Abstract
Cerebral palsy is a static encephalopathy affecting the immature brain and leading into a permanent motor disability. There is a spectrum of causative factors, which may be congenital in origin, or can be related to incidences occurring in the perinatal or postnatal period. The development of spine deformity constitutes a common orthopaedic problem with an increased incidence in children with spasticity. The prevalence of spinal deformity is directly proportionate to the degree of neurological impairment, and inversely proportionate to the ambulatory capacity. Scoliosis is the most common deformity in this group of severely disabled children and is usually associated with significant pelvic obliquity. Scoliosis in this group of severely disabled children decreases their sitting tolerance, causes pain from impingement of their pelvis against the rib cage on the concavity of the scoliosis, and creates cardiopulmonary complications. Patients with walking function gradually lose their abil ...
Cerebral palsy is a static encephalopathy affecting the immature brain and leading into a permanent motor disability. There is a spectrum of causative factors, which may be congenital in origin, or can be related to incidences occurring in the perinatal or postnatal period. The development of spine deformity constitutes a common orthopaedic problem with an increased incidence in children with spasticity. The prevalence of spinal deformity is directly proportionate to the degree of neurological impairment, and inversely proportionate to the ambulatory capacity. Scoliosis is the most common deformity in this group of severely disabled children and is usually associated with significant pelvic obliquity. Scoliosis in this group of severely disabled children decreases their sitting tolerance, causes pain from impingement of their pelvis against the rib cage on the concavity of the scoliosis, and creates cardiopulmonary complications. Patients with walking function gradually lose their ability to ambulate and become wheelchair-dependent. There is a critical effect of the adolescent growth spurt on curve progression with children less than 10 years of age at the time of diagnosis having a significantly higher rate of scoliosis deterioration. Curve progression rate is inversely related to the ambulatory potential with children who do not have walking function presenting with a greater degree of scoliosis progression and a younger age at surgical treatment. The presence of a unilateral hip dislocation or subluxation does not have an independent effect on the natural history of the scoliosis and on the rate of curvature progression. Spinal arthrodesis is indicated in children with progressive curve size and rigidity, which interferes with their level of function. Spine surgery in patients with severe underlying neurological compromise and complex medical problems is associated with technical difficulties and an increased risk of life-threatening complications. However, there is a documented positive impact on these children by correcting the spinal and pelvic deformity and maintaining a good coronal and sagittal balance of the trunk and this is reflected primarily on the patients’ quality of life and their level of function. Spinal fusion is the only surgical procedure that has such a high satisfaction rate among parents and caregivers, especially for quadriplegics and total-body involvement patients. With improved medical management, life expectancy for this group of patients is higher than previously reported and operative procedures to correct the spine have a definite effect in improving the patients' quality of life. The most accurate determinants for survival rates following spinal arthrodesis among this population group are the number of days the patient has to spend postoperatively in the intensive care unit, which reflects the overall medical condition, and the presence of excessive preoperative thoracic kyphosis. Since scoliosis is a very common orthopaedic condition in children with cerebral palsy, especially those with quadriplegia, and there is a well-documented high degree of caretaker satisfaction following deformity correction, the selection of the appropriate operative technique and type of instrumentation should depend on achieving optimum correction of the deformity and decreasing the rate of complications. In contrast, the specific surgical technique is not likely to reduce the risk for the common medical complications related to such major surgical undertaking. However, a good multidisciplinary approach and a meticulous perioperative care protocol should be able to manage effectively the multitude of problems that may arise in this patient population. The Unit Rod instrumentation may be considered the gold standard technique and the primary instrumentation system for the treatment of pediatric patients with cerebral palsy and neuromuscular scoliosis because it is simple to use, it is considerably cheaper than most other systems, and can achieve good deformity correction with a low loss of correction, as well as a low prevalence of associated complications and a low reoperation rate. When this technique is applied in ambulatory patients it does not have an impact on their walking ability, which is retained following long spinal fusions to include the lumbosacral joint. In the presence of a severe and rigid spinal deformity a combined anteroposterior spinal arthrodesis is indicated to improve the surgical outcome and this should be performed in two stages, especially in patients with very large curves and multiple medical co-morbidities.
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