Spine deformities in patients with cerebral palsy; the role of the pelvis

Introduction Progressive neuromuscular spinal deformities with pelvic obliquity and loss of sitting balance are typical features of severely affected patients with cerebral palsy. The pelvis represents the key bone between the spine and the lower extremity when it comes to deciding whether and when to operate and if spine or hip surgery first is beneficial. The pelvis can be looked at as the lowest vertebra and as the rooftop of the lower extremities. Biomechanical considerations To allow for a normal spinal shape, the pelvis needs to be horizontal in the frontal plane and mildly anterior tilted in the sagittal plane, less for sitting and more for standing. Any abnormal pelvic position requires spinal compensation and challenges the equilibrium control of the individual. Both anatomical neighbourhoods – the spine and the hip joints — have to be considered when spinal deformities, hip instability and contractures evolve, in conservative therapy (bracing, physiotherapy, seating in the wheelchair) and when surgical interventions are weighed out against each other. Surgical considerations Multiple anatomical factors such as sagittal profile and pelvic orientiation, pelvic transverse plane asymmetries and lumbosacral malformations have to be considered in case the pelvis is instrumented with sacral and iliac screws. Rotational deformities and asymmetries of the pelvic bones make the safe insertion of long screws challenging. Advantages of primary pelvic fixation include correction of pelvic obliquity, especially considering the lever arm of the whole spinal construct. The risk of revision surgery due to progression of distal curves is also reduced. Disadvantages of pelvic fixation include the complexity of the additional intervention, which may result in longer operating times, increased risk of blood loss, infection and hardware malpositioning.

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Ilio-sacral screw pelvic fixation when correcting spinal deformities with or without pelvic obliquity: our experience over 40 years

Spine Deformity ◽

10.1007/s43390-020-00263-6 ◽

2021 ◽

Author(s):

Jean Dubousset ◽

Mathilde Gaume ◽

Lotfi Miladi

Keyword(s):

Pelvic Obliquity ◽

Spinal Deformities ◽

Pelvic Fixation ◽

Over 40 Years

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Development and conservative treatment of spinal deformities in cerebral palsy

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.14.190127 ◽

2020 ◽

Vol 14 (1) ◽

pp. 2-8 ◽

Cited By ~ 1

Author(s):

Reinald Brunner

Keyword(s):

Cerebral Palsy ◽

Motor Control ◽

Conservative Treatment ◽

Sagittal Plane ◽

System Level ◽

Spinal Deformities ◽

Brace Treatment ◽

Trunk Control ◽

Upper Extremity Function ◽

Change Position

Incidence and cause Cerebral palsy (CP) is characterized by poor motor control. The more severe the affection is, the more patients are prone to deformities. Patients with Gross Motor Function Classification System level V run an up to 90% risk for spinal deformities. These are caused by poor trunk control under load. Although trunk tone is impossible to assess it seems to be low in the majority of patients, leading to collapse under gravity. The constant malposition results in growth asymmetry which leads to fixation and deterioration of the deformity. Brace treatment Brace treatment has a poor reputation in respect to the final outcome. Conventional braces as constructed for other spinal deformities are indeed difficult for patients with CP as they cannot change position in the brace and do not tolerate pressure on the belly for reflux problems. Respecting these points improves the tolerance of braces but still the time of use is far from the necessary when the trunk is upright. Nevertheless, they can help to postpone surgery for scoliosis, but they are very inefficient for sagittal plane deformities. Aim of treatment The lack of trunk control further leads to an impairment of head control and upper extremity function. Providing stability improves these problems. Braces are superior to seating shells for both treating deformity and providing stability as they remain close to the skin and follow movements. Supports on seating shells in contrast are too far away for controlling the deformity and provide stability only if the patient doesn’t move forward.

