Treatment of neuromuscular scoliosis with posterior-only pedicle screw fixation

Bipolar Fusionless Versus Standard Fusion Surgery in Neuromuscular Scoliosis: A Two-center Comparative Study

STUDY DESIGN

Nonrandomized controlled cohort.

OBJECTIVE

To compare early results between bipolar fusionless construct (BFC) and single posterior fusion (SPF) surgery in neuromuscular scoliosis (NMS).

BACKGROUND

Surgical treatments for NMS have traditionally been characterized by high complication rates. A mini-invasive BFC was developed to reduce these risks while maintaining adequate curve reduction. There is, however, a current lack of studies comparing clinical and radiologic perioperative outcomes between both techniques.

METHODS

All patients surgically treated for NMS with to-pelvis construct between 2011 and 2021 at 2 centers were included and divided into 2 groups according to the surgical technique (BFC or SPF). Gender, age, main deformity region, etiology, preoperative and postoperative main curve magnitude and pelvic obliquity, surgery time, estimated blood loss and transfusion rates, length of hospital stay, the magnitude of main curve and pelvic obliquity correction, and early complications were compared. Quantitative data were compared through ANOVA or Mann-Whitney test. Analysis of qualitative outcomes was performed through Fisher exact test and logistic regressions. Kruskal-Wallis test was used to compare complications between groups.

RESULTS

Eighty-nine NMS patients were included: 48 in the SPF group and 41 in the BFC group. Surgery time (203 vs. 241 min), rate (32 vs. 52%) and severity of complications, unplanned returns to the operating room (15 vs. 39%), estimated blood loss (179 vs. 364 cc), and transfusion rates (27 vs. 73%) were lower in the BFC group ( P <0.05). There were no significant differences in age, maturity stage, preoperative curve magnitude, preoperative pelvic obliquity and postoperative curve, and pelvic obliquity correction between groups.

CONCLUSIONS

BFC may be a safer and less invasive option for NMS surgical treatment, resulting in similar curve corrections while significantly decreasing the number and severity of complications as well as intraoperative blood loss when compared with SPF.

LEVEL OF EVIDENCE

Level -lll.

Multi-rod posterior correction only with halo-femoral traction for the management of adult neuromuscular scoliosis (> 100°) with severe pelvic obliquity: a minimum 5-year follow-up

BACKGROUND

Many patients with neuromuscular scoliosis (NMS) experience a variety of difficult medical problems that aggravate the development effects of progressive scoliosis and pelvic obliquity (PO). The objective of the current study was to assess the safety and effectiveness of multi-rod posterior correction only (MRPCO) with halo-femoral traction (HFT) for the management of adult NMS (> 100°) with severe PO.

METHODS

From 2012 to 2017, 13 adult patients who suffered from NMS (> 100°) with severe PO underwent MRPCO with HFT. The radiography parameters in a sitting position, such as the coronal Cobb angle of the main curve, the PO and the trunk shift (TS), were measured at the preoperative, postoperative and final follow-up stages. The preoperative and final follow-up assessment of the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) was taken.

RESULTS

The average follow-up span was 68.15 ± 6.78 months. There was decreased postoperative coronal Cobb angle with an average mean of 125.24° ± 11.78° to 47.55° ± 12.10°, with a correction rate of 62.43%; the PO was reduced to 6.25° ± 1.63° from 36.93° ± 4.25° with a correction rate of 83.07%; the TS was reduced to 2.41 cm ± 1.40 cm from 9.19 cm ± 3.07 cm. There was significant improvement in all parameters compared to the preoperative data. The VAS score reduced from 4.77 ± 0.93 to 0.69 ± 0.75, and the ODI score reduced from 65.38 ± 16.80 to 28.62 ± 12.29 at the final follow-up.

CONCLUSIONS

Treatment of adult NMS (> 100°) with severe PO could be safe and effective with MRPCO with HFT. In order to obtain the optimum sitting balance, this could reduce the prevalence of complications and rectify the curvature and the correction of PO.

Current trends in surgical magnitude of neuromuscular scoliosis curves: a study of 489 operative patients with non-ambulatory cerebral palsy

PURPOSE

A curve magnitude at which posterior spinal fusion (PSF) is indicated for children with cerebral palsy (CP) scoliosis is not defined. We sought to evaluate whether agreement exists for a curve magnitude at which PSF is undertaken for CP scoliosis and to evaluate outcomes by quartile of curve magnitude and flexibility at time of fusion.

METHODS

A prospective multicenter pediatric spine database was queried for patients with a Gross Motor Function Classification Scale (GMFCS) IV or V who underwent PSF for CP scoliosis. Demographics, surgical indications, and correlations between curve magnitude, postoperative radiographic outcomes, and Caregiver's Priorities and Child Health Index of Life and Disabilities (CPCHILD) scores were evaluated for patients with at least 2 years of follow-up.

RESULTS

489 patients from 15 sites were analyzed. Median major Cobb angle at time of PSF was 87° and significantly varied by site (p < 0.001). Median Cobb angle on flexibility studies was 55° and median percent correction on flexibility studies was 36.3%. Severity of the curve at surgery correlated significantly with lower overall quality of life and CPCHILD score (p < 0.05). Larger residual curves correlated with larger operative curves (p < 0.001) and decreased flexibility on preoperative flexibility studies (p < 0.001), although postoperative CPCHILD scores did not differ by curve size or flexibility at time of fusion or by size of residual curve (p > 0.05).

CONCLUSION

The median curve magnitude is large and there is substantial variability in curve size of CP scoliosis at time of fusion, although clinical outcomes are not negatively influenced by larger operative magnitudes. Further study should aim to narrow surgical indications by defining unacceptable radiographic outcomes.

LEVEL OF EVIDENCE

Level III.

