of operation did not influence the frequency of any grade of complication, but the presence of any complication led to an increased length of stay.

CONCLUSION

Overall, 85% of patients with cerebral palsy had at least one complication after spinal deformity surgery and 25% had major complications (Grades III, IV, and V), with proportionate increases in the postoperative length of stay. Patient-specific factors aid in the identification of complication risk.

LEVEL OF EVIDENCE

Level II, prognostic study.

Reliability of a radiation-free, noninvasive and computer-assisted assessment of the spine in children with cerebral palsy

PURPOSE

The radiation-free, noninvasive and computer-assisted Spinal Mouse^® (SM) is a reliable and valid measuring instrument for functional analysis of the pediatric spine. The aim of this study was to examine the intra-rater reliability of the SM measurements in children with cerebral palsy (CP) and to investigate differences after a 1 week of the rehabilitation program.

METHODS

A total of 168 SM investigations in the sagittal plane and frontal plane at three measurement times from a sample of 28 children (n = 10 girls, age 9.7 ± 3.1 years) with CP were eligible for evaluation. For the verification of reliability, the measurement results from the first and second measurement times (t1, t2) were used at intervals of 1 day. In addition, differences after the rehabilitation program the patients underwent (t3) were evaluated using the measurement results of the first and third measurements (5-day interval).

RESULTS

The results show good to excellent intra-rater reliability for the SM measurements, both in the sagittal and in the frontal plane (ICC values = 0.69-0.99). Furthermore, significant changes may occur after only 1 week of therapeutic intervention for total spinal inclination (t1: 12.82 ± 5.40, t3: 11.11 ± 5.60, p = 0.014, Cohen's d = 0.43) and spine length (t1: 401.75 ± 69.05, t3: 409.25 ± 63.58, p = 0.030, Cohen's d = 0.43).

CONCLUSIONS

SM can be used to generate reliable values for functional analysis of the spine in children with CP. Furthermore, significant posture differences can be demonstrated by therapeutic interventions, especially in the spine inclination (Inc) and spine length (SL). These slides can be retrieved under Electronic Supplementary Material.

Asymmetry in children with unilateral cerebral palsy during sit-to-stand movement: Cross-sectional, repeated-measures and comparative study

BACKGROUND

We aimed to compare motor strategies adopted by children with unilateral Cerebral Palsy and typically developing children during the performance of sit-to-stand.

METHODS

Eleven children with unilateral cerebral palsy and 20 typically developing children were evaluated. Kinematic and kinetic analysis of the sit-to-stand movement was performed. Three seat heights were evaluated: neutral (90° of hip-knee-ankle flexion), elevated to 120% of the neutral height, and lowered to 80% of the neutral height. As outcome variables, we considered sit-to-stand duration (temporal); initial, final and maximal sagittal angles and range of motion of trunk, pelvis, hip, knee, and ankle (kinematics); the peak of vertical ground reaction force (kinetics), and asymmetric index. Effect size is represented by η₂p.

FINDINGS

We found that for the lowered seat, all groups presented increased flexion of lower limbs and trunk to initiate sit-to-stand (p≤0.012; η₂p = 0.41-0.84), increased peak flexion of trunk, hip and knee (p≤0.01; η₂p = 0.39-0.88), increased range of motion of knee and trunk (p≤0.01; η₂p = 0.45-0.85) and the duration of sit-to-stand (p≤0.05 η₂p = 0.23-0.56). Children with unilateral cerebral palsy presented increased posterior pelvic tilt (p≤0.01) and decreased hip flexion of both lower limbs (p≤0.01) for all seat heights and moved their non-affected limb backward in the lowered seat (p≤0.01). Asymmetry was observed for the final and the maximal angles of the ankle in neutral and lowered seats in unilateral cerebral palsy (asymmetry index = 3.3-5.8%).

INTERPRETATION

The lowered seat height led to adaptive motor strategies in children with unilateral cerebral palsy, which should be considered in clinical practice.

