Curve flexibility in cerebral palsy-related neuromuscular scoliosis: does the intraoperative prone radiograph reveal more flexibility than preoperative radiographs?

BACKGROUND: Spinal flexibility is determined preoperatively by manipulating the spine and assessing, radiographically, to what extent the amount of deformity reduces. Quantifying spinal flexibility is important when determining the approach to the planned operation in order to achieve the most optimal spinal correction and balance. Currently, supine traction radiography is a popular method used in patients with severe, cerebral palsy-related neuromuscular scoliosis. The different methods for determining spinal flexibility have been studied extensively in the adolescent idiopathic scoliosis population. No such studies exist in the cerebral palsy population. The purpose of this study was to determine how predictive the intraoperative prone radiograph is in determining spinal flexibility in patients with severe, cerebral palsy related neuromuscular scoliosis.  Furthermore, the intraoperative prone radiograph was compared to the preoperatively acquired supine and supine traction radiographs. METHODS: Twenty-five consecutive patients with severe, cerebral palsy-related neuromuscular scoliosis were studied. The Cobb angles of the preoperative supine, preoperative supine traction, and intraoperative prone radiograph were measured and compared. The flexibility indices of these radiographs were calculated and compared. Traction was not applied during acquisition of the intraoperative prone radiograph. The radiograph was taken during the exposure to localize surgical levels, prior to instrumentation. RESULTS: The supine traction radiograph and the intraoperative prone radiograph had higher flexibility indices than the preoperative supine radiograph. These comparisons were statistically significant. The comparison between the flexibility indices of the supine traction radiograph and intraoperative prone radiograph was not statistically significant. When looking at the preoperative supine traction radiograph separately, it was noted that the process of instrumentation led to 30% more correction of the Cobb angle. CONCLUSIONS: The intraoperative prone radiograph is more predictive of spinal flexibility in patients with severe scoliosis related to cerebral palsy when compared to the preoperative supine radiograph but not the preoperative supine traction radiograph. The preoperative supine traction radiograph serves as the optimal method for determining spinal flexibility in patients with severe, cerebral palsy-related neuromuscular scoliosis.