Technical aspects of surgical correction of spinal deformities in cerebral palsy

Abstract

Purpose: Cerebral palsy (CP) is a disorder arising from a non-progressive lesion in the developing immature brain with an encephalopathy, that results in various levels of motor and sensory dysfunction. Motor disability of these children can be assessed by the Gross Motor Function Classification System in five levels, and depending on their motor functional capability, the most severely affected children fall into levels IV and V. Children in groups IV and V present a full spectrum of musculoskeletal deformities, among which, scoliosis is the most frequently found spinal deformity that most often requires surgical treatment. However, these are procedures that are usually technically demanding, requiring experienced surgical teams and a multidisciplinary approach.

Methods: In order to overcome some of the technical pitfalls that may complicate these complex surgical procedures, the authors have gathered together different tips and tricks that may help surgeons performing surgical correction of spinal deformities in CP children.

Conclusion: Although for these children surgery is a major undertaking, with the multidisciplinary approach and advances of technology, anaesthesia and optimization of pre- and postoperative care, complications are manageable in most cases, improving not only the outcome of surgery but also the patient's quality of life and satisfaction of parents and caretakers.

Keywords: cerebral palsy; scoliosis; scoliosis cerebral palsy.

Fig. 1

A 14-year-old male patient with Gross Motor Function Classification System level IV cerebral palsy. He was evaluated for severe spinal deformity and right hip dislocation (a, b). In the traction film under general anaesthesia (TRUGA), the deformity improved by more than 50% and the pelvis paralleled (c). First, posterior instrumentation and fusion combined with multilevel posterior column osteotomies were performed (d, e). At second stage, femoral shortening varus osteotomy and Pemberton acetabuloplasty were performed for hip dislocation. Six months after hip surgery, both the spine and hip were uneventful (f, g).

Fig. 2

A 17-year-old male patient with a diagnosis of total body involved spastic cerebral palsy had undergone Intra Thecal Baclofen pump. As deformity progressed, surgical intervention was planned (a, b). Deformity was rigid, and pelvic obliquity could not be reduced to less than 15° on TRUGA radiograph (c). During the posterior instrumentation and fusion, pedicle subtraction osteotomy was performed at L3 level (d, e).

Fig. 3

Halo-femoral traction with the head prepared for draping.

Fig. 4

Distraction rod technique; a cluster with two pedicular screws at the proximal end of the rod.

Fig. 5

Anal sphincter monitoring.