Spinal Fusion in Ambulatory Cerebral Palsy Patients: Can a Child Walk After Instrumentation to the Pelvis?

Introduction: This is a retrospective study of 26 ambulatory pediatric patients with spastic cerebral palsy (CP)and neuromuscular scoliosis who underwent spinal fusion (PSF)from T1 or T2 to the sacrum with pelvic fixation using unit rod instrumentation. PURPOSE: To evaluate the effect of this surgery on the ambulatory potential of these patients.

Results: The study group is comprised of 18 female and 8 male patients, 20 of whom have quadriplegic CP, 6 who have diplegic CP. There was no difference in the curve type between the two groups. 22 patients had a single thoracolumbar or lumbar scoliotic curve, and 4 patients demonstrated a double curve pattern. Mean age at surgery was 15.4 years. Mean preoperative Cobb angle was 63 degrees and corrected by 68% to 20.4 degrees. Preoperative pelvic obliquity was corrected from 11.7 degrees to 3.3 degrees.The patients were all evaluated clinically preoperatively, postoperatively, and at follow-up with no alteration in their ambulatory status, except one patient who developed bilateral hip heterotopic ossification and gradually lost her ability to ambulate. Clinical follow-up assessment for ambulatory function occurred at a mean of 3.86 years after surgery (2 yrs.-9 yrs.). Fourteen patients underwent both preoperative and postoperative instrumented gait analysis, with no decrease in their ambulatory function. In all 14 patients, the evaluation of the postoperative gait analysis documented a gait pattern similar to or better than the preoperative pattern by six months after PSF. The caretakers of all 24 patients completed an outcome survey which demonstrated significant improvement in the child's appearance, amount of back pain, head and trunk balance, sitting tolerance, respiratory function, and no compromise in ambulatory capacity. All caretakers reported that they would recommend surgery to ambulatory patients with CP who develop significant scoliosis.

Conclusion: This study demonstrates that in ambulatory patients with spastic CP and neuromuscular scoliosis, PSF with unit rod instrumentation provides stable fixation to the pelvis, achieves satisfactory correction of the deformity, and restores trunk balance in the both the coronal and sagittal planes, without compromising the patient's ability to ambulate.