Mortality for Pneumonia and Risk of Pneumonia in Children with Cerebral Palsy Treated with and without Surgery

Mortality for Pneumonia and Risk of Pneumonia in Children with Cerebral Palsy Treated with and without Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Mortality for Pneumonia and Risk of Pneumonia in Children with Cerebral Palsy Treated with and without Surgery Matti Ahonen, Ira Jeglinsky-Kankainen, Mika Gissler, Ilkka Helenius This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8036603/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Nov, 2025 Read the published version in European Spine Journal → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose The aim of this study was to compare the incidence of pneumonia and pneumonia-related mortality in children with cerebral palsy (CP) and scoliosis, with and without scoliosis surgery. Methods National registries care and cause of death registries were searched for individuals with CP and scoliosis born after 1987 with recordings between 1996 and 2021. Identified individuals were categorized according to scoliosis surgery and were compared for pneumonia incidence and pneumonia-related mortality. Multivariable Cox regression examined determinants of mortality. Results We identified 474 children with CP and scoliosis, of these 236 children had not undergone surgery, while 238 had been operated. Both groups had similar rates of comorbidities. While there was no change in number of individuals with at least one hospitalization for pneumonia, there was significant reduction in cumulative pneumonia incidence from before to after surgery (175.5 vs. 121.5 hospitalizations per 1,000 years, p < 0.001), while incidence did not change in non-surgically treated patients (192.8 vs. 203.9, hospitalizations per 1,000 years, p = 0.35). During follow-up pneumonia-related mortality was significantly higher in the non-surgically treated group than in the surgically treated group (n = 21/236, 8.9% vs. n = 8/238, 3.3%, p = 0.008). After adjusting for covariates surgical patients had 87.5% reduction in risk of mortality to pneumonia compared with non-surgically treated patients (hazard ratio: 0.125, 95% confidence interval: 0.051–0.31, p < 0.001). Conclusions These results indicate that surgical treatment of scoliosis in children with CP associates to reduced incidence of pneumonia and pneumonia-related mortality. Figures Figure 1 Figure 2 Introduction Pneumonia is a common cause of morbidity and mortality in children with severe forms of cerebral palsy (CP) [ 1 ]. In non-ambulatory children with CP, neuromuscular scoliosis is common, with its risk increasing with age and greater disability [ 2 ]. Severe scoliosis is associated with abdominal and thoracic crowding, leading to reduced pulmonary function and increased pneumonia risk [ 3 ]. In CP-associated scoliosis, curves exceeding 40° are considered progressive, requiring major surgical treatment, as spinal orthoses are not effective against progressive deformity [ 2 , 3 ]. Surgical treatment has been associated with increase in quality of life with high caregiver satisfaction [ 4 – 6 ]. However, surgical treatment involving correction of scoliosis and posterior spinal fusion carries a significant risk of complications and morbidity due to the commonly associated comorbidities in these children [ 7 – 9 ]. Previous studies have shown that surgical treatment of scoliosis is associated with reduced total mortality in individuals with CP and scoliosis [ 10 ]. Surgical management is beneficial for pulmonary function and the degree of postoperative correction of scoliosis deformity decreases risk of postoperative pneumonia in neuromuscular scoliosis patients [ 11 , 12 ]. However, children with CP who have undergone scoliosis surgery have significantly reduced long-term survival [ 13 , 14 ]. It remains unclear whether surgery for scoliosis reduces the incidence of pneumonia and the risk of pneumonia-related mortality in children with CP. The aim of this register-based study was to evaluate the incidence of pneumonia requiring hospital management in surgically and non-surgically treated individuals with CP and scoliosis. We further aimed to elucidate effect of comorbidities and treatment on risk of death to pneumonia. We hypothesized that incidence of pneumonia and pneumonia as a cause of death are reduced after surgical management of scoliosis in children with CP. Methods Ethical and Regulatory Considerations The study has approval of ethical review board of Helsinki University Hospital and approval of Finnish Institute of Health and Welfare (THL) and Statistics Finland for use of their register data in this study. Data Sources, design, and study cohort This study is based on the data of the Medical Birth Register, the Care Register for Health Care, and the Cause-of-Death Register maintained by the Finnish Institute of Health and Welfare (THL) and Statistics Finland. These registers receive information based on a legally compulsory notifications on all health care providers in our country. Previous investigations have validated the accuracy and high coverage of the data [ 15 ]. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Selection of Cases and Controls The register was searched with CP and scoliosis to identify study population treated surgically or non-surgically during our study period from 1996 to 2021. International Statistical Classification of Diseases and Related Health Problems (ICD, 10th version) codes for comorbidities, pneumonia needing hospital management, and pneumonia as cause of death were compared, as indicated in Tables 1 and 2. Procedures were identified according to Nordic Medico-Statistical Committee (NOMESCO) classification for scoliosis surgery, gastrostomy, tracheostomy, and scoliosis bracing. Statistics All outcomes were calculated per 100 children and per 1000 follow-up years. Comparisons were made between cases and controls and tested with the test of relative proportion and Student’s t-test. Fifteen-year survival was analyzed for cases and controls by using Kaplan–Meier