(iv) The spine in cerebral palsy

Spine deformities in cerebral palsy form an important part of the orthopedic problems in these children. As with all neuromuscular diseases there is multisystem involvement including spasticity, contractures, hip dislocation and subluxation, seizures, mental retardation, vision and hearing deficits and respiratory and feeding problems. A detailed evaluation of all these areas on patient presentation is essential, with, in addition, an evaluation of the child's nutritional status and functional ambulatory level. Non-operative treatment plays a role in following scoliosis for progression, as well as the use of sitting supports to improve the sitting function. The use of orthoses (TLSOs) plays only a small role in the treatment of these children. Surgical treatment in cerebral palsy is controversial, especially in the spastic quadriplegic, both in the indications and the approach (anterior plus posterior or posterior alone). The two main indications for surgery are curve progression and deterioration in sitting function in these severely involved children. A traction film is the best method of determining the flexibility of the spine deformity. In addition the levelling of the pelvis and the balance of the torso over the pelvis is also evaluated on this traction film. A posterior approach alone is used for 'idiopathic-like' curves, and for curves that balance over a level pelvis on the traction film. The majority of fusions are long (T2 to the sacrum) with the Luque Galveston technique being the instrumentation of choice. For curves that do not balance or with pelvic obliquity on the traction film, a combined anterior and posterior fusion is indicated. Postoperative care concentrates on the respiratory system, with early implementation of nutritional support. With care in surgical technique and an experienced postoperative nursing team, complications can be minimised, and the child returned to the preoperative functional level, with a successful surgical result - a solidly fused spine in balance in the coronal and sagittal planes over a level pelvis.