PurposeConcerns about pain control in patients with cerebral palsy (CP) are especially anxiety provoking for parents, given the fact that spasticity, communication issues, and postoperative muscle spasms are significant problems that make pain control difficult in these patients. A better understanding of the magnitude and quality of the pain these patients experience after our surgical procedures would better prepare the patients and their families. The purpose of this study is to quantify the amount of postoperative pain in children with CP undergoing hip reconstruction and spinal fusion. Specifically, the study will compare pain scores and the amount of narcotics used between the two groups.Materials and methodsThis is a retrospective chart review of a consecutive series of children with CP (GMFCS levels IV and V) over a 5-year period undergoing hip reconstruction (femoral osteotomy, pelvic osteotomy, or both) and posterior spinal fusion (PSF) at a tertiary-care pediatric hospital. The primary end point was the total opioid used by the patient during the hospitalization, by converting all forms of narcotics to morphine equivalents. The secondary end point was the documentation of pain with standard pain scores at standard time points postoperatively. Adverse effects related to pain management were documented for both groups. Student’s t-tests were utilized to statistically compare differences between the groups, with significance determined at p < 0.05.ResultsForty-two patients with CP who underwent hip reconstruction (mean age 8.8 years) were compared to 26 patients who underwent PSF (mean age 15.4 years). The total opioid used, normalized by body weight and by days length of stay (DLOS), in the hip group was 0.49 mg morphine/kg/DLOS, compared to 0.24 for the spine group (p = 0.014). The mean pain score for the hip group was 1.52, compared to 0.72 for the spine group (p = 0.013). There were no significant differences in the occurrence of adverse effects related to pain management between the two groups.ConclusionPatients with CP undergoing hip reconstruction surgery had significantly more pain, as exhibited by requiring more narcotics and having higher pain scores, than those patients undergoing PSF. The knowledge that hip reconstruction is more painful than PSF for patients with CP will better prepare families about what to expect in the postoperative period and will alert providers to supply better postoperative pain control in these patients.Level of evidenceIII (case control series).

PurposeNeuromuscular (NM) hip dysplasia is common in patients with cerebral palsy (CP). Traditionally, migration percentage (MP) has been used to measure the severity of NM hip dysplasia; however, the MP has some limitations. The purpose of this study is to determine the intra- and inter-reliability of the Melbourne Cerebral Palsy Hip Classification System in the typical paediatric population of patients with CP.MethodsA total of 65 anteroposterior pelvis radiographs in patients (age range 12 years to 21 years) with CP spanning all grades (I to VI) of the classification system were identified and collected for analysis in this institutional review board approved study. Four paediatric orthopaedic surgeons and one orthopaedic surgical resident classified each radiograph according to the Melbourne system. Then, at least four weeks later, the raters repeated the process with a re-randomised order of radiographs. Statistical analysis was performed using the intraclass correlation coefficient (ICC) where < 0 denotes poor agreement and > 0.8 indicates almost perfect agreement.ResultsThe interobserver reliability was found to be excellent with the ICC of 0.853 (0.813 to 0.887) and 0.839 (0.795 to 0.877). The intraobserver reliability was also found to be excellent with the ICC in the range of 0.838 to 0.933 among the raters. Subgroup analysis indicated no differences in the reliability of observers based on clinical experience.ConclusionThis study independently demonstrates that the Melbourne Cerebral Palsy Hip Classification System for NM hip dysplasia in patients with CP can be reliably used for communication among various healthcare providers and research and epidemiological purposes.

In this case-control analysis, patients with AIS undergoing PSF received more than twice the amount of narcotic compared with a matched group of patients with NM scoliosis. These data suggest that NM patients' pain may be undertreated compared with AIS patients. More study is indicated to investigate pain assessment and pain control in this vulnerable patient population to improve care.