Posted by: seserdr1975 | November 14, 2013

Spinal Surgery for CP Patients

Morning all. I want to address a topic that came up on Facebook today. Spinal surgery for Scoliosis patients with Cerebral Palsy. First of all, I am not a Dr, nor an expert. This is just my opinion, but I think a very serious topic that affects Adults with CP as well.

Surgery is a very tough choice to make, whether you are a patient or a parent of a patient. This biggest advise I want to relay is do whats best for the long term quality of life for the CP patient. Not every surgery is successful, nor is it needed in all cases. The number one goal for anyone who has CP is to positively impact the day to day quality of life.  If you have a spinal curvature over 20% then I encourage a surgical evaluation. Some of the issues of no surgery is that the curvature can worsen at a much higher rate then Idiopathic Scoliosis, which can lead to more serious complications, like respiratory issues, digestive issues and more.

Please read the below text taken from: http://www.orthobullets.com/spine/2057/cerebral-palsy-spine-disorders

Cerebral Palsy Spine Disorders

Author:
Topic updated on 09/26/13 12:58pm
 
Introduction  
  • Scoliosis common in children with cerebral palsy
    • overall incidence is 20%
    • the more involved and severe the cerebral palsy, the higher the likelihood of scoliosis
      • spastic quadriplegic at highest risk, especially if no ability to sit independently.
      • for bedridden children incidence approaches 100%
      • spinal deformity is rare in children who are able to ambulate
  • Scoliosis in patients with cerebral palsy differs from idiopathic scoliosis in that
    • curves are more likely to progress
      • (scoliosis progresses 1° to 2° per month starting at age 8 to 10 years)
    • curve begins at earlier age
    • curve is a long, c-shaped curve in CP
    • bracing is less effective
  • Etiology
    • muscle weakness and truncal imbalance has been implicated as primary etiology (little evidence to support)
    • pelvic obliquity leads to deforming forces on spine and scoliosis
  • Natural history
    • the larger the curve the more likely it is to progress
      • larger curves are associated with pelvic deformity and obliquity
      • some studies show increase incidence of decubitus ulcer in patients with larger curves, other studies did not
Evaluation
  • Treatment of cerebral palsy spine disorders requires a careful risk-benefit analysis. Therefore it is important to have a thorough understanding of the medical history and functional status.
  • History
    • clinical history
      • perinatal history
      • growth & development
      • all medical treatment
    • functional status
      • patients nutritional status
      • respiratory function
      • sitting / standing posture
      • upper and lower extremities function
      • communication skills
      • acuity of hearing and vision
  • Physical Exam
    • muscular-skeletal exam
      • motion, tone, and strength
      • hamstring contracture’s (lead to decreased lumbar lordosis)
      • hip contractures (lead to excessive lumbar lordosis)
    • spine exam
      • look at flexibility of curve
      • spinal balance and shoulder height
      • pelvic obliquity
Classification
  • Weinstein classification
    • Group I – double curves with thoracic and lumbar component and minimal pelvic obliquity
    • Group II – large lumbar or thoracolumbar curves with marked pelvic obliquity
Imaging
  • Radiographs
    • introduction
      • important just to use same radiographic technique in patients over time
        • technique often determined by functional status of patient
        • do standing or erect films whenever possible
    • standard AP & lateral
      • look for rib deformity, wedging, and spinal rotation
      • be sure to evaluate for spondylolithesis on lateral (incidence of 4-21% in patients with spastic diplegia)
    • bending films
      • important to evaluate flexibility of curve
      • use push-pull radiographs or fulcrum bending radiographs if patient can not cooperate
  • MRI
    • preoperative MRI is not routinely performed for patients undergoing spinal deformity surgery
    • indications for MRI include
      • rapid curve progression
      • change in neurologic exam
Treatment
  • Nonoperative
    • observation, custom seat and/or bracing, botox injections
      • indications
        • nonprogressive curves < 50°
        • early stages in patients < 10 years of age
          • goal is to delay surgery until an older age
      • outcomes
        • custom seat orthosis
          • helpful with seating but does not affect natural course of disease
        • bracing
          • TLSO is helpful to improve sitting balance but does not affect natural course of disease