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Correction of Sagittal Plane Spinal Deformities with Unit Rod Instrumentation in Children with Cerebral Palsy

The Journal of Bone and Joint Surgery (American) ◽

10.2106/00004623-200409001-00006 ◽

2004 ◽

Vol 86 ◽

pp. 156-168 ◽

Cited By ~ 16

Author(s):

Kirk W. Dabney ◽

Freeman Miller ◽

Glenn E. Lipton ◽

Eric J. Letonoff ◽

H. Catherine McCarthy

Keyword(s):

Cerebral Palsy ◽

Sagittal Plane ◽

Spinal Deformities ◽

Children With Cerebral Palsy

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The Effects of Acute Intense Physical Exercise on Postural Stability in Children With Cerebral Palsy

Adapted Physical Activity Quarterly ◽

10.1123/apaq.2015-0115 ◽

2016 ◽

Vol 33 (3) ◽

pp. 271-282 ◽

Cited By ~ 3

Author(s):

Matthew J. Leineweber ◽

Dominik Wyss ◽

Sophie-Krystale Dufour ◽

Claire Gane ◽

Karl Zabjek ◽

...

Keyword(s):

Cerebral Palsy ◽

Physical Exercise ◽

Postural Stability ◽

Sagittal Plane ◽

Center Of Pressure ◽

Force Plate ◽

Frontal Plane ◽

Increased Risk ◽

Children With Cerebral Palsy ◽

Risk Of Falls

This study evaluated the effects of intense physical exercise on postural stability of children with cerebral palsy (CP). Center of pressure (CoP) was measured in 9 typically developing (TD) children and 8 with CP before and after a maximal aerobic shuttle-run test (SRT) using a single force plate. Anteroposterior and mediolateral sway velocities, sway area, and sway regularity were calculated from the CoP data and compared between pre- and postexercise levels and between groups. Children with CP demonstrated significantly higher pre-SRT CoP velocities than TD children in the sagittal (18.6 ± 7.6 vs. 6.75 1.78 m/s) and frontal planes (15.4 ± 5.3 vs. 8.04 ± 1.51 m/s). Post-SRT, CoP velocities significantly increased for children with CP in the sagittal plane (27.0 ± 1.2 m/s), with near-significant increases in the frontal plane (25.0 ± 1.5m/s). Similarly, children with CP evidenced larger sway areas than the TD children both pre- and postexercise. The diminished postural stability in children with CP after short but intense physical exercise may have important implications including increased risk of falls and injury.

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CORRECTION OF SAGITTAL PLANE SPINAL DEFORMITIES WITH UNIT ROD INSTRUMENTATION IN CHILDREN WITH CEREBRAL PALSY

The Journal of Bone and Joint Surgery (American) ◽

10.2106/00004623-200312000-00012 ◽

2003 ◽

Vol 85 (12) ◽

pp. 2349-2357 ◽

Cited By ~ 31

Author(s):

GLENN E. LIPTON ◽

ERIC J. LETONOFF ◽

KIRK W. DABNEY ◽

FREEMAN MILLER ◽

H. CATHERINE MCCARTHY

Keyword(s):

Cerebral Palsy ◽

Sagittal Plane ◽

Spinal Deformities ◽

Children With Cerebral Palsy

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Different distal fixation anchors in lumbosacral spinal deformities associated with sacral agenesis: which one is better?

Journal of Neurosurgery Spine ◽

10.3171/2020.9.spine201390 ◽

2021 ◽

pp. 1-6

Author(s):

Tianyuan Zhang ◽

Hongda Bao ◽

Shibin Shu ◽

Zhen Liu ◽

Xu Sun ◽

...

Keyword(s):