The Pros and Cons of Operating Early Versus Late in the Progression of Cerebral Palsy Scoliosis

STUDY DESIGN

Retrospective review of prospective data.

OBJECTIVE

To delineate a curve threshold where further delay of surgery significantly increased the risks for patients with cerebral palsy (CP) scoliosis.

SUMMARY OF BACKGROUND DATA

Two approaches exist in the management of CP scoliosis: a proactive one where surgery is recommended once there is a risk of progression (Cobb > 50°) and a reactive one where surgery is recommended after the patient/caregiver may have significant challenges caused by a large deformity.

METHODS

A prospectively collected CP scoliosis surgical registry was queried for patients with minimum two years of follow-up. Three groups were delineated based on the distribution of curve magnitudes: <70° (proactive), 70°-90°, and >90° (reactive). Radiographic, surgical, and quality of life outcome data were compared between the groups using analysis of variance and chi-square analyses.

RESULTS

There were 38 patients in the <70° group, 44 in the 70°-90° group, and 42 in the >90° group. They were similar in age. The >90° group had significantly longer operative time (p < .001), a higher percentage of anterior/posterior procedures (31% vs 5%), and a higher infection rate requiring I&D (16.7%) than the other groups (<70°: 5.3%; 70°-90°: 6.8%; p < .05). The percentage blood volume loss was significantly higher in the >90° group compared to <70°. There were no differences in length of hospitalization or intensive care unit stay. Preoperatively, the Caregiver Priorities and Child Health Index of Life with Disabilities (CPchild) QOL score was significantly higher for the <70° group. At two years, the <70° and 70°-90° groups reached similar QOL scores, whereas the >90° trended toward a lower postoperative QOL.

CONCLUSIONS

Being proactive (Cobb <70°) has no advantage in terms of decreasing risks or improving outcomes compared to curves 70°-90°. However, delaying surgery to a curve greater than 90° increases the risk of infection, blood loss, and the need for anterior/posterior procedures. Ideally, surgery should be recommended for curves less than 90°.

Shape Memory Ankle-Foot Orthoses

Electrically actuated ankle-foot orthoses (AFOs) were designed and prototyped using shape memory textile composites. Acrylic copolymers were synthesized as the matrix to demonstrate shape memory effects, whereas electrothermal fabrics were embedded to generate uniform heat as a trigger. Superior to conventional polymeric orthoses, shape memory AFOs (SM-AFOs) could be repeatedly programmed at least 20 times with stable shape fixity and recovery. Evidenced by clinical practice, SM-AFOs were effectively actuated at 10 V, allowing the correction of ankle angles with 10° plantarflexion. Ultimately, we envision a smart orthopedic system that can advance progressive rehabilitation with manipulation under safe and convenient conditions.

Incidence of scoliosis in cerebral palsy

Background and purpose - Surveillance of scoliosis in individuals with cerebral palsy (CP) is important for ensuring timely diagnosis and identification of curve progression. We analyzed the incidence of scoliosis in relation to age, sex, and gross motor function in a population-based cohort of individuals with CP. Patients and methods - This was a prospective register study of all 1,025 individuals born 1990-2012 in southern Sweden (1.4 million inhabitants) in the Swedish surveillance program for CP, which included >95% of the total population of people with CP in the area. Annual clinical examinations and radiographic measurement of the Cobb angle of those with a moderate or severe scoliosis were registered. We determined the incidence of scoliosis related to age, sex, and the Gross Motor Function Classification System (GMFCS) level. Results - The inclusion criteria were fulfilled by 962 individuals. The number of people (140/962) with scoliosis increased up to 20-25 years of age. The incidence of scoliosis was related to age and GMFCS level. In individuals at the lowest level of gross motor function (GMFCS V) scoliosis was seen in 10/131 before 5 years of age and at the age of 20 years 75% of these individuals had a Cobb angle ≥40°. No one in the highest level of motor function (GMFCS I) developed a Cobb angle ≥40° Interpretation - Surveillance programs for scoliosis in CP should be based on age and GMFCS level and should be initiated at a young age and continued into adulthood.