RADIOGRAPHIC EVALUATION OF SURGICAL CORRECTION OF SCOLIOSIS DUE TO CEREBRAL PALSY USING INTRA-OPERATIVE TRACTION AND NEW CORRECTION TECHNIQUE WITH 3RD PROVISIONAL ROD

ABSTRACT Objective: Evaluate the radiographic results of patients with cerebral palsy and Lonstein and Akbarnia type II scoliosis who underwent intraoperative halofemoral traction (IFAT) and correction with a 3rd provisional nail. Methods: Retrospective case series study. Were evaluated preoperative (PRE), traction (TR), immediate (POI), and late (POT) total spine radiographs. Were verified the angular value of the main curve (COBB), pelvic obliquity (OP), trunk balance in the coronal plane (CSVA), vertical sagittal alignment (SVA), curve flexibility, and percentage of correction in the final PO. Friedam and Wilcoxon tests were performed (p<0.05). Results: Twenty-one patients were included in the study, with a mean age of 16 (±4.13). There was a statistical difference when comparing COBB PRE with TRACTION to POI and POT (p=0.0001), OP in PRE with TRACTION, and between PRE and POT (p=0.0001). There was a statistical difference in coronal (CSVA) and sagittal (SVA) balance concerning PRE and POT. The percentage of correction for the main curve was 55.75% (± 11.11), and for the O P, 64.86% (± 18.04). Conclusion: The correction technique using the 3rd provisional nail technique and intraoperative traction presents a correction power of 55.75% of the proximal curve and 64% of the pelvic obliquity. In addition, it is easy to assemble, has a short surgical time, and causes little loss of correction during follow-up. Level of Evidence III B; I study a series of retrospective cases.

Effect of pelvic fixation on ambulation in children with neuromuscular scoliosis

BACKGROUND

The effect of posterior spinal fusion (PSF) incorporating the pelvis on an ambulatory patient’s ability to mobilize after the fusion is not well understood.

AIM

To see whether a posterior spinal fusion with pelvic fixation using iliac or sacral alar iliac screws in ambulatory neuromuscular scoliosis (NMS) patients influences postoperative ambulatory ability.

METHODS

A retrospective review of all patients with NMS that underwent PSF with fixation incorporating the pelvis between January 1, 2012 and February 29, 2019. A total of 118 patients were eligible, including 11 ambulatory patients. The primary outcome was the maintenance of ambulatory status postoperatively. Secondary outcomes included postoperative curve magnitude, pelvic obliquity, and complications, comprising infections, instrumentation failure, and any unplanned returns to the operative room.

RESULTS

The ambulatory function was maintained in all 11 ambulatory NMS patients. One patient had an improvement in functional status with equipment-free ambulation postoperatively. An average postoperative follow-up was 19 mo. The overall complication rate was 19.4% (n = 23) with no significant differences between the groups in infection (P = 0.365), hardware failure (P = 0.505), and reoperation rate (P = 1.0). Ambulatory status did not affect complication rate (P = 0.967).

CONCLUSION

Spinal fusion to the pelvis in ambulatory patients with NMS provides effective deformity correction without the reduction in ambulatory capabilities.

From in vitro evaluation of a finite element model of the spine to in silico comparison of spine instrumentations

Growth-preserving spinal surgery suffer from high complications rate. A recent bipolar instrumentation using two anchoring points (thoracic and pelvic) showed lower rates, but its biomechanical behaviour has not been characterised yet. The aim of this work was to combine in vitro and in vivo data to improve and validate a finite element model (FEM) of the spine, and to apply it to compare bipolar and classical all-screws implants. Spinal segments were tested in vitro to measure range of motion (ROM). Thoracic segments were also tested with bipolar instrumentation to measure ROM and rod strain using a strain gage. A subject-specific FEM of the spine, pelvis and ribcage of an in vivo asymptomatic subject was built. Spinal segments were extracted from it to reproduce the in-vitro mechanical tests. Experimental and simulated ROM and rod strain were compared. Then, the full trunk FEM was used to compare bipolar and all-screws instrumentations. The FEM fell within 1° of the experimental corridors, and both in silico and in vitro instrumentation rods showed 0.01% maximal axial strain. Bipolar and all-screws constructs had similar maximal Von Mises stresses. This work represents a first step towards subject-specific simulation to evaluate spinal constructs for neuromuscular scoliosis in children.

Peri-operative management of children with spinal muscular atrophy

Background and Aims:

Current multi-disciplinary management of children with spinal muscular atrophy (SMA) often requires the surgical management of spinal deformities. We present the outcomes of our peri-operative experience around the time of their spinal surgery and share our neuromuscular perioperative protocol.

Methods:

A single-centre retrospective chart review was performed to evaluate all children with SMA types I and II that underwent thoracolumbar spinal deformity correction (posterior spinal fusion or growing rod insertion) from 1990 to 2015. Electronic medical records were reviewed to assess pre-operative, intraoperative, and postoperative variables. T-tests, Wilcoxon Rank Sum, Fisher's Exact tests were performed as appropriate.

Results:

Twelve SMA I and twenty-two SMA II patients were included. Type I patients tended to be smaller and had a higher percentage (36.4% vs 4.5%) of American Society of Anesthesiologists (ASA) class 4 patients. Preoperative total parenteral nutrition (TPN) was utilised in 75.0% of type I and 18.2% type II patients. A difficult intubation was experienced in around 25% of the patients (20.0% SMA I, 27.3% SMA II). Approximately two hours of anaesthetic time was required in addition to the actual surgical time in both types. The intensive care unit (ICU) length of stay averaged 6 (4.0-7.5) days for type I and 3 (3-5) days for type II (p = 0.144). Average post-operative length of stay was (8 (7-9) vs. 7 (6-8)) P = 1.0.

Conclusion:

Children with type I and II SMA have similar hospital courses. The surgical and anaesthesia team should consider perioperative TPN and NIPPV (non-invasive positive-pressure ventilation), anticipate difficult intubations, longer than usual anaesthetic times, and potentially longer ICU stays in both SMA type I and II.

Evaluating Trends and Outcomes of Spinal Deformity Surgery in Cerebral Palsy Patients

Background

There is a paucity of literature examining surgical trends and outcomes in both child and adult cerebral palsy (CP) patients. We aimed to evaluate surgical trends, complications, length of stay, and charges for spinal deformity surgery in CP patients.

Methods

Using the Nationwide Inpatient Sample (NIS) from 2001 to 2013, patients with CP scoliosis who underwent spinal fusion surgery were identified. Patient characteristics and comorbidities were recorded. Trends in spinal fusion approaches were grouped as anterior (ASF), posterior (PSF), or combined anterior-posterior (ASF/PSF). Complication rates, length of stay, and charges for each approach were analyzed. Bivariate analyses using adjusted Wald tests and multivariate analyses using linear (logarithmic transformation) and logistic regressions were performed.

