What is the management for a patient with cerebral palsy (CP) presenting with fractures from C7 to T1 of calcified/fused ligamenta flava?

Management of Fractures of Calcified/Fused Ligamenta Flava in a Patient with Cerebral Palsy

Surgical decompression with stabilization is the recommended management for fractures of calcified/fused ligamenta flava at C7-T1 in a patient with cerebral palsy to prevent neurological deterioration and improve functional outcomes.

Initial Assessment and Imaging

• Immediate CT scan: Perform a CT scan without delay to assess the extent of fractures and calcification of ligamenta flava 1
• MRI evaluation: Essential for assessing:
  • Degree of spinal cord compression
  • Presence of edema
  • Extent of ligamentous injury
  • Soft tissue involvement 1
• CT-angiography: Consider if there are risk factors for vascular injury, particularly with cervical spine fractures 1

Surgical Management

Indications for Surgical Intervention

Surgery is indicated in this case due to:

1. Presence of calcified/fused ligamenta flava causing potential spinal cord compression
2. Fractures at the cervicothoracic junction (C7-T1)
3. Cerebral palsy as a complicating factor increasing fracture risk
4. Risk of progressive neurological deterioration 2

Surgical Approach

1. Posterior decompressive laminectomy:

   • Remove fractured calcified ligamenta flava from C7-T1
   • Decompress the spinal cord to prevent further neurological compromise 3

2. Posterior spinal fusion with instrumentation:

   • Extend fusion one level above and below the affected segments (C6-T2)
   • Use pedicle screw fixation under navigation guidance for accurate placement 4
   • Consider lateral mass screws at cervical levels if pedicle screws are not feasible

3. Bone grafting:

   • Apply autologous or allograft bone to achieve solid fusion

Perioperative Considerations

• Maintain systolic blood pressure >110 mmHg to ensure adequate spinal cord perfusion 1
• Controlled ventilation with end-tidal CO2 monitoring to prevent secondary brain injury 1
• Neurophysiological monitoring during surgery (somatosensory and motor evoked potentials)
• Careful positioning to prevent pressure ulcers, particularly important in patients with CP 1

Postoperative Management

1. Immobilization:

   • Rigid cervical collar for 6-8 weeks
   • Avoid excessive movement during transfers

2. Rehabilitation protocol:

   • Early physical therapy to maintain mobility
   • Occupational therapy for activities of daily living
   • Focus on preventing contractures and maintaining function

3. Bone health optimization:

   • Calcium and vitamin D supplementation
   • Consider bisphosphonates if osteopenia is present 1
   • Nutritional support to improve bone healing 5, 6, 7

Special Considerations for Cerebral Palsy

• Patients with CP have increased risk of low-energy fractures, particularly those who are non-ambulatory 5, 6, 7
• Higher complication rates post-surgery, including:
  • Risk of developing kyphosis after laminectomy 3
  • Delayed fracture healing
  • Pressure ulcers from immobilization

Follow-up Protocol

• Clinical and radiographic assessment at 2 weeks, 6 weeks, 3 months, and 6 months
• Monitor for:
  • Signs of neurological deterioration
  • Hardware complications
  • Development of kyphotic deformity 3
  • Adequate fusion progress

Potential Complications and Management

• Post-laminectomy kyphosis: May require extended fusion if it develops 3
• Hardware failure: May require revision surgery
• Neurological deterioration: Requires immediate imaging and possible surgical revision
• Infection: Treat with appropriate antibiotics and possible surgical debridement

The case described is unusual but has precedent in literature. A similar case of complete calcification of cervical ligamentum flavum resulted in quadriparesis and was successfully treated with C3-C7 laminectomy and C2-C7 fusion, though kyphosis developed postoperatively 3. This underscores the importance of fusion with instrumentation to prevent post-laminectomy deformity.