Complication rates for preexisting baclofen pumps and ventricular shunts following scoliosis correction: a preliminary study

OBJECTIVE Many patients undergoing spinal fusion for neuromuscular scoliosis have preexisting neurosurgical implants, including ventricular shunts (VSs) for hydrocephalus and baclofen pumps (BPs) for spastic cerebral palsy. Recent studies have discussed a possible increase in implant complication rates following spinal fusion, but published data are inconclusive. The authors therefore, sought to investigate: 1) the rate of implant complications following fusion, 2) possible causes of these complications, and 3) factors that place patients at higher risk for implant-related complications. METHODS Cases involving pediatric patients with a preexisting VS or BP who underwent spinal fusion for scoliosis correction between 2005 and 2016 at a single tertiary children's hospital were retrospectively analyzed. Patient demographics, implant characteristics, spinal fusion details, neurosurgical follow-up, and implant complications in the 180 days following fusion were recorded and analyzed. RESULTS Overall, 75 patients who underwent scoliosis correction had preexisting implants: 39 had BPs, 31 VSs, and 5 both. The patients' mean age at fusion was 13.49 ± 2.78 years (range 3.62-18.81 years), and the mean time from the most recent previous implant surgery to fusion was 5.70 ± 4.65 years (range 0.10-17.3 years). The mean preoperative and postoperative Cobb angles were 62.4° ± 18.9° degrees (range 20.9°-109.0°) and 23.5° ± 13.3° degrees (range 2.00°-67.3°), respectively. No VS complications were identified. Two patients with BPs were found to have complications (unintentional cutting of their BP catheter during posterior spinal fusion) within 180 days postfusion. There were no recorded neurosurgical implant infections, failures, fractures, or dislodgements. Although 10 patients required at least 1 surgical procedure for irrigation and debridement of the spine wound following fusion, there were no abdominal or cranial implant wound infections requiring revision, and no implants required removal. CONCLUSIONS The results of this study suggest that spinal fusion for scoliosis correction does not increase the rates of complications involving previously placed neurosurgical implants. A large-scale, prospective, multicenter study is needed to fully explore and confirm this finding.

Assessing the Risk-Benefit Ratio of Scoliosis Surgery in Cerebral Palsy: Surgery Is Worth It

BACKGROUND

The true benefits of scoliosis surgery in cerebral palsy (CP) remain uncertain. Our aims were to determine the benefits of spinal fusion according to health-related quality of life (HRQoL) improvement at long-term follow-up and to explore the effect of surgery-related complications on clinical outcomes.

METHODS

The cases of consecutive patients who had Gross Motor Function Classification System (GMFCS) level-IV or V cerebral palsy with 5-year follow-up from a prospective, longitudinal, multicenter database were analyzed. Caregivers completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire and 4 Likert-type anchor questions preoperatively and at 1, 2, and 5 years of follow-up. Data on complications were collected prospectively. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations using repeated-measures analysis of variance (ANOVA). Spearman correlation coefficient was used to explore the association between changes in the CPCHILD at 1, 2, and 5-year follow-up and the reported complications within the follow-up period. Similarly, a comparative analysis between the percentage distribution of the answers to the 4 anchor questions and the reported complications was also performed.

RESULTS

Sixty-nine patients with a mean age (and standard deviation) of 13.4 ± 2.6 years at enrollment were analyzed. The major Cobb angle was a mean of 81.9° ± 26.7° preoperatively and improved to a mean of 28.7° ± 14.4° at 2 years and 30.7° ± 15.3° at 5 years postoperatively. Significant improvements in CPCHILD personal care, positioning, and comfort domains were noted at all time points. The mean increase in the total score was 7.19 (p < 0.001) at 1 year, and the score gain was maintained at 2 and 5 years postoperatively. The overall complication rate was 46.4% at 1 year, 1.4% between 1 and 2 years, and 4.3% at 2 to 5 years postoperatively, with surgical intervention required in 6 patients within 1 year and in 2 additional patients within 5 years following scoliosis surgery. There was no correlation between complications and CPCHILD scores postoperatively at all time points, with the only exception of a weak correlation (ρ = -0.450, p = 0.002) with CPCHILD comfort score at 1 year after surgery.

