Background: The Gross Motor Function Classification System (GMFCS) of cerebral palsy categorizes patients by mobility. Patients at GMFCS level 5 are considered the most disabled and at high risk of hip and spine problems, yet they represent a wide spectrum of function. Our aim was to subclassify patients at GMFCS level 5 who underwent spinal arthrodesis on the basis of central neuromotor impairments and to assess whether subclassification predicted postoperative complications and changes in health-related quality of life.
Methods: Using a prospective cerebral palsy registry, we identified 199 patients at GMFCS level 5 who underwent spinal arthrodesis from 2008 to 2013. Patients were assigned to subgroups according to preoperative central neuromotor impairments: the presence of a gastrostomy tube, a tracheostomy, history of seizures, and nonverbal status. Nine percent of patients had 0 impairments (GMFCS level 5.0), 14% had 1 impairment (level 5.1), 26% had 2 impairments (level 5.2), and 51% had 3 or 4 impairments (level 5.3). The Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire was used for preoperative and postoperative health-related quality-of-life outcome assessments, and major complications were recorded.
Results: The rate of major complications increased significantly with higher GMFCS level-5 subtype (p = 0.002), with 12% at level 5.0, 21% at level 5.1, 31% at level 5.2, and 49% at level 5.3. Five of the 7 patients who died within the follow-up period were at level 5.3. No significant differences were found among subgroups with respect to the magnitude of correction of the major coronal curve or pelvic obliquity. Preoperative and final follow-up CPCHILD total scores decreased significantly from GMFCS level 5.0 to level 5.3. However, no significant differences were found by subgroup with respect to the magnitude of improvement in CPCHILD total scores from the preoperative to the final follow-up evaluation (p = 0.597).
Conclusions: Stratification based on central neuromotor impairments can help to identify patients with cerebral palsy at GMFCS level 5 who are at higher risk for developing complications after spinal arthrodesis.
Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Investigation performed at the Departments of Orthopaedic Surgery and Anesthesiology, The Johns Hopkins University, Baltimore, Maryland; Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; Department of Orthopaedic Surgery, Shriners Hospitals for Children, Philadelphia, Pennsylvania; Department of Orthopedics, Rady Children’s Hospital of San Diego, San Diego, California; Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia; Setting Scoliosis Straight Foundation, San Diego, California; and Division of Orthopaedic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
Disclosure: Funding was received from DePuy Synthes Spine and K2M to the Setting Scoliosis Straight Foundation to support the cerebral palsy scoliosis research conducted by the Harms Study Group. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work; “yes” to indicate that the author had a patent and/or copyright, planned, pending, or issued, broadly relevant to this work; and “yes” to indicate that the author had other relationships or activities that could be perceived to influence, or have the potential to influence, what was written in this work.
- Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated
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