Surgical management of spinal deformities in cerebral palsy

Abstract

Cerebral palsy is a nonprogressive encephalopathy caused by a brain dysfunction that occurs during the pre-, peri-, or postnatal phase of development. Cerebral palsy can be characterized by a lack of muscle control with increased spasticity or decreased tone, seizure disorder, and variable mental retardation. The overall incidence of CP is estimated to range from 1 to 5 children per 1000 live births. 49 The overall incidence of scoliosis in the CP population is estimated to range from 21% to 76% depending on the series and whether the patient is a walker or is relegated to sitting due to extensive CP. The incidence and severity of the spinal curve appears to be related to the degree of CP involvement. 39,40 Males are more commonly affected, which is in contrast to idiopathic scoliosis with a female predominance. 49 Scoliotic Curve CharacteristicsPatients with neuromuscular scoliosis may have a variety of scoliotic curve types depending on the severity of CP involvement. Lonstein and Akbarnia 37 characterized the deformity into 2 groups that were most common: 1) Group 1 curves are single thoracic or double thoracic and lumbar curves with a level pelvis, commonly noted in ambulatory patients with CP; and 2) Group 2 curves are long thoracolumbar or C-shaped curves with associated pelvic obliquity, often noted in more involved and dependent patients with CP. Hyperlordosis of the lumbar spine or kyphoscoliosis of the thoracic spine is also a common Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VirginiaCerebral 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 LuqueGalveston 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.

Neurogenic Spinal Deformities in Adults: Modern Problems and Approaches to Treatment

“…В связи с ригидными многоплоскостными деформациями для создания мобильности позвоночника осуществляют дискотомии [57,73,82] или вертебротомии, вид которых зависит от тяжести искривления и мобильности [24,38,44,53,85]. Вертебротомии с корригирующими манипуляциями рекомендуется выполнять под контролем интраоперационного нейромониторинга [41,85].…”

Orthopedic surgery in cerebral palsy: Instructional course lecture

“…Persons with these risk factors might benefit from early surgical intervention to prevent severe scoliosis. Bracing traditionally has a very limited role in decreasing curve progression 63. Observation is indicated for flexible curves <40° that do not compromise sitting balance.…”

“…Observation is indicated for flexible curves <40° that do not compromise sitting balance. In most cases of severe scoliosis in CP, spinal instrumentation and fusion are recommended because of significant curve progression, loss of sitting balance, and for improved comfort 63. However, spinal deformity correction is a major task in persons with multiple medical co-morbidities and can be associated with a high risk of complications including pulmonary and neurological complications, hardware related issues, infections and death.…”

Current Proceedings of Cerebral Palsy

“…All treatments are targeted at improving function and reducing disability. Treatment programs for CP encompass (i) pharmacological interventions, include botulinum toxin, type A, phenol, benzodiazepam, trihexyphenidyl, tetrabenazine, carbidopa-levodopa, and dantrolene for dystonia and spasticity; antiepileptic drugs for the termination of clinical and electrical seizure activity (22,33); (ii) surgical interventions, including intrathecal baclofen pump insertion (33), selective dorsal rhizotomy (46), and basal ganglia stimulation (157) for antispasticity, improving rigidity, choreoathetosis, and tremor, and orthopedic surgical intervention for scoliosis or hip dislocation (62,167); (iii) physical and behavioral therapy; (iv) mechanical aids; and (v) management of associated medical conditions. Although these treatments are helpful, none of them have achieved a satisfactory recovery of the damaged brain.…”