CONCLUSIONS

Scoliosis surgery in patients with CP leads to a significant improvement in HRQoL, which is maintained 5 years following surgery. The substantial complication rate does not correlate with HRQoL changes postoperatively, suggesting that the benefits of surgery outweigh the risks in this fragile population.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

ERECTOR SPINAE AND SCOLIOSIS IN A POPULATION WITH CEREBRAL PALSY: A PRELIMINARY STUDY

ABSTRACT Objective: To verify the relation of muscular response to the vestibular stimulation of the erector spinae, specifically longissimus thoracis and iliocostalis lumborum, with the origin of scoliosis in a population of individuals with level V cerebral palsy of the Gross Motor Function Classification System (GMFCS). Methods: Cross-sectional study of 12 individuals aged between four and 14 years. The muscular activity of the longissimus thoracis and iliocostalis lumborum was recorded by electromyography in the presence of anteroposterior and lateral imbalances, comparing it with that obtained in sitting position without imbalances. Scoliosis was assessed by radiological study following Cobb method. Results: Statistically significant differences were found between correct responses of both muscles to anteroposterior imbalances and absence of right thoracolumbar scoliosis (p=0.005; p=0.028), left thoracic scoliosis (p=0.005; p=0.046) and right lumbar scoliosis (p=0.005; p=0.046). Conclusions: The symmetry of muscular responses to anteroposterior imbalances, both of longissimus thoracis and iliocostalis lumborum, seems to be one of the factors that prevent the development of spine deviations in this population. Level of evidence: IV. Type of Study: Case series

Performing a Definitive Fusion in Juvenile CP Patients is a Good Surgical Option

BACKGROUND

In juveniles with progressive curves, there is debate regarding the use of growth friendly implants versus definitive fusion. This study presents outcomes of juvenile cerebral palsy (CP) scoliosis patients who underwent definitive fusion before age 11.

METHODS

A review of a prospective, multicenter registry identified patients 10 years and younger who had a definitive posterior fusion for their CP scoliosis. Preoperative and postoperative demographic and radiographic changes were evaluated with descriptive statistics. Repeated measures analysis of variance were utilized to compare outcome scores.

RESULTS

Fourteen children with a mean age of 9.7 years (8.3 to 10.8 y) and a minimum of 2 years follow-up (range 2 to 3 y) were identified. The mean preoperative curve magnitude and pelvic obliquity was 84±25 degrees (range 63 to 144 degrees) and 25±14 degrees, respectively. All patients were skeletally immature with open triradiate cartilage. Three patients had unit rods with wires while the rest incorporated pedicle screws. Immediately postoperation, the average major curve was 25±17 degrees (P≤0.001, 71% correction rate). At most recent follow-up, the average major curve increased to 30±18 degrees (P≤0.001) for a 65% correction rate. Pelvic obliquity improved to 4±4 degrees (84% correction, P≤0.001) immediately postoperation and to 6±5 degrees (P=0.002) at latest follow-up for a 76% correction rate. None of the patients required revision surgery for progression. From pre to most recent follow-up, the CPchild Health outcome scores improved from 47 to 58 (P=0.019). One patient had a deep infection, and 1 patient had a broken rod that did not require any further treatment.

