Li GY, et al. Spine Deform. 2022;doi:10.1007/s43390-022-00474-z.

Li GY, et al. Spine Deform. 2022;doi:10.1007/s43390-022-00474-z.

Published results showed distal spine anchors may provide better long-term control of the major curve than distal pelvic anchors in children with cerebral palsy scoliosis treated with growth-friendly instrumentation.

“Inserting screws into the pelvis to anchor growing rods is not benign. Screws in that area tend to be more prominent. Prominent screws can be painful and can also cause overlying skin breakdown and lead to infection. In addition, these screws can have a high failure rate,” G. Ying Li, MD, told Healio. “For these reasons, understanding which kids have enough of a tilt in their pelvis and lower lumbar spine to benefit from anchoring the rods into the pelvis is important.”

Distal spine vs. pelvic anchors

Using a multicenter database, Li and colleagues identified children with cerebral palsy scoliosis treated with traditional growing rods, magnetically controlled growing rods or a vertical expandable prosthetic titanium rib with a minimum of 2 years of follow-up. Researchers collected radiographic data prior to the index surgery, immediately after the index surgery and at most recent follow-up. Researchers also collected demographic data, as well as the type of growth-friendly device, type and location of the distal anchors, number of patients with distal spine anchors who underwent extension to the pelvis, number of patients with complications, type of complications and number of patients with unplanned returns to the OR.

Of the 98 patients who met inclusion criteria, researchers found 27 patients had distal spine anchors and 71 patients had distal pelvic anchors placed at the index surgery. Results showed patients who received distal spine anchors had a lower pre-index pelvic obliquity. Although both groups had similar radiographic data at most recent follow-up, researchers noted patients in the distal spine anchor group had a smaller major curve.

Researchers found 22% of patients in the distal spine anchor group underwent extension of instrumentation to the pelvis, most commonly at final fusion. Patients in the distal spine anchor group who underwent extension of instrumentation to the pelvis had a higher pre-index L5 tilt compared with patients who did not require extension, according to results.

At most recent follow-up, patients in the distal spine anchor group who underwent extension of instrumentation had a lower major curve compared with the distal pelvic anchor group, according to subanalysis. Researchers found a higher number of complications per patient in the distal spine anchor group who underwent extension of instrumentation vs. the distal spine anchor group who did not undergo extension of instrumentation.

“Growth-friendly treatment for early onset scoliosis is already associated with more complications than a single spinal fusion. So, for patients with cerebral palsy who have a small enough pelvic tilt, it is beneficial to avoid inserting screws into the pelvis in the early stages of treatment,” Li said. “Even though we did see some children with growing rods anchored to the spine who later needed to have the rods anchored to the pelvis, we inserted those pelvic screws when kids were undergoing their final spinal fusion procedure. These findings provide surgeons with more information to help patients avoid complications while still correcting a curve that can impact quality of life, pain and lung development for children with cerebral palsy.”

David L. Skaggs, MD, MMM

G. Ying Li, MD, and colleagues report on young children with cerebral palsy undergoing growth-friendly instrumentation. This is a fragile population at high risk for complications.

A previous study of fusions in children with neuromuscular scoliosis concluded, “Don’t you wish you went to the pelvis the first time,” because when a revision fusion to the pelvis was needed, the complication rate doubled compared to fusing to the pelvis at the initial surgery.

Li and colleagues report that patients with growth-friendly instrumentation to the pelvis have nearly twice the complications and more than eight times the unplanned return to the OR compared to patients with lowest instrumentation in the spine – warning surgeons to avoid pelvic instrumentation at the initial surgery if possible. 

While this study has inerrant limitations, such as potential selection bias, the take-home message rings true: If there is not too much pelvic obliquity, avoid growth-friendly implants to the pelvis. This approach will not burn bridges, as one can always include the pelvis at the final fusion if needed.

Nielsen E, et al. Spine (Phila Pa 1976). 2019;doi:10.1097/BRS.0000000000002888.

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