survival analysis. Index timepoint for comparison: date of surgery for surgical treatment and date of scoliosis diagnosis for non-surgically treatment. Factors considered significant for pneumonia-related mortality were used to estimate hazard ratios (HRs) for death using Cox Proportional hazards model. Data Availability Individualized data cannot be shared due to legal reasons. Statistical data or permission to get similar individual-level data can be received from Finnish Social and Health Data Permit Authority upon reasonable request. Results We identified 4571 individuals with CP born after 1987 who had their data recorded between 1996 and 2022 in these registers. Four hundred and seventy-four had also been diagnosed with scoliosis and were included in this study: 236 had not been operated on and 238 had been operated on for scoliosis (Fig. 1 ). Mean follow-up for non-surgically treated patients was 18.6 (SD 8.1) years and 22.6 (SD 6.6) years for surgically treated patients (Table 1). In total 39.0% and 14.3% of non-surgically and surgically treated patients had at least 15-year follow-up, respectively. Twenty-three (9.7%) of the non-surgically and 39 (16.4%) of the surgically treated patients had been brace treated for scoliosis (p = 0.227). The majority of the surgically treated patients had undergone posterior instrumented spinal fusion (98.3%, 234/238) and few combined anterior and posterior spinal fusion (1.7%, 4/238). Table 1. Demographics, Comorbidities and Treatments Variables Unoperated children with CP and scoliosis (n = 236) Operated children with CP and scoliosis (n = 238) P Value* Age at diagnosis of CP (years ± SD) 3.0 ± 3.6 4.2 ± 4.8 0.002 Age at diagnosis of scoliosis (years ± SD) 12.1 ± 5.2 12.4 ± 4.0 0.346 Follow-up time (years ± SD) 18.6 ± 8.1 22.8 ± 6.6 < 0.001 Age at death for pneumonia (years ± SD) 17.9 ± 7.6 22.2 ± 5.0 0.076 Birth weight (grams ± SD) 2825 ± 1064 2807 ± 995 0.849 Length of gestation (days ± SD) 259 ± 34 258 ± 32 0.742 Subtype of CP Spastic quadriplegic CP 21.2% (50) 24.4% (58) 0.984 Spastic diplegic CP 17.8% (42) 16.8% (40) 0.497 Spastic hemiplegic CP 15.7% (37) 12.2% (29) 0.158 Dyskinetic/Atactic CP 22.0% (52) 20.6% (49) 0.701 Other/Undefined CP 23.3% (55) 26.1% (58) 0.786 Comorbidities Epilepsy 68.6% (162) 68.9% (164) 0.065 Moderate or severe developmental disability 29.3% (69) 42.9% (102) 0.002 Surgery for hydrocephalus 41.1% (97) 40.3% (96) 0.865 Asthma 24.6% (58) 20.2% (48) 0.033 Chronic respiratory failure 3.4% (8) 5.9% (14) 0.421 Tracheostomy 2.1% (5) 4.6% (11) 0.131 Gastrostomy 32.2% (76) 34.9% (83) 0.427 Fundoplication 5.9% (14) 3.4% (8) 0.070 Pathological fracture 2.5% (6) 8.8% (21) 0.016 Congenital cardiac anomaly 10.2% (24) 13% (31) 0.874 *Comparison between unoperated and operated patients Co-morbidities, including birth weight, length of gestation, neurological, respiratory, gastroenterological, and other comorbidities were similar in both groups, except asthma was more common in non-surgically treated patients. Moderate to severe developmental disability and osteoporotic fractures were more common in surgically treated patients. (Table 1). Incidence of pneumonias did not change during follow-up period in the non-surgical cohort while surgical management significantly reduced the incidence for pneumonia needing hospital management (Table 2). Table 2. Hospitalizations for pneumonia Variable Unoperated children with CP and scoliosis (n = 236) Operated children with CP and scoliosis (n = 238) P Value Individuals with at least one hospitalization for pneumonia 113 (47.9%) 129 (54.2%) 0.527* Pneumonia (cumulative) Before Index n (%) 147 (62.2%) 202 (84.9%) After Index n (%) 104 (44.1%) 97 (40.8%) P Valueb 0.466 < 0.001 Pneumonia incidence Before Index (100/1000 years) 192.8 175.5 After Index (100/1000 years) 203.9 121.5 P Value† 0.346 0.002 *Comparison between unoperated and operated patients †Comparison before and after index day. During follow-up, pneumonia-related mortality was significantly higher in the non-surgically treated group than in the surgically treated group (n = 21/236, 8.9% vs. n = 8/238, 3.3%, p = 0.008). (Fig. 2 ). In Cox proportional hazards regression analysis age at age scoliosis diagnosis, severe to moderate developmental disability, and epilepsy were risk factors for pneumonia mortality, while age at CP diagnosis, asthma and cardiac anomalies were not (Table 3). After adjusting for covariates surgical patients had 87.5% reduction in risk of mortality to pneumonia compared with non-surgically treated patients (HR: 0.125, CI: 0.051–0.31, p < 0.001). Table 3. Cox Proportional Hazards Regression Analysis Variable Hazard Ratio 95% Confidence Interval P Value Age at scoliosis diagnosis 0.84 0.76–0.92 0.001 Age at CP diagnosis 1.02 0.96–1.08 0.590 Epilepsy 8.28 1.07–63.84 0.043 Asthma 0.51 0.17–1.49 0.217 Cardiac anomalies 1.07 0.31–3.72 0.911 Scoliosis surgery 0.13 0.051–0.31 0.001 Discussion This study is the first to describe an association between reduced pneumonia incidence and pneumonia-related mortality and surgical treatment of scoliosis in individuals with CP and scoliosis. Pneumonia represents the main cause of death in children with CP [ 1 ]. Scoliosis is common in these children and affects their pulmonary function [ 2 ]. Neuromuscular scoliosis is progressive when exceeding 40 degrees even after growth period [ 2 ]. However, previous investigations have failed to demonstrate the effect of spinal fusion surgery on the risk of pneumonia in children with neuromuscular scoliosis of various etiologies, while another investigation showed that better correction of scoliosis was associated with a reduction of postoperative pneumonias during two-year follow-up [ 3 , 12 ]. These investigations mainly focus on patients with progressive neurological diseases with various etiologies and have limited numbers of patients. Surgery for neuromuscular scoliosis represents a major physiological stress for children with CP, as extensive instrumented spinal fusion is required [ 9 ]. However, the risk of surgery-related mortality