The surgical treatment of lordoscoliosis and hyperlordosis in patients with quadriplegic cerebral palsy

Abstract

We describe 13 patients with cerebral palsy and lordoscoliosis/hyperlordosis of the lumbar spine who underwent a posterior spinal fusion at a mean age of 14.5 years (10.8 to 17.4) to improve sitting posture and relieve pain. The mean follow-up was 3.3 years (2.2 to 6.2). The mean pre-operative lumbar lordosis was 108(°) (80 to 150(°)) and was corrected to 62(°) (43(°) to 85(°)); the mean thoracic kyphosis from 17(°) (-23(°) to 35(°)) to 47(°) (25(°) to 65(°)); the mean scoliosis from 82(°) (0(°) to 125(°)) to 22(°) (0(°) to 40(°)); the mean pelvic obliquity from 21(°) (0(°) to 38(°)) to 3(°) (0(°) to 15(°)); the mean sacral slope from 79(°) (54(°) to 90(°)) to 50(°) (31(°) to 66(°)). The mean pre-operative coronal imbalance was 5 cm (0 cm to 8.9 cm) and was corrected to 0.6 cm (0 to 3.2). The mean sagittal imbalance of -8 cm (-16 cm to 7.8 cm) was corrected to -1.6 cm (-4 cm to 2.5 cm). The mean operating time was 250 minutes (180 to 360 minutes) and intra-operative blood loss 0.8 of estimated blood volume (0.3 to 2 estimated blood volume). The mean intensive care and hospital stay were 3.5 days (2 to 8) and 14.5 days (10 to 27), respectively. Three patients lost a significant amount of blood intra-operatively and subsequently developed chest or urinary infections and superior mesenteric artery syndrome. An increased pre-operative lumbar lordosis and sacral slope were associated with increased peri-operative morbidity: scoliosis and pelvic obliquity were not. A reduced lumbar lordosis and increased thoracic kyphosis correlated with better global sagittal balance at follow-up. All patients and their parents reported excellent surgical outcomes. Lordoscoliosis and hyperlordosis are associated with significant morbidity in quadriplegic patients. They are rare deformities and their treatment is challenging. Sagittal imbalance is the major component: it can be corrected by posterior fusion of the spine with excellent functional results.

Outcomes after scoliosis surgery for children with cerebral palsy: a systematic review

“…Descriptive information about participants was often missing. Only nine studies used the GMFCS to describe the sample and in these studies over 75% of the sample were classified as GMFCS level IV to V . Twelve studies included posterior approaches to surgery only, 33 studies included posterior approaches or combined/staged anterio‐posterior approaches, while approach was not reported, or was not defined for participants with CP, in six studies.…”

“…Length of follow‐up varied greatly among the studies and all except for five studies did not state measurement time points or they were not standardized. Only six studies reported any missing data or loss to follow‐up . Excluded studies and reasons for exclusion are outlined in Appendix S1.…”

“…Twelve studies reported outcomes related to overall function but with function measured differently between studies. All studies primarily involved parent report through questionnaires or interviews and included items about overall health and function, pain, social and communication, and upper limb function.…”

“…Ten studies reported parent or caregiver outcomes, which were defined and measured differently in all studies but consistently involved questionnaires or interview. Constructs measured included parent satisfaction, ease of care, and parent assessment of utility .…”

“…Ten studies reported parent or caregiver outcomes, which were defined and measured differently in all studies but consistently involved questionnaires or interview. Constructs measured included parent satisfaction, ease of care, and parent assessment of utility . For studies that reported parent satisfaction outcomes were generally positive while mixed ease of care outcomes were reported .…”