The Correction of Sagittal Plane Spinal Deformities in Children with Cerebral Palsy

PURPOSE: Currently no studies exist discussing the indications and treatment of patients with cerebral palsy, kyphosis or lordosis and without scoliosis. The purpose of this study is to identify the indications and resultsof treatment in patients with cerebral palsy who present with spinal curve deformities in the sagittal plane without concomitant coronal plane deformity.

METHODS: A 12 year retrospective review of all patients with cerebral palsy, a sagittal plane spinal curve deformity, without coronal plane deformities and who had undergone posterior spinal fusion with at least a 2 year follow-up (mean 3.5 years) was performed. Medical records and radiographs were reviewed for symptoms, type and magnitude of deformity, age at surgery, length of surgery, nutritional status, complications and concomitant medical problems.

RESULTS: Twenty-five patients were identified, 11 patients were male and 14 were female. Nine patients had hyperlordotic deformities, 14 had hyperkyphotic and 2 exhibited both. Identified indications included; severe seating problems in 12 patients which were unable to be rectified with wheelchair modifications, 5 patients had severe back pain, 5 patients had rapidly progressing deformities, 2 patients had superior mesenteric artery syndromes which were refractory to conservative treatment and 1 patient with a hyperlordotic deformity had a loss of bowel and bladder control. Important differences in surgical technique compared to scoliotic deformities included; for hyperkyphotic deformities the size of unit rod is 1-2 cm shorter than the measured length of the spine and 1-2cm longer for hyperlordotic deformities, correcting a hyperkyphotic deformity may impede venous return to the heart causing a drop in the blood pressure and gradual correction is necessary, the angle of the pelvis in hyperlordotic curves increases likelihood of penetration through the inner iliac table when inserting the unit rod into the pelvis and the iliac ends of the rod may need to be cut, inserted separately and reconnected with connectors. The mean preoperative hyperkyphotic curve was 93.75 degrees. It corrected to a mean of 35.8 degrees postoperatively and was 34.8 degrees at last visit. The mean preoperative hyperlordotic curve was 93.5 degrees. It corrected to a mean of 46.3 degrees postoperatively and was 48.5 degrees at last visit. All patients with seating problems and back pain had improved or resolved after surgery. All patients with superior mesenteric artery syndrome, loss of bowel and bladder function and malnutrition had completely resolved after surgery.

CONCLUSION: Special consideration should be employed in patients with cerebral palsy and sagittal plane deformities when sitting ability or balance, back pain, bowel or bladder control, curve progression, and or superior mesenteric artery syndrome become problematic.