using standardized protocols remains low [ 13 , 14 ]. The current study showed that surgical management of neuromuscular scoliosis results in a decreased incidence of pneumonia requiring hospital treatment and is associated with a reduced risk of death due to pneumonia compared with non-surgically treated neuromuscular scoliosis. In patients with Duchenne muscular dystrophy posterior spinal fusion reduces decline of forced vital capacity (FVC) and improves survival of these individuals [ 11 ]. Severe scoliosis results in restrictive lung disease also in healthy adolescents (adolescent idiopathic scoliosis, AIS). Surgical management of AIS results in an improvement of absolute lung volumes, but not percentage of predicted values in the long-term [ 18 ]. We hypothesize that lung volumes might also be improved in children with CP after spinal fusion, even though evaluation of lung function using spirometry remains difficult in this patient group. Similarly, progressive scoliosis without surgery may result into deterioration of pulmonary function in the non-surgical cohort. This improvement in the surgical and possible deterioration in the non-surgical cohort might explain the differences in the risk of pneumonia and pneumonia as a cause of death in children with CP and scoliosis. Strengths and limitations Our study had several strengths. The registries provide nationwide data with high accuracy, ensure a reasonable sample size for statistical evaluation, and include data regarding hospital treatments beyond surgical units. Additionally, this investigation had a control group of individuals with CP and scoliosis. This investigation is limited by the lack of radiographs, and the lack of data regarding the degree of movement disorder (Gross Motor Function Classification System), which are not recorded in these databases. Second, the reasons for not undergoing surgery in the non-surgically treated cohort are not known, although this may be due to milder scoliosis in these patients despite the fact that a similar number of patients underwent brace treatment in the non-surgical cohort. This is further supported by higher incidence of moderate to severe developmental disability and pathological fractures in the surgical cohort indicating more severe form of CP in surgical cohort resulting in higher likelihood of severe scoliosis. However, we cannot exclude the possibility that small number of the non-surgically treated children were too unfit for surgery even if this seems unlikely as children with CP associated neuromuscular scoliosis of 50 degrees or over are generally regarded as surgical candidates in our country. Conclusion In conclusion, this investigation provides evidence for the first time of a reduction in the incidence of pneumonias and pneumonia-related deaths following surgical treatment of scoliosis in individuals with CP and scoliosis. Declarations Author Contribution M.A., I. J-G, M.G. and I.H. wrote, reviewed and edited the manuscript. M.G. conducted statistics and prepared figure 2. Data Availability Individualized data cannot be shared due to legal reasons. Statistical data or permission to get similar individual-level data can be received from Finnish Social and Health Data Permit Authority upon reasonable request. References Blair E, Langdon K, McIntyre S, Lawrence D, Watson L (2019) Survival and mortality in cerebral palsy: observations to the sixth decade from a data linkage study of a total population register and National Death Index. 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J Pediatr Orthop 42:e234–e241. https://doi.org/10.1097/BPO.0000000000002036 Helenius L, Ahonen M, Syvänen J, Perokorpi T, Helenius I Pulmonary function at minimum 10 years after segmental pedicle screw instrumentation for thoracic adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2024 Apr 1. [Epub ahead of print]. https://doi.org/10.1097/BRS.0000000000004996 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Nov, 2025 Read the published version in European Spine Journal → Version 1 posted Editorial decision: Accepted 21 Nov, 2025 Reviews received at journal 20 Nov, 2025 Reviewers agreed at journal 19 Nov, 2025 Reviews received at journal 13 Nov, 2025 Reviewers agreed at journal 13 Nov, 2025 Reviewers invited by journal 10 Nov, 2025 Editor assigned by journal 06 Nov, 2025 Submission checks completed at journal 06 Nov, 2025 First submitted to journal 05 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8036603","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":544706639,"identity":"a5db85c4-f58f-4e30-a45f-9f426fe30dc9","order_by":0,"name":"Matti 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1","display":"","copyAsset":false,"role":"figure","size":33840,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram representing patient identification based on diagnosis of scoliosis, cerebral palsy and surgical treatment for scoliosis\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8036603/v1/a5de54bf6b263ee935327b3c.png"},{"id":96287066,"identity":"2e96cce0-4897-40cb-8373-6e0a0335b65a","added_by":"auto","created_at":"2025-11-19 12:07:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":48630,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival function in months starting at the age of surgery (median 12.8, IQR 9.2-15.2) in surgically treated patients and at age of diagnosis of scoliosis in non-surgically treated patients\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8036603/v1/6264cb854860b1bd192105ae.png"},{"id":97178405,"identity":"42c1584d-fcbd-4f81-bd67-1744c0bca85a","added_by":"auto","created_at":"2025-12-01 16:09:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":913837,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8036603/v1/fcb8a836-c82f-4f63-9f67-0c5b17679db6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mortality for Pneumonia and Risk of Pneumonia in Children with Cerebral Palsy Treated with and without Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePneumonia is a common cause of morbidity and mortality in children with severe