Pelvic Obliquity ◽

Spinal Deformities ◽

Coronal Balance ◽

Spinopelvic Fixation ◽

Iliac Screws ◽

Group 3 ◽

Group 2 ◽

Distal Fixation ◽

Group 1

OBJECTIVE Sacral agenesis (SA) is a rare congenital malformation of the spine. There has been a paucity of clinical research to investigate the surgical outcome of spinopelvic fixation in these patients. In this study, the authors aimed to evaluate the outcome of different distal fixation anchors in lumbosacral spinal deformities associated with SA and to determine the optimal distal fixation anchor. METHODS Patients with diagnoses of SA and lumbosacral scoliosis undergoing spinopelvic fixation with S1 screws, iliac screws, or S2-alar-iliac (S2AI) screws were analyzed. The main curve, coronal balance distance, and pelvic obliquity were compared at baseline, postoperatively, and during follow-up in three groups. The complications were also recorded. RESULTS A total of 24 patients were included: 8 patients were stratified into group 1 (S1 screws), 9 into group 2 (iliac screws), and 7 into group 3 (S2AI screws). The main curves were well corrected postoperatively (p < 0.05) in all groups. Coronal balance showed a tendency of deterioration during follow-up in patients with S1 screws (from 18.8 mm to 27.0 mm). Regarding pelvic obliquity, patients with both iliac and S2AI screws showed significant correction (from 3.7° to 2.3° and from 3.3° to 1.6°). Implant-related complications were rod breakage in 3 patients and infection in 1 patient in group 2, and no implant-related complications were observed in group 3. There were 3 cases of unilateral S1 pedicle screw misplacement in group 1. CONCLUSIONS Spinopelvic fixation is a safe and effective procedure that can achieve coronal correction in lumbosacral scoliosis associated with SA. Compared with S1 and iliac screws, S2AI screws as distal fixation anchors can achieve a more satisfactory correction with fewer implant-related complications.

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Surgical management of spinal deformities in cerebral palsy

Journal of Neurosurgery Spine ◽

10.3171/2010.5.spine09669 ◽

2010 ◽

Vol 13 (6) ◽

pp. 672-685 ◽

Cited By ~ 17

Author(s):

Sean M. Jones-Quaidoo ◽

Scott Yang ◽

Vincent Arlet

Keyword(s):

Cerebral Palsy ◽

Nutritional Status ◽

Multidisciplinary Approach ◽

Surgical Techniques ◽

Pedicle Screws ◽

Postoperative Management ◽

Pelvic Obliquity ◽

Spinal Deformities ◽

Surgical Interventions ◽

Sacropelvic Fixation

Cerebral palsy (CP) spinal deformities encompass a spectrum of deformities that are often initially treated nonoperatively, only to result in progression of scoliotic curves and further morbidity. Various surgical interventions have been devised to address the progressive curvature of the spine. This endeavor cannot be taken lightly and at times can be encumbered by prior treatments such as the use of baclofen pumps or dorsal rhizotomies. Care of these patients requires a multidisciplinary approach and comprehensive preoperative and postoperative management, including nutritional status, orthopedic assessment of functional level with specific emphasis on the hips and pelvic obliquity, and wheelchair modifications. The surgical techniques in CP scoliosis have progressively evolved from the classic Luque-Galveston fixation methods, the use of unit rods, and lately the use of pedicle screws, to modern sacropelvic fixation. With the latter method, the spinal deformity in patients with CP can usually be almost completely corrected.

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Minimally Invasive Techniques for Iliac Bolt Placement: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab001 ◽

2021 ◽

Vol 20 (4) ◽

pp. E292-E292

Author(s):

Travis Hamilton ◽

Mohamed Macki ◽

Thomas M Zervos ◽

Victor Chang

Keyword(s):