CONCLUSIONS

Progressive scoliosis in juvenile CP patients requires the surgeon to balance the need for further growth with the risks of progression or repeated surgical procedures. Our study demonstrates that definitive fusion once the curves approach 90 degrees results in significant radiographic and quality of life improvements, but further follow-up is needed to determine whether those results remain after skeletal maturity.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Lumbosacral Dorsal Rhizotomy for Spastic Cerebral Palsy: A Health Technology Assessment

BACKGROUND

Cerebral palsy, a spectrum of neuromuscular conditions caused by abnormal brain development or early damage to the brain, is the most common cause of childhood physical disability. Lumbosacral dorsal rhizotomy is a neurosurgical procedure that permanently decreases spasticity and is always followed by physical therapy. The objectives of this health technology assessment were to evaluate the clinical effectiveness, safety, cost effectiveness, and family perspectives of dorsal rhizotomy.

METHODS

We performed a systematic literature search until December 2015 with auto-alerts until December 2016. Search strategies were developed by medical librarians, and a single reviewer reviewed the abstracts. The health technology assessment included a clinical review based on functional outcomes, safety, and treatment satisfaction; an economic study reviewing cost-effective literature; a budget impact analysis; and interviews with families evaluating the intervention.

RESULTS

Eighty-four studies (1 meta-analysis, 5 randomized controlled studies [RCTs], 75 observational pre-post studies, and 3 case reports) were reviewed. A meta-analysis of RCTs involving dorsal rhizotomy and physical therapy versus physical therapy confirmed reduced lower-limb spasticity and increased gross motor function (4.5%, P = .002). Observational studies reported statistically significant improvements in gross motor function over 2 years or less (12 studies, GRADE moderate) and over more than 2 years (10 studies, GRADE moderate) as well as improvements in functional independence in the short term (10 studies, GRADE moderate) and long term (4 studies, GRADE low). Major operative complications, were infrequently reported (4 studies). Bony abnormalities and instabilities monitored radiologically in the spine (15 studies) and hip (8 studies) involved minimal or clinically insignificant changes after surgery. No studies evaluated the cost effectiveness of dorsal rhizotomy. The budget impact of funding dorsal rhizotomy for treatment of Ontario children with cerebral palsy was $1.3 million per year. Families reported perceived improvements in their children and expressed satisfaction with treatment. Ontario families reported inadequate medical information on benefits or risk to make an informed decision, enormous financial burdens, and lack rehabilitation support after surgery.

CONCLUSIONS

Lumbrosacral dorsal rhizotomy and physical therapy effectively reduces lower-limb spasticity in children with spastic cerebral palsy and significantly improves their gross motor function and functional independence. Major peri-operative complications were infrequently reported. Families reported perceived improvements with dorsal rhizotomy, and surgery and post-operative rehabilitation were intensive and demanding.

Effect of Surgical Curve Correction on Exercise Tolerance and Physical Capacities in Patients of Severe Spinal Deformity

INTRODUCTION

Traditionally, surgical intervention for patients with a spinal deformity has been considered for cosmetic benefits, but surgical intervention can alter the lung physiology or volumes and in turn leads to increase in physical capacity and exercise tolerance. Therefore, we conducted this to determine whether a surgical correction would restore the lung physiology, physical capacity and exercise tolerance in patients with kyphoscoliosis.

AIM

To evaluate the usage of six-minute walk test scores and modified Borg scores as tools/measures for exercise tolerance in patients with spinal deformity and to study the effects of surgical correction of spinal deformity on exercise tolerance with above parameters as the measures.

MATERIALS AND METHODS

Thirty patients with spinal deformity, who had undergone surgery for deformity correction, were evaluated. All patients were investigated pre-operatively with x-rays of the spine (anteroposterior and lateral views). Clinical tests like breath holding time (after full inspiration) in number of seconds, modified Borg scores, six-minute walk test scores (heart rate, respiratory rate, maximum distance walked); were recorded as measures of exercise tolerance. The patients were followed up on the first, third, sixth and twelfth month post-operatively and tested clinically for breath holding time, modified Borg scores, six-minute walk test scores (heart rate, respiratory rate, maximum distance walked) and x-rays of the spine (anteroposterior and lateral views).