Results

Of the 5191 adult CP patients who underwent spinal fusion the majority underwent PSF (86.5%), followed by the ASF/PSF approach (9.3%). The rate of PSF for cerebral palsy patients with spinal deformity increased significantly per 1 million people in the US population (0.90 to 1.30; P = .048). Complication rate, hospital length of stay, and charges were higher for patients undergoing ASF/PSF (P < .05). The overall complication rate for all surgical approaches was 25.7%. Patient comorbidities and combined ASF/PSF increased the odds of complication. Combined ASF/PSF was also associated with an increased length of stay and charges.

Conclusion

Combined ASF/PSF in patients with CP accounted for only 9.3% of surgical cases but was associated with the longest hospital stay, highest charges, and increased complications. Further scrutiny of the surgical indications and preoperative risk stratification should be undertaken to minimize complications, reduce length of stay, and decrease charges for CP patients undergoing spinal fusion.

Level of Evidence

IV.

Segmental Pedicle Screw Instrumentation and Fusion Only to L5 in the Surgical Treatment of Flaccid Neuromuscular Scoliosis

STUDY DESIGN

A retrospective cohort study was performed.

OBJECTIVE

The purpose of this study was to determine the efficacy and safety of stopping segmental pedicle screw instrumentation constructs at L5 in the treatment of neuromuscular scoliosis.

SUMMARY OF BACKGROUND DATA

Duchenne muscular dystrophy and spinal muscular atrophy are flaccid neuromuscular disorders in which gradual deterioration is the hallmark and have a lot of characteristics in common despite differences in etiology. Instrumentation and fusion to the sacrum/pelvis has been a mainstay in the surgical treatment of flaccid neuromuscular scoliosis and recommended to correct pelvic obliquity. However, the caudal extent of instrumentation and fusion in the surgical treatment of flaccid neuromuscular scoliosis has remained a matter of considerable debate and there have been few studies on the use of segmental pedicle screw instrumentation for flaccid neuromuscular scoliosis.

METHOD

From 2005 to 2007, a total of 27 consecutive patients with neuromuscular disorders (20 Duchenne muscular dystrophy and 7 spinal muscular atrophy), aged 11 to 17 years, underwent segmental pedicle screw instrumentation and fusion only to L5. Assessment was performed clinically and with radiologic measurements. Minimum 2-year follow-up was required for inclusion in this study.

RESULTS

Twenty patients were enrolled in this study. No patient was lost to follow-up. All patients had L5 tilt of less than 15° and a coronal curve with apex L2 or higher preoperatively. Preoperative coronal curve averaged 70° (range: 51°-88°), with a postoperative mean of 15° (range: 5°-25°) and 17° (range: 6°-27°) at the last follow-up. The pelvic obliquity improved from 15° (range: 9°-25°) preoperatively to 5° (range: 3°-8°) postoperatively and 6° (range: 3°-8°) at the last follow-up. The L5 tilt improved from 9° (range: 2°-14°) preoperatively to 2° (range: 0°-4°) postoperatively and 2° (range: 0°-5°) at the last follow-up. Physiologic sagittal plane alignment was recreated after surgery and maintained long-term. There was no significant loss of correction of coronal curve and pelvic obliquity. There was no major complication.

CONCLUSION

Segmental pedicle screw instrumentation and fusion to L5 was safe and effective in patients with flaccid neuromuscular scoliosis with apex L2 or higher and minimal L5 tilt of less than 15°. Segmental pedicle screw instrumentation ending at L5 offered the ability to correct spinal deformity and pelvic obliquity initially, intermediate and even long-term, with no major complications. This method in appropriate patients can be a viable alternative to instrumentation and fusion to the sacrum/pelvis in the surgical treatment of flaccid neuromuscular scoliosis.

LEVEL OF EVIDENCE

N/A.

Surgical Correction of Scoliosis in Patients With Duchenne Muscular Dystrophy: 30-Year Experience

BACKGROUND

The natural history of scoliosis in Duchenne muscular dystrophy (DMD) is progressive and debilitating if neglected. The purpose of this study was to evaluate outcomes related to spinal deformity surgery in patients with DMD over a 30-year period.

METHODS

This was a single center retrospective study of all operatively treated scoliosis in DMD patients over 30 years. Minimum follow-up was 2 years. Owing to changes in instrumentation over time, patients were divided into 2 groups: Luque or pedicle screws (PS) constructs. Radiographic, perioperative variables, pulmonary function test (preoperatively and postoperatively), and complication data were evaluated.

RESULTS

There were 60 subjects (Luque: 47, PS: 13). The Luque group was on average 13 years old, 53 kg, and had 7 years of follow-up. Coronal Cobb was 31±12 degrees preoperatively, 16±11 degrees at first postoperatively, and 21±15 degrees at final follow-up (P≤0.001). Pelvic obliquity was 7±6 degrees preoperatively, 5±5 degrees at first postoperatively (P=0.43), and 5±4 degrees at final follow-up (P=0.77). The majority of this group was fused to L5 (45%) or the sacrum (49%). The PS group was on average 14 years old, 65 kg, and had 4 years of follow-up. Coronal Cobb was 43±19 degrees preoperatively, 12±9 degrees at first postoperatively (P≤0.001), and 12±8 degrees at final follow-up. Pelvic obliquity was 6±5 degrees preoperatively, 3±3 degrees at first postoperatively (P=0.06), and 2±2 degrees at final follow-up (P=0.053). The majority were fused to the pelvis (92%). Both groups' pulmonary function declined with time. Both groups had high complication rates (Luque 68%; PS group 54%). The Luque group had more implant-related complications (26%); the PS group had a higher rate of early postoperative infections (23%).

CONCLUSIONS

Over a 30-year period of operative treatment of scoliosis in DMD, both PS constructs and Luque instrumentation improved coronal Cobb. The PS group had improved and maintained pelvic obliquity. Both groups had high complication rates.

LEVEL OF EVIDENCE

Level IV-therapeutic.