forms of cerebral palsy (CP) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In non-ambulatory children with CP, neuromuscular scoliosis is common, with its risk increasing with age and greater disability [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Severe scoliosis is associated with abdominal and thoracic crowding, leading to reduced pulmonary function and increased pneumonia risk [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In CP-associated scoliosis, curves exceeding 40\u0026deg; are considered progressive, requiring major surgical treatment, as spinal orthoses are not effective against progressive deformity [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Surgical treatment has been associated with increase in quality of life with high caregiver satisfaction [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, surgical treatment involving correction of scoliosis and posterior spinal fusion carries a significant risk of complications and morbidity due to the commonly associated comorbidities in these children [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Previous studies have shown that surgical treatment of scoliosis is associated with reduced total mortality in individuals with CP and scoliosis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Surgical management is beneficial for pulmonary function and the degree of postoperative correction of scoliosis deformity decreases risk of postoperative pneumonia in neuromuscular scoliosis patients [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, children with CP who have undergone scoliosis surgery have significantly reduced long-term survival [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It remains unclear whether surgery for scoliosis reduces the incidence of pneumonia and the risk of pneumonia-related mortality in children with CP.\u003c/p\u003e\u003cp\u003eThe aim of this register-based study was to evaluate the incidence of pneumonia requiring hospital management in surgically and non-surgically treated individuals with CP and scoliosis. We further aimed to elucidate effect of comorbidities and treatment on risk of death to pneumonia. We hypothesized that incidence of pneumonia and pneumonia as a cause of death are reduced after surgical management of scoliosis in children with CP.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eEthical and Regulatory Considerations\u003c/h2\u003e\u003cp\u003e The study has approval of ethical review board of Helsinki University Hospital and approval of Finnish Institute of Health and Welfare (THL) and Statistics Finland for use of their register data in this study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Sources, design, and study cohort\u003c/h3\u003e\n\u003cp\u003eThis study is based on the data of the Medical Birth Register, the Care Register for Health Care, and the Cause-of-Death Register maintained by the Finnish Institute of Health and Welfare (THL) and Statistics Finland. These registers receive information based on a legally compulsory notifications on all health care providers in our country. Previous investigations have validated the accuracy and high coverage of the data [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.\u003c/p\u003e\n\u003ch3\u003eSelection of Cases and Controls\u003c/h3\u003e\n\u003cp\u003eThe register was searched with CP and scoliosis to identify study population treated surgically or non-surgically during our study period from 1996 to 2021. International Statistical Classification of Diseases and Related Health Problems (ICD, 10th version) codes for comorbidities, pneumonia needing hospital management, and pneumonia as cause of death were compared, as indicated in Tables\u0026nbsp;1 and 2. Procedures were identified according to Nordic Medico-Statistical Committee (NOMESCO) classification for scoliosis surgery, gastrostomy, tracheostomy, and scoliosis bracing.\u003c/p\u003e\n\u003ch3\u003eStatistics\u003c/h3\u003e\n\u003cp\u003eAll outcomes were calculated per 100 children and per 1000 follow-up years. Comparisons were made between cases and controls and tested with the test of relative proportion and Student\u0026rsquo;s t-test. Fifteen-year survival was analyzed for cases and controls by using Kaplan\u0026ndash;Meier survival analysis. Index timepoint for comparison: date of surgery for surgical treatment and date of scoliosis diagnosis for non-surgically treatment. Factors considered significant for pneumonia-related mortality were used to estimate hazard ratios (HRs) for death using Cox Proportional hazards model.\u003c/p\u003e\n\u003ch3\u003eData Availability\u003c/h3\u003e\n\u003cp\u003eIndividualized data cannot be shared due to legal reasons. Statistical data or permission to get similar individual-level data can be received from Finnish Social and Health Data Permit Authority upon reasonable request.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe identified 4571 individuals with CP born after 1987 who had their data recorded between 1996 and 2022 in these registers. Four hundred and seventy-four had also been diagnosed with scoliosis and were included in this study: 236 had not been operated on and 238 had been operated on for scoliosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMean follow-up for non-surgically treated patients was 18.6 (SD 8.1) years and 22.6 (SD 6.6) years for surgically treated patients (Table\u0026nbsp;1). In total 39.0% and 14.3% of non-surgically and surgically treated patients had at least 15-year follow-up, respectively. Twenty-three (9.7%) of the non-surgically and 39 (16.4%) of the surgically treated patients had been brace treated for scoliosis (p\u0026thinsp;=\u0026thinsp;0.227). The majority of the surgically treated patients had undergone posterior instrumented spinal fusion (98.3%, 234/238) and few combined anterior and posterior spinal fusion (1.7%, 4/238).