{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T03:31:09Z","timestamp":1792812669479,"version":"4.5.0"},"reference-count":30,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,4,22]],"date-time":"2026-04-22T00:00:00Z","timestamp":1776816000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: 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. Methods: 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 (\u226580%) and good (\u226573%) agreement. Results: The panel reached excellent consensus (93%) on a \u201cTraffic Light\u201d system based on the Gross Motor Function Classification System (GMFCS) levels. Green Group (Walkers, GMFCS I\u2013II): Clinical surveillance. Amber Group (Poor Walkers, GMFCS III, and asymmetric hemiplegic GMFCS I\u2013II): Annual radiographs starting at ages 3\u20138. Red Group (Non-Walkers, GMFCS IV\u2013V): Six-monthly radiographs starting at ages 3\u20135. 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 &gt;20\u00b0, pelvic obliquity \u22655\u00b0, or a progression rate \u22651\u00b0 per month. Conclusions: The \u201cTraffic Light\u201d protocol helps identify the \u201cwindow of opportunity\u201d for intervention before reaching the 90\u00b0 \u201cpoint of no return,\u201d where surgical risks increase nonlinearly. This proactive approach aims to reduce surgical complications and systemic delays in specialized care.<\/jats:p>","DOI":"10.3390\/jcm15093205","type":"journal-article","created":{"date-parts":[[2026,4,23]],"date-time":"2026-04-23T08:11:14Z","timestamp":1776931874000},"page":"3205","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["The Traffic Light Protocol: Preventing the 90\u00b0 \u2018Point of No Return\u2019 Through Risk-Stratified Spinal Surveillance in Children with Cerebral Palsy"],"prefix":"10.3390","volume":"15","author":[{"given":"Micha\u0142","family":"Latalski","sequence":"first","affiliation":[{"name":"Children\u2019s Orthopaedic Department, Medical University of Lublin, 20-093 Lublin, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0884-7498","authenticated-orcid":false,"given":"Anna","family":"Danielewicz","sequence":"additional","affiliation":[{"name":"Children\u2019s Orthopaedic Department, Medical University of Lublin, 20-093 Lublin, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"Repko","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Faculty of Medicine, Masaryk University, 625-00 Brno, Czech Republic"},{"name":"University Hospital Brno, 625-00 Brno, Czech Republic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Athanasios I.","family":"Tsirikos","sequence":"additional","affiliation":[{"name":"Scottish National Spine Deformity Center, Royal Hospital for Children and Young People, 50 Little France Crescent Edinburgh BioQuarter, Edinburgh EH 16 4TJ, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0810-9361","authenticated-orcid":false,"given":"Tomasz","family":"Kotwicki","sequence":"additional","affiliation":[{"name":"Department of Spine Disorders and Paediatric Orthopedics, Wiktor Dega Orthopedic Institute, Poznan University of Medical Sciences, 61-545 Pozna\u0144, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9019-8644","authenticated-orcid":false,"given":"Tomasz","family":"Potaczek","sequence":"additional","affiliation":[{"name":"Department of Orthopedics and Rehabilitation, Medical College, Jagiellonian University, 34-500 Zakopane, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johanna","family":"Syv\u00e4nen","sequence":"additional","affiliation":[{"name":"Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, 20520 Turku, Finland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7059-2935","authenticated-orcid":false,"given":"Pawe\u0142","family":"Grabala","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Polish-Mother\u2019s Memorial Hospital Research Institute, Rzgowska 281\/289, 93-338 Lodz, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wiktor","family":"Urba\u0144ski","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Wroclaw Medical University, 50-556 Wroclaw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"Pr\u00fdmek","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Faculty of Medicine, Masaryk University, 625-00 Brno, Czech Republic"},{"name":"University Hospital Brno, 625-00 Brno, Czech Republic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5702-4933","authenticated-orcid":false,"given":"Piotr","family":"Janusz","sequence":"additional","affiliation":[{"name":"Department of Spine Disorders and Paediatric Orthopedics, Wiktor Dega Orthopedic Institute, Poznan University of Medical Sciences, 61-545 Pozna\u0144, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7152-2012","authenticated-orcid":false,"given":"Barbara","family":"Jasiewicz","sequence":"additional","affiliation":[{"name":"Department of Orthopedics and Rehabilitation, Medical College, Jagiellonian University, 34-500 Zakopane, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0330-5032","authenticated-orcid":false,"given":"Matti","family":"Ahonen","sequence":"additional","affiliation":[{"name":"Department of Paediatric Orthopaedics, Helsinki New Children\u2019s Hospital, 00280 Helsinki, Finland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5200-3279","authenticated-orcid":false,"given":"Ilkka","family":"Helenius","sequence":"additional","affiliation":[{"name":"Department of Paediatric Orthopaedics, Helsinki New Children\u2019s Hospital, 00280 Helsinki, Finland"},{"name":"Department of Orthopaedics and Traumatology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Himmelmann, K., McIntyre, S., Goldsmith, S., Smithers-Sheedy, H., and Watson, L. 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