[Characteristics of neuromuscular scoliosis]

Usually, neuromuscular scolioses become clinically symptomatic relatively early and are rapidly progressive even after the end of growth. Without sufficient treatment they lead to a severe reduction of quality of life, to a loss of the ability of walking, standing or sitting as well as to an impairment of the cardiopulmonary system resulting in an increased mortality. Therefore, an intensive interdisciplinary treatment by physio- and ergotherapists, internists, pediatricians, orthotists, and orthopedists is indispensable. In contrast to idiopathic scoliosis the treatment of patients with neuromuscular scoliosis with orthosis is controversially discussed, whereas physiotherapy is established and essential to prevent contractures and to maintain the residual sensorimotor function.Frequently, the surgical treatment of the scoliosis is indicated. It should be noted that only long-segment posterior correction and fusion of the whole deformity leads to a significant improvement of the quality of life as well as to a prevention of a progression of the scoliosis and the development of junctional problems. The surgical intervention is usually performed before the end of growth. A prolonged delay of surgical intervention does not result in an increased height but only in a deformity progression and is therefore not justifiable. In early onset neuromuscular scolioses guided-growth implants are used to guarantee the adequat development. Because of the high complication rates, further optimization of these implant systems with regard to efficiency and safety have to be addressed in future research.

Spinal fusion for pediatric neuromuscular scoliosis: national trends, complications, and in-hospital outcomes

OBJECTIVE The objective of this study was to determine if the recent changes in technology, surgical techniques, and surgical literature have influenced practice trends in spinal fusion surgery for pediatric neuromuscular scoliosis (NMS). In this study the authors analyzed recent trends in the surgical management of NMS and investigated the effect of various patient and surgical factors on in-hospital complications, outcomes, and costs, using the Nationwide Inpatient Sample (NIS) database. METHODS The NIS was queried from 2002 to 2011 using International Classification of Diseases, Ninth Edition, Clinical Modification codes to identify pediatric cases (age < 18 years) of spinal fusion for NMS. Several patient, surgical, and short-term outcome factors were included in the analyses. Trend analyses of these factors were conducted. Both univariate and multivariable analyses were used to determine the effect of the various patient and surgical factors on short-term outcomes. RESULTS Between 2002 and 2011, a total of 2154 NMS fusion cases were identified, and the volume of spinal fusion procedures increased 93% from 148 in 2002 to 286 in 2011 (p < 0.0001). The mean patient age was 12.8 ± 3.10 years, and 45.6% of the study population was female. The overall complication rate was 40.1% and the respiratory complication rate was 28.2%. From 2002 to 2011, upward trends (p < 0.0001) were demonstrated in Medicaid insurance status (36.5% to 52.8%), presence of ≥ 1 comorbidity (40.2% to 52.1%), and blood transfusions (25.2% to 57.3%). Utilization of posterior-only fusions (PSFs) increased from 66.2% to 90.2% (p < 0.0001) while combined anterior release/fusions and PSF (AR/PSF) decreased from 33.8% to 9.8% (< 0.0001). Intraoperative neurophysiological monitoring (IONM) underwent increasing utilization from 2009 to 2011 (15.5% to 20.3%, p < 0.0001). The use/harvest of autograft underwent a significant upward trend between 2002 and 2011 (31.3% to 59.8%, p < 0.0001). In univariate analysis, IONM use was associated with decreased complications (40.7% to 33.1%, p = 0.049) and length of stay (LOS; 9.21 to 6.70 days, p <0.0001). Inflation-adjusted mean hospital costs increased nearly 75% from 2002 to 2011 ($36,805 to $65,244, p < 0.0001). In the multivariable analysis, nonwhite race, highest quartile of median household income, greater preexisting comorbidity, long-segment fusions, and use of blood transfusions were found to increase the likelihood of complication occurrence (all p < 0.05). In further multivariable analysis, independent predictors of prolonged LOS included older age, increased preexisting comorbidity, the AR/PSF approach, and long-segment fusions (all p < 0.05). Lastly, the likelihood of increased hospital costs (at or above the 90th percentile for LOS, 14 days) was increased by older age, female sex, Medicaid insurance status, highest quartile of median household income, AR/PSF approach, long-segment fusion, and blood transfusion (all p < 0.05). In multivariable analysis, the use of autograft was associated with a lower likelihood of complication occurrence and prolonged LOS (both p < 0.05). CONCLUSIONS Increasing use of IONM and posterior-only approaches may combat the high complication rates in NMS. The trends of increasing comorbidities, blood transfusions, and total costs in spinal fusion surgery for pediatric NMS may indicate an increasingly aggressive approach to these cases.

Surgery for scoliosis in Duchenne muscular dystrophy

BACKGROUND

Scoliosis in patients with Duchenne muscular dystrophy (DMD) is usually progressive and is treated with surgery. However, it is unclear whether the existing evidence is sufficiently scientifically rigorous to support a recommendation for spinal surgery for most patients with DMD and scoliosis. This is an updated review, and an updated search was undertaken in which no new studies were found for inclusion.

OBJECTIVES

To determine the effectiveness and safety of spinal surgery in patients with DMD with scoliosis. We intended to test whether spinal surgery is effective in increasing survival and improving respiratory function, quality of life, and overall functioning, and whether spinal surgery is associated with severe adverse effects.

SEARCH METHODS

On 16 June 2015 we searched the Cochrane Neuromuscular Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL Plus. We also searched ProQuest Dissertation and Thesis database (January 1980 to June 2015), the National Institutes of Health Clinical Trials Database (6 January 2015), and the WHO International Clinical Trials Registry Platform (17 June 2015), and checked references. We imposed no language restrictions.

SELECTION CRITERIA

We planned to include controlled clinical trials using random or quasi-random allocation of treatment evaluating all forms of spinal surgery for scoliosis in patients with DMD in the review. The control interventions would have been no treatment, non-operative treatment, or a different form of spinal surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. Two review authors independently examined the search results and evaluated the study characteristics against inclusion criteria in order to decide which studies to include in the review.

MAIN RESULTS

Of the 49 relevant studies we found, none met the inclusion criteria for the review because they were not clinical trials, but prospective or retrospective reviews of case series.

AUTHORS' CONCLUSIONS

Since no randomized controlled clinical trials were available to evaluate the effectiveness of scoliosis surgery in patients with DMD, we can make no good evidence-based conclusion to guide clinical practice. Patients with scoliosis should be informed as to the uncertainty of benefits and potential risks of surgery for scoliosis. Randomized controlled trials are needed to investigate the effectiveness of scoliosis surgery, in terms of quality of life, functional status, respiratory function, and life expectancy.

