The Pros and Cons of Operating Early Versus Late in the Progression of Cerebral Palsy Scoliosis

Study Design: Retrospective review of prospective data. Objective: To delineate a curve threshold where further delay of surgery significantly increased the risks for patients with cerebral palsy (CP) scoliosis. Summary of Background Data: Two approaches exist in the management of CP scoliosis: a proactive one where surgery is recommended once there is a risk of progression (Cobb > 50°) and a reactive one where surgery is recommended after the patient/caregiver may have significant challenges caused by a large deformity. Methods: A prospectively collected CP scoliosis surgical registry was queried for patients with minimum two years of follow-up. Three groups were delineated based on the distribution of curve magnitudes: <70° (proactive), 70°–90°, and >90° (reactive). Radiographic, surgical, and quality of life outcome data were compared between the groups using analysis of variance and chi-square analyses. Results: There were 38 patients in the <70° group, 44 in the 70°–90° group, and 42 in the >90° group. They were similar in age. The >90° group had significantly longer operative time (p < .001), a higher percentage of anterior/posterior procedures (31% vs 5%), and a higher infection rate requiring I&D (16.7%) than the other groups (<70°: 5.3%; 70°–90°: 6.8%; p < .05). The percentage blood volume loss was significantly higher in the >90° group compared to <70°. There were no differences in length of hospitalization or intensive care unit stay. Preoperatively, the Caregiver Priorities and Child Health Index of Life with Disabilities (CPchild) QOL score was significantly higher for the <70° group. At two years, the <70° and 70°–90° groups reached similar QOL scores, whereas the >90° trended toward a lower postoperative QOL. Conclusions: Being proactive (Cobb <70°) has no advantage in terms of decreasing risks or improving outcomes compared to curves 70°–90°. However, delaying surgery to a curve greater than 90° increases the risk of infection, blood loss, and the need for anterior/posterior procedures. Ideally, surgery should be recommended for curves less than 90°.