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Assessing the Risk-Benefit Ratio of Scoliosis Surgery in Cerebral Palsy: Surgery Is Worth It

Miyanji, Firoz, MD, FRCS(C)1,a; Nasto, Luigi, A., MD1; Sponseller, Paul, D., MD2; Shah, Suken, A., MD3; Samdani, Amer, F., MD4; Lonner, Baron, MD5; Yaszay, Burt, MD6; Clements, David, H., MD7; Narayanan, Unni, MBBS, FRCS(C)8; Newton, Peter, O., MD6

The Journal of Bone and Joint Surgery: April 4, 2018 - Volume 100 - Issue 7 - p 556–563
doi: 10.2106/JBJS.17.00621
Scientific Articles
Supplementary Content

Background: The true benefits of scoliosis surgery in cerebral palsy (CP) remain uncertain. Our aims were to determine the benefits of spinal fusion according to health-related quality of life (HRQoL) improvement at long-term follow-up and to explore the effect of surgery-related complications on clinical outcomes.

Methods: The cases of consecutive patients who had Gross Motor Function Classification System (GMFCS) level-IV or V cerebral palsy with 5-year follow-up from a prospective, longitudinal, multicenter database were analyzed. Caregivers completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire and 4 Likert-type anchor questions preoperatively and at 1, 2, and 5 years of follow-up. Data on complications were collected prospectively. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations using repeated-measures analysis of variance (ANOVA). Spearman correlation coefficient was used to explore the association between changes in the CPCHILD at 1, 2, and 5-year follow-up and the reported complications within the follow-up period. Similarly, a comparative analysis between the percentage distribution of the answers to the 4 anchor questions and the reported complications was also performed.

Results: Sixty-nine patients with a mean age (and standard deviation) of 13.4 ± 2.6 years at enrollment were analyzed. The major Cobb angle was a mean of 81.9° ± 26.7° preoperatively and improved to a mean of 28.7° ± 14.4° at 2 years and 30.7° ± 15.3° at 5 years postoperatively. Significant improvements in CPCHILD personal care, positioning, and comfort domains were noted at all time points. The mean increase in the total score was 7.19 (p < 0.001) at 1 year, and the score gain was maintained at 2 and 5 years postoperatively. The overall complication rate was 46.4% at 1 year, 1.4% between 1 and 2 years, and 4.3% at 2 to 5 years postoperatively, with surgical intervention required in 6 patients within 1 year and in 2 additional patients within 5 years following scoliosis surgery. There was no correlation between complications and CPCHILD scores postoperatively at all time points, with the only exception of a weak correlation (ρ = –0.450, p = 0.002) with CPCHILD comfort score at 1 year after surgery.

Conclusions: Scoliosis surgery in patients with CP leads to a significant improvement in HRQoL, which is maintained 5 years following surgery. The substantial complication rate does not correlate with HRQoL changes postoperatively, suggesting that the benefits of surgery outweigh the risks in this fragile population.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

1British Columbia Children’s Hospital, Vancouver, British Columbia, Canada

2Johns Hopkins Children’s Center, Baltimore, Maryland

3Nemours Alfred I. duPont Hospital for Children, Wilmington, Delaware

4Shriners Hospital for Children, Philadelphia, Pennsylvania

5Mount Sinai Hospital, New York, NY

6Rady Children’s Hospital and Health Center, San Diego, California

7Cooper Medical School of Rowan University, Camden, New Jersey

8Faculty of Medicine, Dean’s Office, Medical Sciences Building, Toronto, Ontario, Canada

E-mail address for F. Miyanji:

Copyright 2018 by The Journal of Bone and Joint Surgery, Incorporated
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