Predicting Failure of Iliac Fixation in Neuromuscular Spine Deformity

STUDY DESIGN

Retrospective comparative cohort study.

OBJECTIVES

Identify whether there are patient or surgical risk factors to predict the probability of failure of iliac screw fixation after correction of neuromuscular scoliosis.

SUMMARY OF BACKGROUND DATA

There are high reported failure rates of pelvic fixation in long posterior spinal fusion (PSF) constructs to the sacrum for neuromuscular scoliosis.

METHODS

Patients aged 5 to 25 years, at a single institution, had PSF to the sacrum from 2001 to 2009 with pelvic fixation using iliac screws. Clinical data were retrospectively reviewed to identify patient and surgical variables related to surgery. Failure of iliac fixation was identified strictly as a broken screw, disengagement of the screw from the connector or the connector from the rod, or set plug failure. Lucency around the screws greater than 2 mm was recorded but not considered a failure. Variables were analyzed in a statistical model to identify predictors of failure.

RESULTS

A total of 108 patients met inclusion criteria; 100 (38 female and 62 male) had appropriate radiographs and minimum 2-year follow-up (average, 5.5 years). Coronal deformity correction averaged 59%. Most patients (89%) had fill of 6 of 8 possible distal fixation points composed of L4, L5, S1, and ilium bilaterally. Iliac screw failure occurred in 27 patients (27%). The initial single predictor statistical model identified 2 possible predictors of failure (patient: spastic tone; and surgical: absence of distal crosslink). In the multivariable model, spastic tone remained a predictor of failure (p = .0103), whereas absence of distal crosslink bordered on significance (p = .0516).

CONCLUSIONS

Iliac screw fixation failure is common in patients with long PSF constructs for neuromuscular scoliosis. Spastic tone is a risk factor for failure of pelvic fixation. A distal crosslink may protect against pelvic fixation failure. Alternative techniques for pelvic fixation should be studied in an attempt to improve the failure rates of iliac screw pelvic fixation.

Are Breech Rates for Pedicle Screws Higher in the Upper Thoracic Spine?

STUDY DESIGN

A case-control study.

OBJECTIVES

To evaluate pedicle screw placement in pediatric patients with various etiologies of scoliosis, and to identify predictors of misplacement.

SUMMARY OF BACKGROUND DATA

Accuracy of placement of pedicle screws has not been well documented for posterior spinal instrumentation and fusion performed in the non-idiopathic population.

METHODS

A total of 54 patients (29 idiopathic, 16 neuromuscular, and 9 congenital/syndromic scoliosis), ages 5-19 years, were included. Computed tomography scans were obtained on patients postoperatively to assess screw position. Three pediatric orthopedic surgeons evaluated screw placement, and risk factors for misplacement were examined.

RESULTS

Of 1,042 pedicle screws, 8.3% were misplaced. Among all etiologies, screws placed at T1 (28.6%) and T2 (18.2%) had higher misplacement rates. T2 screws and curve correction greater than 75% had higher misplacement rates in congenital/syndromic patients; screws at T3, screws at upper end of construct, and proximal screws had significantly higher misplacement rates in neuromuscular patients; and no variables predicted misplacement in idiopathics. Screws placed at the most proximal end of the screw/rod construct also had a higher misplacement rate (14.1%) compared with all remaining levels (7.8%). Nonidiopathic patients had higher anterior misplacement compared with idiopathic. No screws were removed or revised, and no screw-related complications were observed.

CONCLUSIONS

Pedicle screw instrumentation in the thoracolumbar spine was safe for pediatric patients. We found that pedicle screws placed at top levels are at higher risk for misplacement among all pediatric scoliosis patients. Nonidiopathic patients are at higher risk for anterior screw misplacement, and the predictive effect of vertebral level is more profound in nonidiopathic patients. Because of these findings, we routinely use fluoroscopic guidance for the placement of T1 and T2 screws, and screws at the proximal end of construct.

Surgery for scoliosis in Duchenne muscular dystrophy

BACKGROUND

Scoliosis in people with Duchenne muscular dystrophy is usually progressive and treated with surgery. However, it is unclear whether the existing evidence is sufficiently scientifically rigorous to support a recommendation for spinal surgery for most people with Duchenne muscular dystrophy and scoliosis. This is an updated review and an updated search was undertaken in which no new studies were found.

OBJECTIVES

To determine the effectiveness and safety of spinal surgery in people with Duchenne muscular dystrophy with scoliosis. We intended to test whether spinal surgery is effective in increasing survival, improving respiratory function, improving quality of life and overall functioning; and whether spinal surgery is associated with severe adverse effects.

SEARCH METHODS

We searched the specialized registers of the Cochrane Neuromuscular Disease Group (31 July 2012), MEDLINE (January 1966 to July 2012), EMBASE (January 1947 to July 2012), CENTRAL (2012, Issue 7 in the Cochrane Library), CINAHL Plus(January 1937 to July 2012), Proquest Dissertation and Thesis Database (January 1980 to July 2012), and the National Institute of Health Clinical Trials Database (July 2012). No language restrictions were imposed.

SELECTION CRITERIA

We planned to include controlled clinical trials using random or quasi-random allocation of treatment evaluating all forms of spinal surgery for scoliosis in people with Duchenne muscular dystrophy in the review. The control interventions would have been no treatment, non-operative treatment, or a different form of spinal surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the search results and evaluated the study characteristics against inclusion criteria to decide which ones would be included in the review.

MAIN RESULTS

On searching, 47 studies were relevant but none met the inclusion criteria for the review, because they were not clinical trials but prospective or retrospective reviews of case series.

AUTHORS' CONCLUSIONS

Since there were no randomized controlled clinical trials available to evaluate the effectiveness of scoliosis surgery in people with Duchenne muscular dystrophy, no evidence-based recommendation can be made for clinical practice. People with scoliosis should be informed about the uncertainty of benefits and potential risks of surgery for scoliosis. Randomized controlled trials are needed to investigate the effectiveness of scoliosis surgery, in terms of quality of life, functional status, respiratory function and life expectancy.