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTable\u0026nbsp;1. Demographics, Comorbidities and Treatments\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnoperated children with CP and scoliosis (n\u0026thinsp;=\u0026thinsp;236)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOperated children with CP and scoliosis (n\u0026thinsp;=\u0026thinsp;238)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP Value*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at diagnosis of CP (years\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at diagnosis of scoliosis (years\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.346\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up time (years\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at death for pneumonia (years\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.076\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth weight (grams\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2825\u0026thinsp;\u0026plusmn;\u0026thinsp;1064\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2807\u0026thinsp;\u0026plusmn;\u0026thinsp;995\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.849\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of gestation (days\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e259\u0026thinsp;\u0026plusmn;\u0026thinsp;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e258\u0026thinsp;\u0026plusmn;\u0026thinsp;32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.742\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubtype of CP\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpastic quadriplegic CP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.2% (50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.4% (58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.984\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpastic diplegic CP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.8% (42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.8% (40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.497\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpastic hemiplegic CP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.7% (37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.2% (29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.158\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDyskinetic/Atactic CP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.0% (52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.6% (49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.701\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther/Undefined CP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.3% (55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.1% (58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.786\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEpilepsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68.6% (162)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68.9% (164)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate or severe developmental disability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29.3% (69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.9% (102)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery for hydrocephalus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.1% (97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.3% (96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.865\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsthma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.6% (58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.2% (48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic respiratory failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.4% (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.9% (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.421\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTracheostomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.1% (5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.6% (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.131\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGastrostomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32.2% (76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.9% (83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.427\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFundoplication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.9% (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.4% (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.070\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePathological fracture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.5% (6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.8% (21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCongenital cardiac anomaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.2% (24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13% (31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.874\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e*Comparison between unoperated and operated patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCo-morbidities, including birth weight, length of gestation, neurological, respiratory, gastroenterological, and other comorbidities were similar in both groups, except asthma was more common in non-surgically treated patients. Moderate to severe developmental disability and osteoporotic fractures were more common in surgically treated patients. (Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eIncidence of pneumonias did not change during follow-up period in the non-surgical cohort while surgical management significantly reduced the incidence for pneumonia needing hospital management (Table\u0026nbsp;2).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTable\u0026nbsp;2. Hospitalizations for pneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnoperated children with CP and scoliosis (n\u0026thinsp;=\u0026thinsp;236)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOperated children with CP and scoliosis (n\u0026thinsp;=\u0026thinsp;238)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIndividuals with at least one hospitalization for pneumonia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e113 (47.