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The Role of Cross-Links in Posterior Spinal Fusion for Cerebral Palsy–Related Scoliosis

Usmani, M. Farooq MSc; Shah, Suken A. MD; Yaszay, Burt MD; Samdani, Amer F. MD§; Cahill, Patrick J. MD; Newton, Peter O. MD; Marks, Michelle C. MS, PT∗∗; Sponseller, Paul D. MD, MBA††

doi: 10.1097/BRS.0000000000003117

Study Design. Retrospective review of a multicenter, prospective database.

Objective. Our aim was to compare complication rates and maintenance of radiographic correction at 2 years after posterior spinal fusion (PSF) with or without cross-links in patients with cerebral palsy (CP)–related scoliosis.

Summary of Background Data. Cross-links are frequently used in PSF to correct scoliosis in patients with CP because they are thought to increase the stiffness and torsional rigidity of the construct.

Methods. We reviewed the records of patients with CP who underwent primary PSF with or without cross-links between August 2008 and April 2015. Inclusion criteria were minimum follow-up of 2 years, availability of complications data (implant failure, surgical site infection, revision), and pre- and postoperative measurements of the major curve (measured using the Cobb method). The 256 patients included in this analysis had a mean age of 14.1 ± 2.7 years. Ninety-four patients had cross-links (57% using one cross-link; 43% using two cross-links) and 162 patients did not have cross-links. P < 0.05 was considered statistically significant.

Results. The two groups did not differ significantly with regard to sex, age at surgery, preoperative menarche status, Gross Motor Function Classification System level, major curve magnitude, pelvic obliquity, kyphosis, and lordosis angles. There were no significant differences between groups in the correction achieved or the maintenance of correction at 2 years for the major curve, pelvic obliquity, kyphosis, or lordosis (all P > 0.05). Complication rates were similar between the cross-link group (16%, N = 15) and the non–cross-link group (14%, N = 22).

Conclusion. At 2 years after PSF to treat CP-related scoliosis, patients had no significant differences in the degree of correction achieved, the maintenance of correction, or the rate of complications between those whose fusion constructs used cross-links and those whose constructs did not.

Level of Evidence: 3

Using data from a multicenter cohort of patients with cerebral palsy–related scoliosis, we evaluated the utility of cross-links in posterior spinal fusion. Cross-links were not associated with a significant difference in the deformity correction achieved, the rate of complications, or the maintenance of correction at 2-year follow-up.

The Johns Hopkins University School of Medicine, Baltimore, MD

Department of Orthopedic Surgery, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE

Department of Orthopedics, Rady Children's Hospital of San Diego, San Diego, CA

§Department of Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, PA

Department of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA

∗∗Setting Scoliosis Straight Foundation, San Diego, CA

††Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD.

Address correspondence and reprint requests to Paul D. Sponseller, MD, MBA, Bloomberg Children's Center, 1800 Orleans Street, 7359A, Baltimore, MD 21287; E-mail:

Received 18 December, 2018

Revised 6 March, 2019

Accepted 8 May, 2019

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, grants, royalties, stocks, employment.

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