Minimally Invasive ◽

Imaging System ◽

Pedicle Screws ◽

Vertical Axis ◽

Spinal Diseases ◽

Open Approach ◽

Sagittal Vertical Axis ◽

Pelvic Fixation ◽

Iliac Screws ◽

Invasive Techniques

Abstract As the popularity of minimally invasive surgery (MIS) continues to grow, novel techniques are needed to meet the demands of multisegment fixation for advanced spinal diseases. In one such example, iliac bolts are often required to anchor large fusion constructs, but MIS technical notes are missing from the literature. A 67-yr-old female presented with a symptomatic coronal deformity: preoperative pelvic incidence = 47°, pelvic tilt = 19°, and lumbar lordosis = 29°, sagittal vertical axis = +5.4 cm with 30° of scoliosis. The operative plan included T10-ilium fusion with transforaminal interbody grafts at L2-3, L3-4, L4-5, and L5-S1. The intraoperative video is of minimally invasive placement of iliac bolts using the O-Arm Surgical Imaging System (Medtronic®). The patient consented to the procedure. A mini-open exposure that remains above the fascial planes allows for multilevel instrumentation with appropriate decompression at the interbody segments. After the placement of the pedicle screws under image-guidance, the direction is turned to the minimally invasive iliac bolts. Following the trajectory described in the standard open approach,1 the posterior superior iliac spine (PSIS) is identified with the navigation probe, which will guide the Bovie cautery through the fascia. This opening assists in the trajectory of the navigated-awl tap toward the anterior superior iliac spine (ASIS). Next, 8.5 mm x 90 mm iliac screws were placed in the cannulated bone under navigation. After intraoperative image confirmation of screw placement, the contoured rods are threaded under the fascia. The setscrews lock the rod in position. MIS approaches obviate cross-linking the rods, rendering pelvic fixation more facile. This technique allows for minimal dissection of the posterior pelvic soft tissue while maintaining adequate fixation.

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Mechanical Ventilation in Preterm Infants: Neurosonographic and Developmental Studies

PEDIATRICS ◽

10.1542/peds.90.4.515 ◽

1992 ◽

Vol 90 (4) ◽

pp. 515-522 ◽

Cited By ~ 2

Author(s):

Leonard J. Graziani ◽

Alan R. Spitzer ◽

Donald G. Mitchell ◽

Daniel A. Merton ◽

Christian Stanley ◽

...

Keyword(s):

Mechanical Ventilation ◽

Early Childhood ◽

Cerebral Palsy ◽

Developmental Delay ◽

Preterm Infants ◽

Intracranial Hemorrhage ◽

Apgar Scores ◽

Mechanically Ventilated ◽

Increased Risk ◽

Grade Iii

Surviving preterm infants of less than 34 weeks' gestation who were selected on the basis of serial cranial ultrasonographic findings during their nursery course had repeated neurologic and developmental examinations during late infancy and early childhood that established the presence (n = 46) or absence (n = 205) of spastic forms of cerebral palsy. Of the 205 infants without cerebral palsy, 22 scored abnormally low on standardized developmental testing during early childhood. The need for mechanical ventilation beginning on the first day of life (n = 92) was significantly related to gestational age, birth weight, Apgar scores, patent ductus arteriosus, grade III/IV intracranial hemorrhage, large periventricular cysts, and the development of cerebral palsy. In the 192 mechanically ventilated infants, vaginal bleeding during the third trimester, low Apgar scores, and maximally low Pco2 values during the first 3 days of life were significantly related to large periventricular cysts (n = 41) and cerebral palsy (n = 43), but not to developmental delay in the absence of cerebral palsy (n = 18). The severity of intracranial hemorrhage in mechanically ventilated infants was significantly associated with gestational age and maximally low measurements of Pco2 and pH, but not with Apgar scores or maximally low measurements of Po2. Logistic regression analyses controlling for possible confounding variables disclosed that Pco2 values of less than 17 mm Hg during the first 3 days of life in mechanically ventilated infants were associated with a significantly increased risk of moderate to severe periventricular echodensity, large periventricular cysts, grade III/IV intracranial hemorrhage, and cerebral palsy. Neurosonographic abnormalities were highly predictive of cerebral palsy independent of Pco2 measurements. However, neither hypocarbia nor neurosonographic abnormalities were associated with a significantly increased risk of developmental delay in the absence of cerebral palsy. In this preterm infant population, therefore, the risk factors for developmental delay differed from those predictive of spastic forms of cerebral palsy. Of the 57 ventilated preterm infants who were exposed to a maximally low Pco2 of less than 20 mm Hg at least once during the first 3 days of life, 21 developed large periventricular cysts or cerebral palsy or both. Those results suggest that prenatal and neonatal factors including the need for mechanical ventilation beginning on the first day of life and marked hypocarbia during the first 3 postnatal days are associated with an increased risk of damage to the periventricular white matter of some preterm infants. However, a causal relationship between hypocarbia and brain damage in preterm infants remains unproven.

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