RESULTS

In our study, breath holding time (p-value = 0.001) and modified Borg scores (p-value = 0.012) showed a significant improvement at 12 months post-operatively. We noted similar findings with heart rate, respiratory rate and maximum distance walked after a six-minute walk test. Improvements were noted in all the parameters, especially in the group of patients with greater than 60 degrees of cobb angle. However, the differences between the two groups (pre-operative cobb angle less than 60 degrees and pre-operative cobb angle more than 60 degrees) were not significant. The results were analysed and tested for significance using Student's t-test (paired and unpaired as appropriate) and Wilcoxon signed rank test.

CONCLUSION

Surgical correction in cases of spinal deformity improves the cosmetic appearance and balance in the patients. Favourable results of surgical intervention were found in exercise tolerance with improvements in modified Borg scores, six-minute walk test results and breath holding time. The above parameters appear to be good tools for the assessment of physical capacity and exercise tolerance in patients with spinal deformity.

The management of scoliosis in children with cerebral palsy: a review

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.

One Size Care Does Not Fit All Patients Undergoing a Spinal Fusion

PURPOSE

Spinal fusion (SF) surgery is a complex procedure that affects children with and without underlying disabilities. The purpose of this article was to describe the necessary steps when preparing a child, specifically with cerebral palsy (CP), and family for an SF, while also emphasizing the postoperative care during discharge planning.

DESIGN

Literature review on pediatric patients undergoing SF and those who have CP.

METHODS

Literature was searched using the CINAHL database, from 2009 to 2016. Key terms included spinal fusion, cerebral palsy, pediatrics, orthopedic surgery, team approach, management and developmental disability, or disability. Literature was reviewed to provide recommendations on caring for children undergoing an SF who also have CP as little literature supports exact care measures on this cohort of patients.

FINDINGS

Variations exist in the surgery type, specification, and approach, as well as history, growth, and developmental capabilities of the child and caregiver's expectations. Nurses must be aware of all of these factors to promote safe, effective, timely, and patient-centered care. In particular, patients with an underlying condition of CP may be more likely to experience complications that make understanding these processes essential to the surgery itself.

CONCLUSIONS

Although an SF may be a necessary surgery to correct a curve or spine deformity, there are many complications that a child with CP might encounter. The health care team must work closely with the child and the family to ensure that all treatment recommendations are met to minimize any unnecessary complications. Each surgery must focus specifically on meeting the child's and family's needs to ensure success while incorporating the health care team's approach.

CLINICAL RELEVANCE

Providing patient and family-centered care for children having an SF is essential to optimize outcomes and improve quality of life for patients and caregivers.

The use of dynamic elastomeric fabric orthosis suits as an orthotic intervention in the management of children with neuropathic onset scoliosis: A retrospective audit of routine clinical case notes

Background

To date the main treatment approach for neuropathic onset scoliosis has utilised thoracic lumbar sacral orthoses (TLSO) to stabilize the spine and enable stable sitting. Dynamic elastomeric fabric orthoses (DEFOs) may achieve both of these aims if used as an early intervention. Due to a lack of evidence in this area, a retrospective audit of case notes was undertaken to understand current orthotic practice investigating the usage, outcomes and clinical characteristics of treated children with neuropathic onset scoliosis. Clinical notes of 180 children at risk for, or identified with, scoliosis were audited using a search matrix to identify diagnostic group, spinal muscle tone, Gross Motor Functional Classification Scale (GMFCS) level, orthotic treatment modalities, scoliosis specific data, surgical interventions, adaptive technologies used, and outcome measurements reported.

Results

Of the 180 notes examined, 85 were male; mean age nine years one month [SD four years seven months]. Spinal muscle tone was reported in 137 cases: 122/137 presented as low tone, 4/137 high tone, 6/137 fluctuating tone and 5/137 typical tone. Scoliosis was confirmed in (77/180) of whom (39/77) used a DEFO. Another (43/180) had a spinal curve developing, of whom (22/43) used a DEFO. The remaining (60/180) had no report of spinal curvature, but used a DEFO as a preventative measure. GMFCS scores were reported for 49 children of whom 14/49 were graded as level 4 and 17/49 level 5. Of the children with scoliosis who had spinal curve shapes reported, 48/60 had a C-shape presentation and 12/60 had an S-shape.