          • some studies have supported use as a palliative measure to slow progression in skeletally immature patients only
        • botox
          • competitive inhibitor of presynaptic cholinergic receptor with a finite lifetime (usually last 2-3 months)
          • provide some short term benefit in patients with spinal deformity
  • Operative
    • goals of surgery
      •  obtain painless solid fusion with well corrected, well balanced spine with level pelvis
      • decision to proceed with surgery must include careful assessment of family’s goals and careful risk-benefit analysis
    • PSF with/without extension to the pelvis
      • indications
        • Group I curves 50° to 90° in ambulators that is progressive or interfering with sitting position
        • patient > 10 yrs of age
        • adequate hip range of motion
        • stable nutritional and medical status
      • technique
        • treated as idiopathic scoliosis with selective fusion
        • can result in worsening pelvic obliquity and sitting imbalance
    • PSF +/- ASF with/without extension to pelvis
      • indicated for
        • Group I curves >90° and in non-ambulators 
        • Group II curves 
        • children who have not yet reached skeletal maturity (avoid crankshaft phenomenon)
    • extension to pelvis
      • indications
        • pelvic obliquity > 15°
        • required due to increased pseudoarthosis rate if you do not do it
Preoperative Assessment & Planning
  • Overview
    • treatment of cerebral palsy spine disorders is complicated by medical comorbidities
      • all patients should have a thorough multidisciplinary approach
  • Nutritional status
    • increase complications (infection, length of intubation, longer hospital stays)
      • associated with poor nutritional status (weight less than fifth percentile)
      • be sure patient has adequate nutrition before surgery (serum albumin > 3.5 g/dL, consider gastrostomy tube if not)
  • Respiratory status
    • difficult to do formal pulmonary functional capacity testing
    • can use respiratory history, clinical evaluation, and chest radiographs
  • GI evaluation
    • preoperative management of GERD is important in prevention of aspiration pneumonia
  • Neurologic function
    • if patients have seizure disorder (common) be sure it is under control
      • if patient taking valproic acid, obtain bleeding time as these patients may have increased risk of bleeding
Surgical Techniques
  • Fusion levels
    • proximal fusion should extend to T1 or T2 (otherwise risk of proximal thoracic kyphosis)
    • distal fusion depends on curve pattern
      • due to long curves in CP often extends to L4 or L5
      • extend to pelvis whenever pelvic obliquity is > 15°
  • Posterior fixation techniques
    • Luque rod with subliminar wires technique 
    • Unit rod with sublaminar wires technique 
    • Pedicle screw fixation technique 
      • may provide better correction and eliminate need for anterior surgery
  • Pelvic fixation techniques
    • Galveston Technique 
      • technique to fuse to pelvis with goal of a stability and truncal balance and a level pelvis
      • caudal ends of rods are bent from lamina of S1 to pass into the posterosuperior iliac spine and between the tables of the ileum just anterior to the sciatic notch
    • bilatral sacral screws
    • iliosacral screws 
    • spinopelvic transiliac fixation
    • Dunn-McCarthy technique (S-contoured rod that wraps over sacral ala)
  • Anterior and Posterior Techniques
    • use of anterior procedures decreasing with improved posterior constructs
    • higher complication rate in anterior surgery in CP spinal deformity than idiopathic scoliosis
      • decrease complication rate if A/P done on same day verses staging procedure (improved nutritional status, decreased blood loss, short length of hospitalization)
  • Preoperative traction
    • may be option in severe and rigid curve
  • Postoperative bracing
    • usually not required
      • may be used in patients with osteoporosis or tenuous fixation
Complications
  • Implant failure
    • sometimes may be asymptomatic and not require treatment
    • includes penetration of pelvic limb of unit rod into pelvis
  • Pulmonary complications
    • chronic aspiration
    • pulmonary insufficiency most common complication in recent study
    • pneumonia
  • GI complications
    • GERD
    • poor nutrition and delayed growth
  • Neurologic complications
    • seizures
  • Wound infection
    • more common in CP than idiopathic scoliosis
    • occurs in 3-5% and usually can be treated with local wound debridement alone 
  • Death (0-7%)
Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Categories

%d bloggers like this: