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Background: Hip displacement in children with cerebral palsy (CP) is monitored by measuring migration percentage on anteroposterior pelvis radiographs. However, proper positioning for radiography in children with spasticity is difficult. The reliability and accuracy of migration percentage as a function of patient positioning is unknown., Objective: To determine the effects of patient positioning on migration percentage measurements in children with CP., Materials and Methods: We identified children with CP (≤18-year-old) with pelvis CT and anteroposterior pelvis radiograph obtained <6 months apart (10/2018-11/2021). Digitally reconstructed radiographs were generated from each pelvis CT, to simulate nine different patient positions: neutral; 10° and 20° lordosis and kyphosis; and 10° and 20° right rotation and left rotation. Two radiologists measured migration percentages from the simulated and real pelvis radiographs. We used Spearman's rho to assess inter-rater reliability, and Wilcoxon signed rank test to determine statistical significance., Results: We studied sixty-three children (male=41; median age=8 years; range=4-18 years). The two radiologists' migration percentage measurements were highly correlated with each other across all simulated and real radiographs (Spearman's rho=0.86-0.99, P<0.01). For both readers and hips, migration percentages measured from real radiographs were significantly different from those measured from neutral simulated radiographs (P<0.01), with median absolute difference=5-6 percentage points (PP) and interquartile range (IQR)=9-12 PP. When comparing migration percentage measurements from neutral simulated radiographs to those in kyphosis/lordosis and right/left rotations, median absolute differences were 2-4 PP (IQR=3-8 PP) and 4-15 PP (IQR=6-17 PP), respectively., Conclusion: Inter-rater reliability of measured migration percentages is high, but accuracy decreases with patient positional changes., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Children with cerebral palsy are at increased risk of hip dislocation. Detecting hip subluxation through radiographic hip screening is an essential component of hip surveillance and has been shown to prevent hip dislocations. Large-scale hip surveillance programs are being implemented nationwide, highlighting the importance of uniform technical and reporting standards., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Intrathecal baclofen has long been known to be an efficacious treatment of spasticity in children with cerebral palsy. Test bolus administration is often necessary to ensure patients will benefit from this treatment. The introduction of a intrathecal catheter for test bolus administration can prove challenging in a subset of this population, particularly those who have received surgery with postoperative spinal fusion masses. We outline a novel technique of inserting a spinal catheter for test bolus administration in a patient with a postoperative fusion mass whereby a fenestration is created through the lamina using an osteotomy needle.

Background: Respiratory and cardiovascular diseases are the most common causes of death in children with cerebral palsy., Objective: To evaluate sonographic carotid intima-media thickness, an early marker of atherosclerosis, in children with cerebral palsy and in healthy controls., Materials and Methods: One hundred children with cerebral palsy (65 boys), mean age 6.2 (SD, 2.1) years, and 35 age-matched and sex-matched healthy controls were included. Common carotid artery intima-media thickness was measured sonographically. Differences between patients and controls were evaluated with an independent samples t-test., Results: Age, sex distribution and levels of serum lipids were comparable between patients and controls. Average, right and left carotid artery intima-media were thicker in patients compared with controls (mean ± SD, 0.61 ± 0.13 mm vs 0.40 ± 0.03 mm; 0.61 ± 0.14 mm vs 0.40 ± 0.03 mm; 0.61 ± 0.13 mm vs 0.40 ± 0.03 mm, respectively; all P < 0.001)., Conclusion: Carotid intima-media is sonographically thicker in children with cerebral palsy compared with healthy controls, which may express an increased risk of atherosclerotic diseases.

Background: In the nonambulatory cerebral palsy (CP) population with a prior history of fracture, the use of pamidronate is not always effective in preventing further fractures., Objective: To test the hypothesis that when fractures occur after cyclic pamidronate, they will be at the proximal or distal end of a pamidronate band., Materials and Methods: Retrospective review of our CP patient database revealed 53 children who had received one or more complete courses of pamidronate therapy (five cycles over 12 months). Medical records were screened to identify children who had sustained a fracture or fractures after completing treatment., Results: Of 53 patients treated with pamidronate, only 14 sustained fractures after treatment. Radiographs were available for 11 patients, showing 19 fractures. Sixty-three percent of these fractures were located at a junction with pamidronate bands but not within the bands., Conclusions: We propose stress risers as the mechanism for fractures that have occurred where bone mineral density abruptly changes as a result of cyclic administration of pamidronate. We show a theoretical example of how alternative dosing might reduce the ratio and therefore decrease the chance of formation of a stress riser.

Background: Transient periventricular echodensities (PVE) in preterm infants affect neurodevelopmental outcome., Objective: To correlate the duration and grading of PVE with neurodevelopmental outcome., Materials and Methods: A retrospective, single-centre cohort study of infants with PVE diagnosed by ultrasonography from 1995 to 2000 with blinded grading and recognition of duration of PVE., Results: A total of 72 infants (median gestational age 32 weeks, median birth weight 1,668 g) were diagnosed as having PVE. Minor neurological abnormalities were diagnosed in seven (10%), cerebral palsy in six (8%), developmental delay in seven (10%), and mild mental retardation in two (3%) of the infants. Differences regarding adverse outcome were not significant between infants with severity grade 1 compared to severity grade 2 (16% and 22%, respectively). There was a significant increase in adverse neurodevelopmental outcome with increasing duration of PVE. Of 33 infants with duration of PVE<7 days, 1 (3%) had an adverse neurodevelopmental outcome, compared to 6 (24%) of 25 infants with a duration of PVE of 7-14 days, and 6 (43%) of 14 infants with a duration of PVE>14 days (P<0.002, RR 7.920, 95% CI 1.017-61.661; P<0.001, RR 14.143, 95% CI 1.871-106.895, respectively)., Conclusion: The duration, but not the grading, of transient PVE was significantly correlated with neurodevelopmental outcome.

Background: A high prevalence of abnormal cerebral MRI findings has been reported in low-birth-weight children., Objective: To compare MRI findings in very-low-birth-weight (VLBW) and term small-for-gestational-age (SGA) children with controls in early adolescence., Materials and Methods: Cerebral MRI was used to examine 55 VLBW, 54 SGA and 66 controls at 15 years of age. The MR images were qualitatively assessed, and size of ventricles, white-matter and grey-matter abnormalities were reported., Results: The VLBW teenagers had a higher prevalence of various MRI abnormalities than SGA children and controls. Dilation of the ventricular system, especially of the occipital horns, was found in 82% of the VLBW group, in 19% of the SGA group and in 21% of controls. White-matter reduction was found in 53% of the VLBW, in 6% of the SGA and in 2% of controls. Corpus callosum thinning was found in 47% of the VLBW, in 2% of the SGA and in 6% of controls. Periventricular gliosis was found in 29% of the VLBW, in 4% of the SGA and in 8% of controls., Conclusions: Cerebral MRI pathology in white matter is a common finding in VLBW teenagers. The findings may indicate minor perinatal PVL with resulting loss of white-matter tissue and ventricular dilation.

Background: Pediatric patients are being treated with bisphosphonates for low bone mineral density. Skeletal radiographic findings have been described with bisphosphonates given orally and intravenously., Objective: To determine and describe the radiographic findings of cyclic intravenous bisphosphonate therapy in the growing skeleton., Materials and Methods: Retrospective review of radiographs of 32 patients with osteogenesis imperfecta or cerebral palsy treated with intravenous bisphosphonates on a quarterly schedule., Results: Principal observations were metaphyseal bands and increased bone mineral density. The bands varied in spacing according to the age of the patient, rate of growth, and the location of the metaphysis. Fractures continued to be seen in patients with osteogenesis imperfecta., Conclusion: Cyclic bisphosphonate therapy results in distinctive radiographic findings in the growing skeleton.

Background: Children with cerebral palsy (CP), often nonambulatory and/or on anticonvulsants, are at increased risk for fractures. Bone mineral density (BMD) measured by the conventional techniques of dual-energy X-ray absorptiometry (DXA) often cannot be reliably or easily measured in these patients., Objective: To find an alternative site to whole body, spine and hip that can be conveniently used to measure BMD in CP patients., Materials and Methods: Having observed that CP patients prefer to lie on their sides, we explored measuring BMD at the distal femur in the lateral projection. A total of 92 scans were performed without sedation in 34 children and adolescents with CP, aged 4-19 years. Four femoral shaft subregions were created: two trabecular and two cortical., Results: The coefficients of variation (CV %) were generally higher for opposite-side comparisons (n = 12 patients) than for same-side comparisons (n = 16 patients). For intra- and interobserver analyses, CV % were higher for cortical regions than for trabecular regions. Overall, the CV % were similar to those for hip and spine., Conclusion: This peripheral site in the femur should be considered as an alternative for patients with CP when whole-body, hip and spine DXA are not practical.

Parameters of linear measurement were compared with actual brain volume to assess the significance of linear measurements as indices of atrophy in 31 neurologically normal children and 22 neurologically abnormal children. Brain volume was established by means of an image-analyzing system using contiguous CT scans. The parameters or indices estimated were: (1) the maximum transverse width of both hemispheres, (2) the maximum longitudinal length of both hemispheres, (3) the maximum frontal subarachnoid space, (4) the maximum width of the interhemispheric fissure, (5) the maximum width of the Sylvian fissure, (6) Evans' ratio, (7) the maximum width of the third ventricle, (8) the cella media index, (9) the maximum width of the fourth ventricle. In neurologically normal children, the maximum transverse width of both hemispheres, the maximum longitudinal length of both hemispheres, the maximum width of the interhemispheric fissure and the maximum width of the Sylvian fissure correlated significantly with the combined volume (CV) of both hemispheres and basal ganglia. In particular, the maximum transverse width of both hemispheres and the maximum longitudinal length of both hemispheres had a high correlation. In neurologically abnormal children the maximum transverse width of both hemispheres and the maximum width of the interhemispheric fissure were significantly correlated with the CV of both hemispheres and basal ganglia.

The CT findings in 120 cerebral palsied children are analysed. The 72.5% positive findings are correlated with the clinical types, as well as the aetiological basis for the cerebral palsy. The spastic type, 83.3% of the total number of children, had the highest positive findings. The yield was increased in children with seizures (91.3%) and those in the postnatal group (90%), as well as those with birth trauma and neonatal asphyxia (94%). The findings were those of atrophy in 30.8%, hydrocephalus, in 10%, infarct in 11.6%, porencephaly in 8.3% and others. The atropic changes and their patterns are explained. Treatable lesions, such as tumour, hydrocephalus, subdural haematoma, porencephaly and hygroma were identified in 22.5% of cases. It is concluded that CT scan is definitely efficacious in the management of cerebral palsied children.