Conclusions

The findings confirm previously reported papers in children with neuropathic onset scoliosis in relation to curve shape and GMFCS levels. It provides some evidence of the role DEFOs may have in the management of these children, and highlights the need for further research in this area due to the lack of peer-reviewed publications.

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.

Trunk movements during gait in cerebral palsy

BACKGROUND

Lower limb deficits have been widely studied during gait in cerebral palsy, deficits in upper body have received little attention. The purpose of this research was to describe the characteristics of trunk movement of cerebral palsy children in terms of type of deficits (diplegia/hemiplegia) and gross motor function classification system (1, 2 or 3).

METHODS

Data from 92 cerebral palsy children, which corresponds to 141 clinical gait analysis, were retrospectively selected. Kinematic parameters of trunk were extracted from thorax and spine angles in the sagittal, transverse and coronal planes. The range of motion and the mean positions over the gait cycle were analysed. Intra-group differences between the children with diplegia or hemiplegia, gross motor function classification systems 1 to 3 and typically developing participants were analysed with Kruskal-Wallis tests and post hoc tests. Pearson correlation coefficients between the gait profile score normalised walking speed and kinematic parameters of the thorax were assessed.

FINDINGS

The results revealed: 1) the range of motion of the thorax and spine exhibited more significant differences between groups than the mean positions; 2) greater levels of impairment were associated with higher thorax range of motion, and 3) the children with diplegia and gross motor function classification system 3 exhibited a greater range of motion for all planes with the exception of spine rotation.

INTERPRETATION

This study confirmed that greater levels of impairment in cerebral palsy are associated with greater thorax range of motion during gait. The thorax plays an important role during gait in cerebral palsy.

A preliminary study to evaluate postural improvement in subjects with scoliosis: active therapeutic movement version 2 device and home exercises using the Mulligan's mobilization-with-movement concept

OBJECTIVE

The purpose of this preliminary study was to determine if the use of Active Therapeutic Movement Version 2 (ATM2) device and home exercises using the Mulligan's mobilization-with-movement concept by subjects with scoliosis would result in postural improvement and to document any changes in trunk range of motion and quality of life.

METHODS

Forty-three subjects between the ages of 12 to 75 years were recruited for the study. Each subject underwent a low back evaluation along with specific measurements for their scoliosis. Subjects participated in a 4-week intervention, 2 times a week consisting of treatment utilizing the ATM2 and were also given a home exercise program to mimic the specific movement(s) they performed on the ATM2. Photographic assessment of posture was taken before and after the intervention. Subjects were surveyed during the initial assessment and again at the final intervention using the following outcome measures: Fear Avoidance Belief Questionnaire, Short-Form Health Survey-36, Oswestry Disability Index, and a Numeric Pain Rating Scale.

RESULTS

Results were significant for most of the variables measured. Subjects gained improvement in spinal ranges of motion for all directions except for flexion and extension (most subjects had reference range of flexion and extension at the beginning of the study). Most subjects had improved pelvic alignment after the intervention. Before and after photographs demonstrated improved posture. Subjective measurements of pain, disability, and quality of life improved.

CONCLUSIONS

Results of this preliminary study showed improvement for selected variables. The use of ATM2 and home exercises using the Mulligan's mobilization-with-movement concept by subjects with scoliosis appears to be a potentially viable conservative treatment alternative to address various findings associated with scoliosis, including posture improvement.

Surgical correction of spinal deformity in patients with cerebral palsy using pedicle screw instrumentation

STUDY DESIGN

Retrospective review of a prospectively collected single surgeon's series.

OBJECTIVE

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.