Neuromuscular scoliosis

Scoliosis is a common deformity in many types of neuromuscular disease. Severe spinal curvature can cause difficulty in sitting. Conservative and surgical treatment of neuromuscular scoliosis differs from idiopathic scoliosis, being more complex and with a higher complications rate. Non-surgical measures rarely fully control progressive scoliosis, but aim to prevent spinal deformities secondary to muscular hypotonia or contracture. Twenty-four hour bracing should be adjusted throughout growth, and may induce functional impairment and loss of independence. Corrective surgery requires multidisciplinary management and perioperative screening. Pelvic obliquity is commonly associated with neuromuscular scoliosis, making sitting difficult: correction needs to be considered during surgical planning. The goal of surgical correction is to obtain and maintain a well-balanced spine above a well-positioned pelvis. Preoperative multidisciplinary assessment enables potential problems of terrain to be anticipated. Respiratory function investigation will guide possible non-invasive perioperative ventilation. Nutritional and psychosocial assessment should also be incorporated in this preparation, as should overall postoperative care. Implementing this overall strategic planning can achieve a good surgical and functional result in the vast majority of cases.

Spinal muscular atrophy: manifestations and management

Spinal muscular atrophy (SMA) is an autosomal recessive disorder caused by a homozygous deletion in the SMN1 gene and is manifested by loss of the anterior horn cells of the spinal cord. Classifications of the disorder are based on age of onset and the patient's level of function. Scoliosis and hip subluxation or dislocation are two musculoskeletal manifestations associated with SMA. Severity of scoliosis correlates with age at presentation. Bracing has been unsuccessful in halting curve progression and may interfere with respiratory effort. Early onset scoliosis associated with SMA has been successfully treated with growing rod constructs, and posterior spinal fusion can be used in older children. Hip subluxations and dislocations are best treated nonsurgically if the patient reports no pain because a high rate of recurrent dislocation has been reported with surgical intervention.

Infections after spinal correction and fusion for spinal deformities in childhood and adolescence

BACKGROUND

Infection after spinal fusion for scoliosis is a commonly reported complication. Although techniques in paediatric spinal fusion have improved with regard to infection prophylaxis, postoperative infection rates range from 0.4% to 8.7%.

INFECTION RATES AND CAUSATIVE FACTORS

The rate of infection in surgery for adolescent idiopathic scoliosis (AIS) has ranged from 0.9% to 3%. The rate of infection in spinal surgery for deformity related to myelomeningocele has been reported to be from 8% to 24%. The rate of infection in spinal surgery for deformity related to cerebral palsy has been reported to be from 6.1% to 8.7%. Infection after spinal fusion for scoliosis related to a muscular dystrophy is generally less frequent. Despite a large number of cases and studies, the literature did not provide documentation of several factors that may be related to the occurrence of wound infection. The rate of wound infection after spine surgery is dependent on many factors, including the complexity of the procedure, health status of the patient, and potentially the experience and technique of the operating surgeon.

TREATMENT ALGORITHM

The general algorithm for treatment depends on a variety of factors, including the delay from the index procedure, the infecting organism, the location and extent of the infection, the gross appearance of the fusion mass, and the surgical strategy used to correct the initial deformity. For infections that develop within the first 90 days after the index procedure all attempts to retain the instrumentation should be made. In late infections, the fusion mass must be carefully inspected before instrumentation removal is considered. Although fusion may appear to be solid both radiographically and intra-operatively, there still may be the possibility of loss of correction at last follow-up.

CONCLUSION

Deep wound infection after instrumented fusion of the spine remains a difficult and challenging clinical problem and entails substantial morbidity, cost, and recovery time for the patient. An aggressive approach to deep wound infection emphasising early irrigation and debridement allowed preservation of instrumentation and successful fusion in most cases. At the conclusion of treatment, patients can expect a medium-term clinical outcome similar to patients in whom infectious complication did not occur.

The "T-construct" for spinopelvic fixation in neuromuscular spinal deformities. Preliminary results of a prospective series of 15 patients

BACKGROUND

We present the results of a prospective series of 15 patients treated for neuromuscular spinal deformities with an original spinopelvic construct using two sacral screws and two iliac screws. Results were compared to a prospective cohort of 62 patients treated for neuromuscular spinal deformities by spinopelvic fixation using iliosacral screws.

METHODS

From November 2005 to June 2007, the clinical data of every patient who underwent spinopelvic fixation for treatment of a neuromuscular spinal deformity were recorded prospectively.

RESULTS

Fifteen patients weighting less than 35 kg were operated on with a special segmental construct using two sacral screws and two iliac screws for pelvic anchorage. Sixty-two patients had spinopelvic fixation using iliosacral screws. Severity of the curve (Cobb angle) and reducibility were statistically equal in both groups. Operative time and blood loss were statistically identical in both groups. Curve correction was similar in both groups and postoperative pelvic obliquity ranged between 2° and 4°. No significant loss of correction was noted at the last follow-up. Fifteen patients had early postoperative infection of the posterior wound requiring re-operation.

CONCLUSIONS

Despite a high rate of infectious complications, optimal correction of pelvic obliquity requires extension of spinal instrumentation to the pelvis. Pelvic fixation with the "T-construct" did provide effective and improved spinal stabilization in these patients, while reducing the need for a postoperative cast or brace. As a result, patients had a favorable postoperative course with early mobilization and return to a comfortable sitting position.

The flying buttress construct for posterior spinopelvic fixation: a technical note

Background

Posterior fusion of the spine to the pelvis in paediatric and adult spinal deformity is still challenging. Especially assembling of the posterior rod construct to the iliac screw is considered technically difficult. A variety of spinopelvic fixation techniques have been developed. However, extreme bending of the longitudinal rods or the use of 90-degree lateral offset connectors proved to be difficult, because the angle between the rod and the iliac screw varies from patient to patient.

Methods

We adopted a new spinopelvic fixation system, in which iliac screws are side-to-side connected to the posterior thoracolumbar rod construct, independent of the angle between the rod and the iliac screw. Open angled parallel connectors are used to connect short iliac rods from the posterior rod construct to the iliac screws at both sides. The construct resembles in form and function an architectural Flying Buttress, or lateral support arches, used in Gothic cathedrals.

Results and discussion

Three different cases that illustrate the Flying Buttress construct for spinopelvic fixation are reported here with the clinical details, radiographic findings and surgical technique used.

