Spinal fusion for spastic neuromuscular scoliosis: Is anterior releasing necessary when intraoperative halo-femoral traction is used?

Study Design.: Retrospective radiographic and clinical study. Objective.: To compare the complications and radiographic outcomes of 2 types of surgical treatments, posterior-only fusion and circumferential fusion, in patients with nonambulatory quadriplegic cerebral palsy treated with adjunctive intraoperative halo-femoral traction. Summary of Background Data.: Circumferential anterior-posterior spinal fusion (A/PSF) has been used to improve deformity correction and rate of fusion in patients with neuromuscular scoliosis (NMS) but is associated with increased morbidity. Anterior procedures may increase operative time (OR time) and estimated blood loss (EBL) as well as compromise pulmonary function. Posterior-only spinal fusion (PSF-only) may be sufficient, thereby forgoing the need for the anterior approach without sacrificing deformity correction or outcome. Methods.: Twenty-six patients (age <21 years) who underwent PSF-only for spastic NMS (quadriplegic cerebral palsy) were matched with a comparison cohort of 26 patients who underwent A/PSF (11 staged, 15 same day). All posterior fusions extended from the proximal thoracic spine (T2/T3) to the pelvis. Anterior fusions used a thoracoabdominal approach. All 52 patients underwent intraoperative halo-femoral traction. Mean follow-up for PSF-only was 2.9 years and A/PSF 3.3 years. Results.: There were no significant differences between the 2 groups in demographic data or preoperative radiographic measures. The PSF-only group had statistically significant shorter OR time (6.1 vs. 10.3 hours), lower EBL (873 vs. 1361 mL), lower frequency of postoperative intubation (38% vs. 81%), shorter length of postoperative intubation (2 vs. 6.5 days), and lower frequency of postoperative pulmonary complications (7.7% vs. 26.9%). There were no statistically significant differences at the final follow-up for thoracolumbar/lumbar curve Cobb, % correction of thoracolumbar/lumbar Cobb, pelvic obliquity, C7 plumb line and the center sacral vertical line, sagittal T5-T12, sagittal T10-L2, and sagittal T12-S1 Cobb measurements. There were no halo-femoral traction-related complications. Conclusions.: When intraoperative halo-femoral traction is used, PSF-only surgery for NMS can provide excellent curve correction and spinal balance. In this study, the PSF-only group had shorter OR time, lower EBL, lower frequency of postoperative intubation, and fewer cases of pneumonias when compared with A/PSF with similar radiographic outcomes at 2-year follow-up.