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e129 (54.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.527*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePneumonia (cumulative)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBefore Index n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e147 (62.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e202 (84.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAfter Index n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e104 (44.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97 (40.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP Valueb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.466\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePneumonia incidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBefore Index (100/1000 years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e192.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e175.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAfter Index (100/1000 years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e203.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e121.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP Value\u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.346\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e*Comparison between unoperated and operated patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026dagger;Comparison before and after index day.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDuring follow-up, pneumonia-related mortality was significantly higher in the non-surgically treated group than in the surgically treated group (n\u0026thinsp;=\u0026thinsp;21/236, 8.9% vs. n\u0026thinsp;=\u0026thinsp;8/238, 3.3%, p\u0026thinsp;=\u0026thinsp;0.008). (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn Cox proportional hazards regression analysis age at age scoliosis diagnosis, severe to moderate developmental disability, and epilepsy were risk factors for pneumonia mortality, while age at CP diagnosis, asthma and cardiac anomalies were not (Table\u0026nbsp;3). After adjusting for covariates surgical patients had 87.5% reduction in risk of mortality to pneumonia compared with non-surgically treated patients (HR: 0.125, CI: 0.051\u0026ndash;0.31, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTable\u0026nbsp;3. Cox Proportional Hazards Regression Analysis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHazard Ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% Confidence Interval\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at scoliosis diagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.76\u0026ndash;0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at CP diagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.96\u0026ndash;1.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.590\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEpilepsy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.07\u0026ndash;63.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.043\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAsthma\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.17\u0026ndash;1.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.217\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCardiac anomalies\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.31\u0026ndash;3.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.911\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eScoliosis surgery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.051\u0026ndash;0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to describe an association between reduced pneumonia incidence and pneumonia-related mortality and surgical treatment of scoliosis in individuals with CP and scoliosis.\u003c/p\u003e\u003cp\u003ePneumonia represents the main cause of death in children with CP [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Scoliosis is common in these children and affects their pulmonary function [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Neuromuscular scoliosis is progressive when exceeding 40 degrees even after growth period [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, previous investigations have failed to demonstrate the effect of spinal fusion surgery on the risk of pneumonia in children with neuromuscular scoliosis of various etiologies, while another investigation showed that better correction of scoliosis was associated with a reduction of postoperative pneumonias during two-year follow-up [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These investigations mainly focus on patients with progressive neurological diseases with various etiologies and have limited numbers of patients. Surgery for neuromuscular scoliosis represents a major physiological stress for children with CP, as extensive instrumented spinal fusion is required [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the risk of surgery-related mortality using standardized protocols remains low [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The current study showed that surgical management of neuromuscular scoliosis results in a decreased incidence of pneumonia requiring hospital treatment and is associated with a reduced risk of death due to pneumonia compared with non-surgically treated neuromuscular scoliosis.\u003c/p\u003e\u003cp\u003eIn patients with Duchenne muscular dystrophy posterior spinal fusion reduces decline of forced vital capacity (FVC) and improves survival of these individuals [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Severe scoliosis results in restrictive lung disease also in healthy adolescents (adolescent idiopathic scoliosis, AIS). Surgical management of AIS results in an improvement of absolute lung volumes, but not percentage of predicted values in the long-term [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. We hypothesize that lung volumes might also be improved in children with CP after spinal fusion, even though evaluation of lung function using spirometry remains difficult in this patient group. Similarly, progressive scoliosis without surgery may result into deterioration of pulmonary function in the non-surgical cohort. This improvement in the surgical and possible deterioration in the non-surgical cohort might explain the differences in the risk of pneumonia and pneumonia as a cause of death in children with CP and scoliosis.