Conclusion

The Flying Buttress construct may offer an alternative surgical option for spinopelvic fixation in circumstances wherein coronal or sagittal balance cannot be achieved, for example in cases with significant residual pelvic obliquity, or in revision spinal surgery for failed lumbosacral fusion.

Adult thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia: a retrospective study of correction and fusion strategies

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To study the correction and fusion strategies for adult thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia by using posterior pedicle screw instrumentation (PPSI). Surgical intervention for Chiari malformation and syringomyelia before surgical correction of scoliosis has been reported; however, there are no clinical trials for the PPSI-based correction and fusion procedures used in these patients.

METHODS

From 2002 to 2009, 13 adult patients (mean age, 34.9 years) suffering from thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia underwent correction and fusion by using PPSI. Preoperative, postoperative, and final follow-up coronary Cobb angle, correction rate, pelvic obliquity (PO), apical vertebral rotation (AVR), apical vertebral translation (AVT), trunk shift (TS), sagittal thoracic kyphosis angle, and lumbar lordosis angle were analyzed on radiographs.

RESULTS

The preoperative and postoperative mean coronary Cobb angle was from 46.8° to 9.2°, correction rate was 80.7%, PO from 9.9° to 3.2°, AVR from 1.9° to 0.3°, AVT from 3.6 to 0.8 cm, TS from 16.8 to 1.6 cm, sagittal thoracic kyphosis angle from 18.2° to 23.5°, and lumbar lordosis angle was from 37.4° to 41.8°. The mean follow-up period was 35.2 months (range, 24-50 months). There were no obvious pseudoarticulations or loss of correction and trunk equilibrium at the final follow-up; no aggravation of the original neural symptoms or new irreversible neural injury was observed.

CONCLUSIONS

In patients with mild or moderate adult thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia, the correction and fusion by using PPSI can yield a satisfactory clinical effect.

Management of spinal deformity in cerebral palsy

An understanding of the three-dimensional components of spinal deformity in children with cerebral palsy is necessary to recommend treatments that will positively affect these patients' quality of life. Management of these deformities can be challenging and orthopedic surgeons should be familiar with the different treatments available for this patient population. This article discusses the incidence, causes, natural history, and treatment of patients with scoliosis.

Can the caudal extent of fusion in the surgical treatment of scoliosis in Duchenne muscular dystrophy be stopped at lumbar 5?

Instrumentation and fusion to the sacrum/pelvis has been a mainstay in the surgical treatment of scoliosis in Duchenne muscular dystrophy (DMD) and is recommended to correct pelvic obliquity. The caudal extent of instrumentation and fusion in the surgical treatment of scoliosis in DMD has remained a matter of considerable debate, and there have been few studies on the use of segmental pedicle screw instrumentation for this pathology. From 2004 to 2007, a total of 28 patients with DMD underwent segmental pedicle screw instrumentation and fusion only to L5. Assessment was performed clinically and with radiologic measurements. All patients had a curve with the apex at L2 or higher preoperatively. Preoperative coronal curve averaged 74 degrees, with a postoperative mean of 14 degrees, and 17 degrees at the last follow-up. The pelvic obliquity improved from 17 degrees preoperatively to 6 degrees postoperatively, and 6 degrees at the last follow-up. Good sagittal plane alignment was recreated after surgery and maintained long term. In 23 patients with a preoperative L5 tilt of less than 15 degrees, the pelvic obliquity was effectively corrected to less than 10 degrees and maintained by adequately addressing spinal deformity, while five patients with a preoperative L5 tilt of more than 15 degrees had a postoperative pelvic obliquity of more than 15 degrees. Segmental pedicle screw instrumentation and fusion to L5 was effective and safe in patients with DMD scoliosis with a minimal L5 tilt (<15 degrees) and a curve with the apex at L2 or higher, both initially and long term, obviating the need for fixation to the sacrum/pelvis. Segmental pedicle screw instrumentation and fusion to L5 was safe and effective in patients with DMD scoliosis with stable L5/S1 articulation as evidenced by a minimal L5 tilt of less than 15 degrees, even though pelvic obliquity was significant. There was no major complication. With rigid segmental pedicle screw instrumentation, the caudal extent of fusion in the treatment of DMD scoliosis should be determined by the degree of L5 tilt. This method in appropriate patients can be a viable alternative to instrumentation and fusion to the sacrum/pelvis in the surgical treatment of DMD scoliosis.

Two-year results for scoliosis secondary to Duchenne muscular dystrophy fused to lumbar 5 with segmental pedicle screw instrumentation

BACKGROUND

Instrumentation and fusion to the sacrum/pelvis has been a mainstay in the surgical treatment of scoliosis in patients with Duchenne muscular dystrophy since the development of the intrailiac post. It is recommended for correcting pelvic obliquity. However, caudal extent of instrumentation and fusion has remained a matter of considerable debate. This study was performed to determine the efficacy and safety of stopping segmental pedicle screw constructs at L5 during surgical treatment of scoliosis associated with Duchenne muscular dystrophy (DMD).

METHODS

From May 2005 to June 2007, a total of 20 consecutive patients underwent posterior spinal fusion and segmental pedicle screw instrumentation only to L5 for scoliosis secondary to DMD. All patients had progressive scoliosis, difficulty sitting, and back pain before surgery. A minimum 2-year follow-up was required for inclusion in this study. Assessment was performed clinically and with radiological measurements. The Cobb angles of the curves and spinal pelvic obliquity were measured on the coronal plane. Thoracic kyphosis and lumbar lordosis were measured on the sagittal plane. These radiographic assessments were performed before surgery, immediately after surgery, and at a 3-month interval thereafter. The operating time, blood loss, and complications were evaluated. Patients were questioned about whether they had difficulty sitting and felt back pain before surgery and at 6 weeks, 1 year, and 2 years after surgery.

RESULTS

A total of 20 patients, aged 11-17 years, were enrolled. The average follow-up period was 37 months. Preoperative coronal curves averaged 70 degrees (range 51 degrees -85 degrees ), with a postoperative mean of 15 degrees (range 8 degrees -25 degrees ) and a mean of 17 degrees (range 9 degrees -27 degrees ) at the last follow-up. Pelvic obliquity improved from 13 degrees (range 7 degrees -15 degrees ) preoperatively to 5 degrees degrees (range 3 degrees -8 degrees ) postoperatively and 6 degrees (range 3 degrees -9 degrees ) at the last follow-up. Good sagittal plane alignment was recreated and maintained. Only a small loss of correction of scoliosis and pelvic obliquity was noted. The mean operating time was 271 min (range 232-308 min). The mean intraoperative blood loss was 890 ml (range 660-1260 ml). The mean total blood loss was 2100 ml (range 1250-2880 ml). There was no major complication. All patients reported that difficulty sitting and back pain were alleviated after surgery.

