What is curvature of the spine?
Curvature of the spine, or scoliosis, occurs when the spine develops a sideways curvature. Curvature of the spine is common in people with cerebral palsy who are unable to walk independently or with support. Poor posture due to increased stiffness of the muscles and muscle weakness can contribute to a lack of support of the spine. The reported incidence of scoliosis among people with cerebral palsy varies between different studies but overall, it seems to be that around 20-25% of those affected by cerebral palsy are also affected by curvature of the spine, albeit this percentage increases as the severity of cerebral palsy increases.
When does spinal surgery for curvature of the spine become necessary?
Severe scoliosis can be painful and reduce quality of life. It can also make breathing more difficult and make sitting and transfers more uncomfortable. Therefore, the overall goal in managing spinal deformity is to maintain, or ideally improve, functional ability and quality of life.
Treatment of curvature of the spine generally starts with conservative measures such as adaptive seating, progressing to spinal orthoses and, finally, surgical treatment. A study in Oxford found that by adapting seating, with the inclusion of pads at the side of the body, a significant improvement to the shape of the spine can be achieved. A spinal orthosis acts in a similar but more consistent way, providing an external support aid to the spine. Some children do not tolerate the spinal orthosis. In particular, the spinal orthosis is poorly tolerated by children who have breathing difficulties.
When more conservative options for the treatment of scoliosis have been exhausted, surgical treatment of the spine will be considered. Surgical treatment for scoliosis (spinal fusion) involves inserting metal rods to support the spine and bone graft that leads to fusion of the vertebrae, the bony blocks of the spine, so that they form a single bone. Once bony fusion is completed (usually within 6 months) the rods become redundant but are not routinely removed unless they cause problems.
What are the risks and benefits of spinal surgery?
One way of measuring quality of life is by reference to the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire. The questionnaire asks parents and carers to consider the level of difficulty a child has in performing certain tasks over the course of the previous two weeks such as eating and drinking, dressing, toileting and getting in and out of car; and the level of pain or discomfort experienced during those tasks. The questionnaire also explores mood, communication skills and overall quality of life.
A study carried out in Boston, USA, compared CPCHILD questionnaire scores for children with cerebral palsy both before and after spinal surgery. The study found that at one year after surgery, the overall scores had increased, reflecting a positive increase in the parent’s or caregiver’s perception of the child’s quality of life but that at two years after surgery, the CPCHILD scores were back at the baseline, reflecting no overall improvement. However, another study from British Columbia, Canada, found that parents and caregivers reported improvements on the CPCHILD questionnaire at one, two and five years postoperatively.
A decision to provide surgical treatment should be given thorough consideration because of the risks involved. The risks of spinal fusion surgery include postoperative chest infection; blood loss during the operation; and wound infection. However, for those with cerebral palsy, the risks of each of these can be higher due to weakness in the chest muscles and swallowing difficulties; clotting abnormalities from medication; and the increased potential for infection caused by being incontinent. These risks and complications should be balanced against the risk of severe scoliosis compromising cardiopulmonary function and quality of life.
How much does spinal surgery cost?
When spinal surgery for curvature of the spine becomes necessary, many people will choose to have this under the care of the NHS. For others, treatment in the private sector is an option. The average cost of such treatment in the private sector would be in the range of £42,000 – £48,000. However, this can vary considerably between different Institutions .