Scoliosis in Cerebral Palsy

Scoliosis in Cerebral PalsyScoliosis in cerebral palsy develops in about two-thirds of patients with total body involvement. The relationship between scoliosis and hip dislocations is not well established. Risk factors for progression include curves >40° before age 15 years, thoracolumbar location and coexisting pelvic obliquity. These curves differ from idiopathic scoliosis by having an earlier onset, a greater likelihood of progressing before and after skeletal maturity, less likely to respond to orthotic management, and more likely to require operative stabilization. Progression after skeletal maturation is greatest if curves >50°, with progression of about 1.5° per year.

The disability from scoliosis includes difficulty in sitting and balance, cardiopulmonary and GI problems, ischial ulcers, and complications in custodial care.

Evaluation

These children have a systemic illness, and a total evaluation is essential.

General evaluation Be certain the diagnosis is accurate to better understand the natural history and potential for disability. Assess the child’s motor and mental status, family situation, nutritional status, pulmonary status, and general health.

Back examination Observe the child sitting, standing, and walking. Note balance, sagittal alignment, and severity. Examine the child prone to assess pelvic obliquity. If the scoliosis is secondary to infrapelvic obliquity, focus attention on the hips rather than the spine. Assess sagittal alignment.

Curve patterns fall into several categories.

Imaging Study with an AP and lateral 36-inch radiographs made with the child sitting. If the hip examination is abnormal, add an AP film that includes the pelvis on the same film to assess the relationship of the hip and spine deformity. Make the spine radiographs with the child sitting when possible.

Laboratory evaluation Make these essential studies prior to any surgical procedure. Assess albumen levels, pulmonary function (vital capacity), and lymphocyte count.

Treatment of Scoliosis in Cerebral Palsy

Manage considering the natural history, the potential for disability, and the effectiveness of the various treatment options. Because management is often complex, controversial, and long-term, give greater consideration to the family’s wishes than is usually appropriate when medical indications are better established.

Observation is the initial and often primary mode of management for most curves. During each clinic visit, screen for scoliosis with a forward bending test as part of the general physical examination.

Orthotic management may be tried at bedtime and to provide stability for sitting and wheelchair support. Often orthotic management is combined with special seating devices to provide stability and symmetry. Orthotics and exercise treatments do not change the progression of the curve.

Operative correction Certain principles guide operative correction. Control progressive curves by surgery to provide stability for sitting. Posterior fusion is usually adequate for curves under about 70°. Large curves may require anterior release followed by posterior fusion. This correction is usually achieved in one operative session. Most fusions are long and extend to include the pelvis. A major effort is made to provide sagittal plane correction to facilitate sitting and promote cardiopulmonary function.

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