The Traffic Light Protocol: Preventing the 90° 'Point of No Return' Through Risk-Stratified Spinal Surveillance in Children with Cerebral Palsy

Abstract

<p><strong>Background</strong>: Cerebral palsy (CP) is the leading cause of permanent physical disability in children. Although hip surveillance is a global standard, spinal surveillance remains inconsistent, often leading to reactive rather than proactive management of neuromuscular scoliosis. This study aims to establish an international consensus on a risk-based spinal surveillance protocol. <br></p><p><strong>Methods</strong>: A three-round modified Delphi process was conducted in 2024 with 15 international pediatric spine surgeons, identified through purposive sampling. The process adhered to CREDES standards and focused on establishing standards for timing, frequency, and radiographic surveillance. Consensus thresholds were defined a priori as excellent (≥80%) and good (≥73%) agreement. <br></p><p><strong>Results</strong>: The panel reached excellent consensus (93%) on a “Traffic Light” system based on the Gross Motor Function Classification System (GMFCS) levels. Green Group (Walkers, GMFCS I–II): Clinical surveillance. Amber Group (Poor Walkers, GMFCS III, and asymmetric hemiplegic GMFCS I–II): Annual radiographs starting at ages 3–8. Red Group (Non-Walkers, GMFCS IV–V): Six-monthly radiographs starting at ages 3–5. There was 100% consensus on the mandatory use of sitting radiographs for non-ambulatory patients to prevent masking true pelvic decompensation. Critical referral triggers were identified as a Cobb angle >20°, pelvic obliquity ≥5°, or a progression rate ≥1° per month. <br></p><p><strong>Conclusions</strong>: The “Traffic Light” protocol helps identify the “window of opportunity” for intervention before reaching the 90° “point of no return,” where surgical risks increase nonlinearly. This proactive approach aims to reduce surgical complications and systemic delays in specialized care.</p>