SUMMARY OF BACKGROUND DATA

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Prevalence of complications in neuromuscular scoliosis surgery: a literature meta-analysis from the past 15 years

PURPOSE

Our objectives were primarily to review the published literature on complications in neuromuscular scoliosis (NMS) surgery and secondarily, by means of a meta-analysis, to determine the overall pooled rates (PR) of various complications associated with NMS surgery.

METHODS

PubMed and Embase databases were searched for studies reporting the outcomes and complications of NMS surgery, published from 1997 to May 2011. We focused on NMS as defined by the Scoliosis Research Society's classification. We measured the pooled estimate of the overall complication rates (PR) using a random effects meta-analytic model. This model considers both intra- and inter-study variation in calculating PR.

RESULTS

Systematic review and meta-analysis were performed for 68 cohort and case-control studies with a total of 15,218 NMS patients. Pulmonary complications were the most reported (PR = 22.71 %) followed by implant complications (PR = 12.51 %), infections (PR = 10.91 %), neurological complications (PR = 3.01 %) and pseudoarthrosis (PR = 1.88 %). Revision, removal and extension of implant had highest PR (7.87 %) followed by malplacement of the pedicle screws (4.81 %). Rates of individual studies have moderate to high variability. The studies were heterogeneous in methodology and outcome types, which are plausible explanations for the variability; sensitivity analysis with respect to age at surgery, sample size, publication year and diagnosis could also partly explain this variability. In regard to surgical complications affiliated with various surgical techniques in NMS, the level of evidence of published literature ranges between 2+ to 2-; the subsequent recommendations are level C.

CONCLUSION

NMS patients have diverse and high complication rates after scoliosis surgery. High PRs of complications warrant more attention from the surgical community. Although the PR of all complications are affected by heterogeneity, they nevertheless provide valuable insights into the impact of methodological settings (sample size), patient characteristics (age at surgery), and continual advances in patient care on complication rates.

Automatic recognition of surface landmarks of anatomical structures of back and posture

Faulty postures, scoliosis and sagittal plane deformities should be detected as early as possible to apply preventive and treatment measures against major clinical consequences. To support documentation of the severity of deformity and diminish x-ray exposures, several solutions utilizing analysis of back surface topography data were introduced. A novel approach to automatic recognition and localization of anatomical landmarks of the human back is presented that may provide more repeatable results and speed up the whole procedure. The algorithm was designed as a two-step process involving a statistical model built upon expert knowledge and analysis of three-dimensional back surface shape data. Voronoi diagram is used to connect mean geometric relations, which provide a first approximation of the positions, with surface curvature distribution, which further guides the recognition process and gives final locations of landmarks. Positions obtained using the developed algorithms are validated with respect to accuracy of manual landmark indication by experts. Preliminary validation proved that the landmarks were localized correctly, with accuracy depending mostly on the characteristics of a given structure. It was concluded that recognition should mainly take into account the shape of the back surface, putting as little emphasis on the statistical approximation as possible.

Pathways that distinguish simple from complex scoliosis repair and their outcomes

PURPOSE OF REVIEW

Surgical management of spinal deformities in patients with neuromuscular diseases or other underlying comorbidities is often challenging, as this population is at an increased risk of experiencing complications. Identifying these patients early on in the preoperative planning process is imperative in order to improve patient outcomes.

RECENT FINDINGS

Many recent studies have identified risk factors associated with perioperative and postoperative complications, including neuromuscular diseases, genetic syndromes, traumatic nerve/muscle injuries, seizure disorders, decreased cognitive ability, poor pulmonary status, restrictive lung disease, history of frequent pneumonias, sleep apnea, malnutrition, cardiac disease, immune-compromised patients, social status, ambulatory status, and the complexity of the procedure itself.

SUMMARY

Management of spinal deformities in patients with neuromuscular diseases or other underlying comorbidities must be approached cautiously and in a multidisciplinary manner. Identifying these comorbidities early on, understanding their influence on patient outcomes after spinal surgery and managing high-risk patients through a common therapeutic and clinical pathway can help to improve patient outcomes.