David J. Abraham, M.D.,
Freeman Miller, M.D.
Alfred I. duPont Institute
1600 Rockland Road
Wilmington, Delaware 19803
INTRODUCTION: Scoliosis in patients with cerebral palsy is common, difficult to control with bracing, and often progressive in nature. Frequently the deformity includes significant pelvic obliquity which negatively impacts the patients ability to sit comfortably and ambulate. Previous indications for extending a posterior spine fusion to the pelvis for scoliosis in patients with cerebral palsy included significant (greater than 15 degrees) pelvic obliquity, progression of pelvic obliquity below a fusion mass, and spastic quadriplegia in non-ambulatory patients with a level pelvis. Fusion to the pelvis in ambulatory patients has been condemned because it was thought to compromise ambulation. However, some surgeons routinely perform posterior spine fusions to the pelvis in ambulatory patients. The purpose of this study is to determine whether posterior spine fusion to the sacrum adversely affects ambulation in cerebral palsy patients with scoliosis.
MATERIALS AND METHODS: Fourteen ambulatory patients with cerebral palsy and scoliosis were treated with posterior spine fusion to the pelvis augmented with the Unit Rod at the A.I. duPont Institute between 1988 and 1995. No postoperative immobilization was used. Cobb angles, pelvic obliquity, truncal decompensation, kyphosis, and lordosis were measured preoperatively, postoperatively and at follow-up. The patients were followed clinically and radiographically at six month intervals, and a telephone interview was completed which compared preoperative ambulation with postoperative ambulation. An ambulation scale was developed to assess ambulatory function preoperatively and at follow-up.
RESULTS: The mean preoperative curve was 66 degrees with a mean pelvic obliquity of 23 degrees. The mean postoperative curve was 26 degrees (60.1 % correction) with a mean postoperative pelvic obliquity of 3 degrees (88.5 % correction). The mean truncal decompensation decreased from 12.1 cm to 1.9 cm. Eleven of 14 patients had improved ambulation or had no change in ambulation at follow-up which averaged 4.2 years. Three patients worsened during the postoperative period. Two patients walked less postoperatively due to the development of heterotopic ossification of the hips. The other patient developed a persistent seizure disorder. All caretakers except one would repeat their decision to have the child undergo spine fusion to the pelvis.
CONCLUSION: Posterior spinal fusion to the pelvis in the treatment of neuromuscular scoliosis does not adversely affect ambulation.
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