Retrospective Cohort Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Apr 18, 2022; 13(4): 365-372
Published online Apr 18, 2022. doi: 10.5312/wjo.v13.i4.365
Is it necessary to fuse to the pelvis when correcting scoliosis in cerebral palsy?
Shane F Strom, Matthew C Hess, Achraf H Jardaly, Michael J Conklin, Shawn R Gilbert
Shane F Strom, Matthew C Hess, Michael J Conklin, Shawn R Gilbert, Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Al 35294, United States
Achraf H Jardaly, Department of Orthopaedics, The Hughston Clinic/Hughston Foundation, Columbus, GA 31908, United States
Author contributions: Jardaly AH, Conklin MJ, and Gilbert SR designed the research study; Strom SF, Hess MC, Jardaly AH, Conklin MJ, and Gilbert SR performed the data collection; Jardaly AH analyzed the data; Strom SS, Hess MC, and Jardaly AH wrote the manuscript; all authors thoroughly edited the manuscript; all authors have read and approve the final manuscript.
Institutional review board statement: The University of Alabama’s Institutional Review Board approved this study. The approval ID is IRB-300005435.
Informed consent statement: Informed consent was waived as per the University of Alabama at Birmingham’s IRB guidelines.
Conflict-of-interest statement: All authors declare that they do not have any conflict of interest.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Shawn R Gilbert, MD, Surgeon, Department of Orthopaedics, University of Alabama at Birmingham, ACC Suite 316, Children’s Hospital, 1600 7th Avenue South, Birmingham, Al 35294, United States. srgilbert@uabmc.edu
Received: July 27, 2021
Peer-review started: July 27, 2021
First decision: November 11, 2021
Revised: November 30, 2021
Accepted: February 23, 2022
Article in press: February 23, 2022
Published online: April 18, 2022
Abstract
BACKGROUND

Neuromuscular scoliosis is commonly associated with a large pelvic obliquity. Scoliosis in children with cerebral palsy is most commonly managed with posterior spinal instrumentation and fusion. While consensus is reached regarding the proximal starting point of fusion, controversy exists as to whether the distal level of spinal fusion should include the pelvis to correct the pelvic obliquity.

AIM

To assess the role of pelvic fusion in posterior spinal instrumentation and fusion, particularly it impact on pelvic obliquity correction, and to assess if the rate of complications differed as a function of pelvic fusion.

METHODS

This was a retrospective, cohort study in which we reviewed the medical records of children with cerebral palsy scoliosis treated with posterior instrumentation and fusion at a single institution. Minimum follow-up was six months. Patients were stratified into two groups: Those who were fused to the pelvis and those fused to L4/L5. The major outcomes were complications and radiographic parameters. The former were stratified into major and minor complications, and the latter consisted of preoperative and final Cobb angles, L5-S1 tilt and pelvic obliquity.

RESULTS

The study included 47 patients. The correction of the L5 tilt was 60% in patients fused to the pelvis and 67% in patients fused to L4/L5 (P = 0.22). The pelvic obliquity was corrected by 43% and 36% in each group, respectively (P = 0.12). Regarding complications, patients fused to the pelvis had more total complications as compared to the other group (63.0% vs 30%, respectively, P = 0.025). After adjusting for differences in radiographic parameters (lumbar curve, L5 tilt, and pelvic obliquity), these patients had a 79% increased chance of developing complications (Relative risk = 1.79; 95%CI: 1.011-3.41).

CONCLUSION

Including the pelvis in the distal level of fusion for cerebral palsy scoliosis places patients at an increased risk of postoperative complications. The added value that pelvic fusion offers in terms of correcting pelvic obliquity is not clear, as these patients had similar percent correction of their pelvic obliquity and L5 tilt compared to children whose fusion was stopped at L4/L5. Therefore, in a select patient population, spinal fusion can be stopped at the distal lumbar levels without adversely affecting the surgical outcomes.

Keywords: Cerebral palsy, Scoliosis, Pelvic fusion, Pelvic obliquity, Spinal fusion, Distal lumbar level

Core Tip: The value of including the pelvis in the distal level of fusion in children with cerebral palsy scoliosis is not clear with respect to correcting pelvic obliquity or L5 tilt. This does, however, increase the risk of complications. After careful patient selection, spinal fusion can be stopped at the distal lumbar levels without adversely affecting the surgical outcomes.