management of scoliosis in - universitair ziekenhuis gent · 2019. 2. 19. · progressive scoliosis...
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Management of Scoliosis in Cerebral Palsy
Is it worth it?
Prof. Dr. Frank S Plasschaert, MD PhD
Dr. Sophie Lauwagie, MD
Children’s Paedicatric Orthopaedic Unit
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Objectives of this lecture
Epidemiology of scoliosis in cerebral palsy
Natural history
Principles of management for scoliosis in CP
Positioning, seating and bracing
The interrelationship with tone reduction
Growing rod
Spinal fusion
PROM patient related outcome measurement for CP scoliosis surgery
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Epidemiology
Progressive scoliosis has been reported to occur in 64% to 74% of severely impaired, nonambulatory patients with cerebralpalsy (CP) who are classified as functioning at level IV or V according to the Gross Motor Function Classification System (GMFCS)
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Balmer GA, MacEwen GD. The incidence and treatment of scoliosis in cerebral palsy. J Bone
Joint Surg Br. 1970 Feb;52(1):134-7.
Madigan RR, Wallace SL. Scoliosis in the institutionalized cerebral palsy population. Spine (Phila
Pa 1976). 1981 Nov-Dec;6(6):583-90.
Persson-Bunke M, Ha ̈gglund G, Lauge-Pedersen H, Wagner P, Westbom L. Scoliosis in a total
population of children with cerebral palsy. Spine (Phila Pa 1976). 2012 May 20;37(12):E708-13.
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Natural History
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Natural History
Curve progression in 37 ‘untreated’ severe spastic CP patients
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Natural History
Curve progression as a function of spasticity
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Total Body Involved Non-Total Body Involved
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Natural History
Curve progression as a function of initial physical capability
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Walkers Sitters Bed-Ridden
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Natural History
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Natural History
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Windswept deformity of the hips develops in about 30% of CP childrenGMFCS III-V.
In most children, WS develops before 10 years of age, but the risk continues up to 20 years of age.
With early inclusion in a hip surveillance program, and early treatment of contractures, the frequency of WS starting in the lower extremities can bereduced.
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Early treatment of scoliosis might reduce the development of pelvic obliquity and WS.
With improved knowledge of the risk factors for progressionand new surgical techniques that allow for further growth, thismight be one way to reduce WS in the future.
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The Problem of the Growing Spine.
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Lung Function and Spinal Growth
Intrinsic alveolar hypoplasia
In the normal lung
• Alveolar hyperplasia (multiplication of alveoli) continues till the age of 8
• Hypertrophy of the existing alveoli till the end of growth (of the thorax)
lung “growth” (hyperplasia and airway expansion) is essentially complete by age 8 years, with a “golden period” of maximum growth occurring before age 5 years
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Lung Function and Spinal Growth
Intrinsic alveolar hypoplasia
The “golden period” of rapid growth of the thoracic spine and rib cage thuscoincides with lung development.
• The circumference of the thorax, which is only 7% of adult size at birth, increases to 30% by age 5 years and 50% by 10 years.
• The length of the thoracic spine increases by 50% (from 12 to 18 cm) from birthto age 5 years, achieving some 60% of the adult length by that age
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Fusion of the Spine before the Age of 8
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Karol LA, Johnston CE, Mladenov K, et al: The effect of early thoracic fusion on pulmonary function in
non-neuromuscular scoliosis. 40th Annual Meeting of the SRS, 2005, Miami, Fla.
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Early fusion of the Spine
The principle that a short, straight spine produced by early fusionis better than a long, curved spine is no longer generallyaccepted!
The goal of management must be to control spinal deformitywithout impeding thoracic growth!
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Non Fusion Techniques
Seating
Bracing
Casting
Growing Rods
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Bracing
bracing remains ineffectivein preventing progression in case of scoliosis in Cerebral Palsy GMFCS III-V
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Miller A, Temple T, Miller F. Impact of
orthoses on the rate of scoliosis
progression in children with cerebral palsy.
J Pediatr Orthop. 1996 May-Jun;16(3):332-
5.
Terjesen T, Lange JE, Steen H. Treatment
of scoliosis with spinal bracing in
quadriplegic cerebral palsy. Dev Med Child
Neurol. 2000 Jul;42(7):448-54.
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Growing Rods
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Growing Rods
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Growing Rods
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Growing Rods in CP
GRs are an effective treatment for scoliosis and pelvic obliquity in childrenwith CP and offer the benefit of delayingfusion until skeletal maturity.
Dual GR constructs that extend to the pelvis exhibit better pelvic obliquitycontrol but similar curve control compared with a single-rod or dual-rods ending in the lumbar region.
Deep wound infections are the most common surgical complications and maylead to instrumentation removal in thiscomplex patient population.
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(Posterior) Spinal Fusion in the
Treatment of Scoliosis in Cerebral
Palsy
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Objectives of Scoliosis Surgery in CP
To obtain a balanced spine
In order to facilitate equilibrium / sitting balance
To improve on pulmonary function
Lessen nursing demands
With the use of a safe technique!
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What makes people consider surgery?
Seating difficulties
Pain because of rib-pelvis impingement
Back Pain
Gastro-intestinal problems
Progression of deformity – sagittal plane problems with diffultsitting
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What makes surgeons consider surgery?
Aims
Stable hips
Level pelvis
Compensated/ balancedspine
Rewards
Comfortably seatedchild/patient
No pressure sores
Minimal/improved nursing care
Child can concentrate on his potential
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The Orthopaedic Solutions
Lucque technique
Segmental Instrumentation with the inclusion of pedicle screws
Pelvic fixation (Galvestone – Pedicle Screws)
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The problem of ‘Pelvic Obliquity’
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Is Scoliosis Surgery in Cerebral Palsy
Patients ‘truly’ Beneficial?
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Need for Pre-operative Assessment
Respiratory
Nutritional/Immunological
Intra-operatve blood-loss
Behvarioral/neurological
Metabolic
Risk of infection
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In Conclusion
The course of development of scoliosis in CP remains partiallyunclear… but:
Early management to keep midline arrangement ( seating –physiotherapy) is essential in order to protect the spine
This does involve multidisciplinary approach (tone – seating-…)
Growing rods might address the problem of early spine deformationand alter the development op windswept deformity
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In Conclusion
On the basis of the natural history and risk factors for progression of scoliosis in spastic cerebral palsy:
A patient with severe spastic cerebral palsy should be examined fromas young an age as possible to determine onset of scoliosis.
Surgical treatment should be considered an option if the spinal curve exceeds 40° before age 15 years.
When the patients have total body involvement, are bedridden, or have a thoracolumbar curve, early surgical intervention, we believe, would be desirable.
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In Conclusion
Scoliosis surgery leads to a significant improvement in HRQoL for patients with CP who have GMFCS level-IV or V function.
The effects of surgery are maintained 5 years after surgery.
The overall complication rate for scoliosis surgery in CP is around 45 % at 1 year, with an additional 5 % up to 5 years ….
These complications did not correlate with HRQoL gains and perceived satisfaction with surgery as reported by the caregivers
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In Conclusion
Continued discussion is needed regarding the most technicallyand ethically suitable treatments for these patients.
We believe that the natural course of scoliosis in patients withsevere spastic cerebral palsy represents important background data for guiding these difficult therapeutic choices.
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