Is it necessary to fuse to the pelvis when correcting scoliosis in cerebral palsy?

Background: Neuromuscular scoliosis is commonly associated with a large pelvic obliquity. Scoliosis in children with cerebral palsy is most commonly managed with posterior spinal instrumentation and fusion. While consensus is reached regarding the proximal starting point of fusion, controversy exists as to whether the distal level of spinal fusion should include the pelvis to correct the pelvic obliquity.

Aim: To assess the role of pelvic fusion in posterior spinal instrumentation and fusion, particularly it impact on pelvic obliquity correction, and to assess if the rate of complications differed as a function of pelvic fusion.

Methods: This was a retrospective, cohort study in which we reviewed the medical records of children with cerebral palsy scoliosis treated with posterior instrumentation and fusion at a single institution. Minimum follow-up was six months. Patients were stratified into two groups: Those who were fused to the pelvis and those fused to L4/L5. The major outcomes were complications and radiographic parameters. The former were stratified into major and minor complications, and the latter consisted of preoperative and final Cobb angles, L5-S1 tilt and pelvic obliquity.

Results: The study included 47 patients. The correction of the L5 tilt was 60% in patients fused to the pelvis and 67% in patients fused to L4/L5 ( 0.22). The pelvic obliquity was corrected by 43% and 36% in each group, respectively ( = 0.12). Regarding complications, patients fused to the pelvis had more total complications as compared to the other group (63.0% 30%, respectively, = 0.025). After adjusting for differences in radiographic parameters (lumbar curve, L5 tilt, and pelvic obliquity), these patients had a 79% increased chance of developing complications (Relative risk = 1.79; 95%CI: 1.011-3.41).

Conclusion: Including the pelvis in the distal level of fusion for cerebral palsy scoliosis places patients at an increased risk of postoperative complications. The added value that pelvic fusion offers in terms of correcting pelvic obliquity is not clear, as these patients had similar percent correction of their pelvic obliquity and L5 tilt compared to children whose fusion was stopped at L4/L5. Therefore, in a select patient population, spinal fusion can be stopped at the distal lumbar levels without adversely affecting the surgical outcomes.