\u003c/p\u003e\n\u003ch3\u003eStrengths and limitations\u003c/h3\u003e\n\u003cp\u003eOur study had several strengths. The registries provide nationwide data with high accuracy, ensure a reasonable sample size for statistical evaluation, and include data regarding hospital treatments beyond surgical units. Additionally, this investigation had a control group of individuals with CP and scoliosis.\u003c/p\u003e\u003cp\u003eThis investigation is limited by the lack of radiographs, and the lack of data regarding the degree of movement disorder (Gross Motor Function Classification System), which are not recorded in these databases. Second, the reasons for not undergoing surgery in the non-surgically treated cohort are not known, although this may be due to milder scoliosis in these patients despite the fact that a similar number of patients underwent brace treatment in the non-surgical cohort. This is further supported by higher incidence of moderate to severe developmental disability and pathological fractures in the surgical cohort indicating more severe form of CP in surgical cohort resulting in higher likelihood of severe scoliosis. However, we cannot exclude the possibility that small number of the non-surgically treated children were too unfit for surgery even if this seems unlikely as children with CP associated neuromuscular scoliosis of 50 degrees or over are generally regarded as surgical candidates in our country.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this investigation provides evidence for the first time of a reduction in the incidence of pneumonias and pneumonia-related deaths following surgical treatment of scoliosis in individuals with CP and scoliosis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.A., I. J-G, M.G. and I.H. wrote, reviewed and edited the manuscript. M.G. conducted statistics and prepared figure 2.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eIndividualized data cannot be shared due to legal reasons. Statistical data or permission to get similar individual-level data can be received from Finnish Social and Health Data Permit Authority upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBlair E, Langdon K, McIntyre S, Lawrence D, Watson L (2019) Survival and mortality in cerebral palsy: observations to the sixth decade from a data linkage study of a total population register and National Death Index. BMC Neurol 19:111. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12883-019-1343-1\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eSaito N, Ebara S, Ohotsuka K, Kumeta H, Takaoka K (1998) Natural history of scoliosis in spastic cerebral palsy. 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J Pediatr Orthop 40:e186\u0026ndash;e192. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BPO.0000000000001424\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eBohtz C, Meyer-Heim A, Min K (2011) Changes in health-related quality of life after spinal fusion and scoliosis correction in patients with cerebral palsy. J Pediatr Orthop 31:668\u0026ndash;673. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BPO.0b013e318221093c\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eTsirikos AI, Chang WN, Dabney KW, Miller F (2004) Comparison of parents\u0026rsquo; and caregivers\u0026rsquo; satisfaction after spinal fusion in children with cerebral palsy. J Pediatr Orthop 24:54\u0026ndash;58. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00004694-200401000-00010\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eCognetti D, Keeny HM, Samdani AF, Pahys JM, Hanson DS, Blanke K, Hwang SW (2017) Neuromuscular scoliosis complication rates from 2004 to 2015: a report from the Scoliosis Research Society Morbidity and Mortality database. Neurosurg Focus 43:E10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3171/2017.7.FOCUS17384\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eNishnianidze T, Bayhan IA, Abousamra O, Sees J, Rogers KJ, Dabney KW, Miller F (2016) Factors predicting postoperative complications following spinal fusions in children with cerebral palsy scoliosis. Eur Spine J 25(2):627\u0026ndash;634. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00586-015-4243-0\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eJain A, Sponseller PD, Shah SA, Samdani A, Cahill PJ, Yaszay B, Njoku DB, Abel MF, Newton PO, Marks MC, Narayanan UG, Harms Study Group (2016) Subclassification of GMFCS level-5 cerebral palsy as a predictor of complications and health-related quality of life after spinal arthrodesis. J Bone Joint Surg Am 98:1821\u0026ndash;1828. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/JBJS.15.01359\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eAhonen M, Helenius I, Gissler M, Jeglinsky-Kankainen I (2023) Mortality and causes of death in children with cerebral palsy with scoliosis treated with and without surgery. Neurology 101:e1787\u0026ndash;e1792. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1212/WNL.0000000000207796\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eYang JH, Kim KS, Lee GH, Kim HS (2020) Comparison of survival analysis between surgical and non-surgical treatments in Duchenne muscular dystrophy scoliosis. Spine J 20:1840\u0026ndash;1849. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.spinee.2020.06.004\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eLevine SB, Fields MW, Boby AZ, Matsumoto H, Skaggs KF, Roye BD, Vitale MG (2022) Degree of postoperative curve correction decreases risks of postoperative pneumonia in patients undergoing both fusion and growth-friendly surgical treatment of neuromuscular scoliosis. J Pediatr Orthop 42:372\u0026ndash;375. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BPO.0000000000002155\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eTsirikos AI, Chang WN, Dabney KW, Freeman M, Glutting J (2003) Life expectancy in pediatric patients with cerebral palsy and neuromuscular scoliosis who underwent spinal fusion. Dev Med Child Neurol 45:677\u0026ndash;682. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/s0012162203001269\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eHariharan A, Sees JP, Pargas C, Rogers KJ, Niiler T, Shrader MW, Miller F (2023) Mortality after spinal fusion in children with cerebral palsy and cerebral-palsy-like conditions: a 30-year follow-up study. Dev Med Child Neurol 65:1190\u0026ndash;1198. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/dmcn.15568\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eLaugesen K, Ludvigsson JF, Schmidt M, Gissler M, Valdimarsdottir UA, Lunde A, S\u0026oslash;rensen HT (2021) Nordic health registry-based research: a review of health care systems and key registries. Clin Epidemiol 13:533\u0026ndash;554. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/CLEP.S314959\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eMcCarthy JJ, D\u0026rsquo;Andrea LP, Betz RR, Clements D (2006) Scoliosis in the child with cerebral palsy. J Am Acad Orthop Surg 14:367\u0026ndash;375. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5435/00124635-200606000-00006\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eMatsumoto H, Fano AN, Herman ET, Snyder B, Roye BD, Cahill P, Ramo B, Sponseller P, Vitale MG (2022) Mortality in neuromuscular early onset scoliosis following spinal deformity surgery. J Pediatr Orthop 42:e234\u0026ndash;e241. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BPO.0000000000002036\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eHelenius L, Ahonen M, Syv\u0026auml;nen J, Perokorpi T, Helenius I Pulmonary function at minimum 10 years after segmental pedicle screw instrumentation for thoracic adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2024 Apr 1. [Epub ahead of print].\u0026nbsp;\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BRS.0000000000004996\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8036603/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8036603/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eThe aim of this study was to compare the incidence of pneumonia and pneumonia-related mortality in children with cerebral palsy (CP) and scoliosis, with and without scoliosis surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eNational registries care and cause of death registries were searched for individuals with CP and scoliosis born after 1987 with recordings between 1996 and 2021. Identified individuals were categorized according to scoliosis surgery and were compared for pneumonia incidence and pneumonia-related mortality. Multivariable Cox regression examined determinants of mortality.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eWe identified 474 children with CP and scoliosis, of these 236 children had not undergone surgery, while 238 had been operated. Both groups had similar rates of comorbidities. While there was no change in number of individuals with at least one hospitalization for pneumonia, there was significant reduction in cumulative pneumonia incidence from before to after surgery (175.5 vs. 121.5 hospitalizations per 1,000 years, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while incidence did not change in non-surgically treated patients (192.8 vs. 203.9, hospitalizations per 1,000 years, p\u0026thinsp;=\u0026thinsp;0.35). During follow-up pneumonia-related mortality was significantly higher in the non-surgically treated group than in the surgically treated group (n\u0026thinsp;=\u0026thinsp;21/236, 8.9% vs. n\u0026thinsp;=\u0026thinsp;8/238, 3.3%, p\u0026thinsp;=\u0026thinsp;0.008). After adjusting for covariates surgical patients had 87.5% reduction in risk of mortality to pneumonia compared with non-surgically treated patients (hazard ratio: 0.125, 95% confidence interval: 0.051\u0026ndash;0.31, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThese results indicate that surgical treatment of scoliosis in children with CP associates to reduced incidence of pneumonia and pneumonia-related mortality.\u003c/p\u003e","manuscriptTitle":"Mortality for Pneumonia and Risk of Pneumonia in Children with Cerebral Palsy Treated with and without Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 12:07:29","doi":"10.21203/rs.3.rs-8036603/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-11-21T14:06:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-20T22:18:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187851578564035907708655169186839639197","date":"2025-11-19T19:46:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-13T18:25:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140133478776400960564311860313188732130","date":"2025-11-13T18:14:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-10T10:27:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-07T01:27:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-07T01:27:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2025-11-05T09:08:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9faaf0c3-889f-42bc-8615-8daa0291060b","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:01:57+00:00","versionOfRecord":{"articleIdentity":"rs-8036603","link":"https://doi.org/10.1007/s00586-025-09625-y","journal":{"identity":"european-spine-journal","isVorOnly":false,"title":"European Spine Journal"},"publishedOn":"2025-11-26 15:57:41","publishedOnDateReadable":"November 26th, 2025"},"versionCreatedAt":"2025-11-19 12:07:29","video":"","vorDoi":"10.1007/s00586-025-09625-y","vorDoiUrl":"https://doi.org/10.1007/s00586-025-09625-y","workflowStages":[]},"version":"v1","identity":"rs-8036603","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8036603","identity":"rs-8036603","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}