CONCLUSION

Segmental pedicle screw instrumentation and fusion only to L5 is safe and effective in patients with DMD scoliosis of <85 degrees and pelvic obliquity of <15 degrees . Good sagittal plane alignment was achieved and maintained. All patients benefited from surgery in terms of improved quality of life. There was no major complication.

Spinopelvic fixation with iliosacral screws in neuromuscular spinal deformities: results in a prospective cohort of 62 patients

PURPOSE

The results of a prospective series of 62 patients treated for neuromuscular spinal deformities with spinopelvic fixation using iliosacral screws are presented and discussed.

METHODS

Sixty-two consecutive patients diagnosed with neuromuscular disorders were prospectively included. Pelvic obliquity and other angular parameters were measured.

RESULTS

Mean age was 15.2 years (11.9 to 19.2 years). Spinal deformity was a thoracolumbar curve in 36 cases, a lumbosacral curve in 14 cases, a lumbar curve in four cases, and a combined thoracic and lumbar curve in eight cases. Lumbo-pelvic correction was done using two different strategies. In 15 patients with a normal frontal spinopelvic balance, the two rods were extended directly down to the iliosacral screws. In 47 patients with pelvic obliquity, iliosacral screws were linked to two short rods. The correction was then corrected by distraction and contraction maneuvers applied between the long and short rods. Postoperative angular parameters showed a good correction of spinal deformity in both groups. Patients with preoperative pelvic obliquity had a satisfactory and stable correction at final follow-up.

CONCLUSIONS

The technique of pelvic fixation using iliosacral screws and connectors reduce difficulties and operative time due to the complicated three-dimensional bending of the rods for proper placement within the ilium. In patients with preoperative pelvic imbalance, a powerful pelvic anchorage as the iliosacral fixation allowed to use intraoperative reduction maneuvers. Despite the high rate of infectious complications in our patients, we think that our technique provided effective and improved spinal correction for patients with neuromuscular scoliosis.

Correlação entre o número de parafusos e o percentual de correção no tratamento cirúrgico da escoliose neuromuscular

OBJETIVO: avaliar se existe relação entre o número de parafusos pediculares (densidade de parafusos) e o percentual de correção da curva principal no tratamento cirúrgico das escolioses neuromusculares. MÉTODOS: foram avaliados, retrospectivamente, 55 pacientes portadores de escoliose neuromuscular submetidos ao tratamento cirúrgico por meio de artrodese exclusivamente pela via posterior. Foram analisados o valor da curva pré-operatória, o percentual de correção e o valor da curva pós-operatória nas radiografias no pré-operatório e no pós-operatório imediato. Foi calculada a densidade de parafuso (número de parafusos por pedículo na área correspondente à curva principal) e avaliada a sua relação com o percentual de correção pela análise de correlação de Spearman. RESULTADOS: dos 55 pacientes, 28 (51%) eram do sexo feminino e 27 (49%) do masculino, com média de idade de 16,04 anos (dp=4,45). A doença de base mais frequente foi a paralisia cerebral. O valor da escoliose pré-operatória foi, em média, de 81,96º (dp=25,49) e da escoliose residual de 33,82º (dp=19,02), com percentual de correção de 60,28% (dp=15,89). Houve uma relação positiva (r=0,266) e estatisticamente significante entre a densidade de parafusos e a correção da deformidade (p=0,045). CONCLUSÕES: no tratamento cirúrgico das deformidades neuromusculares existe uma relação positiva entre o maior número de parafusos dentro da área da curva principal e o percentual de correção.

Comparação do poder de correção do instrumental de Luque-Galveston e do parafuso pedicular no tratamento cirúrgico da escoliose neuromuscular

OBJETIVO: avaliar o poder de correção do parafuso pedicular em comparação ao sistema de Luque-Galveston no tratamento cirúrgico da escoliose neuromuscular. MÉTODOS: foram avaliados 74 pacientes submetidos à artrodese exclusivamente pela via posterior, estendendo-se da região torácica alta ao sacro. Vinte e quatro pacientes foram submetidos à fixação com sistema de Luque-Galveston (Grupo 1) e 50, com parafusos pediculares (Grupo 2). Foram avaliadas as radiografias pré-operatórias, em tração e no pós-operatório imediato e mediu-se o valor da curva principal do período pré-operatório (Cobb pré), na tração (Cobb tração), e no pós-operatório (Cobb pós), e calculou-se a flexibilidade da curva e a correção final. Também foi calculado o Índice de Cincinnati, que leva em consideração a correção final e a flexibilidade (Cincinnati = Correção/Flexibilidade). Os mesmos parâmetros foram calculados para a obliquidade pélvica (OP): OP pré, OP tração, OP pós, Flexibilidade OP, Correção OP e Índice de Cincinnati para OP. RESULTADOS: a média da idade dos pacientes do Grupo 1 foi de 12,24 anos e do Grupo 2, de 16,13 anos (p=0,001). No Grupo 1, a principal doença foi a amiotrofia espinhal (38%) e no Grupo 2, a paralisia cerebral (62%). O ângulo de Cobb pré foi de 76,67º para o Grupo 1 e 85,54º para o Grupo 2. A flexibilidade foi de 45,32% para o Grupo 1 e 39,47% para o Grupo 2. A Correção foi de 63,07% para o Grupo 1 e 59,80% para o Grupo 2. O índice de Cincinnati para o Grupo 1 foi de 1,44 e de 1,71 para o Grupo 2. Quanto à OP, tivemos OP pré de 20,71º para o Grupo 1 e 26,60º para o Grupo 2. A Flexibilidade OP foi de 73,61% para o Grupo 1 e 56,54% para o Grupo 2 (p=0,047). A Correção OP foi de 73,47% para o Grupo 1 e de 72,11% para o Grupo 2. O Índice de Cincinnati da OP foi de 1,09 e 1,49, respectivamente para os Grupos 1 e 2 (p=0,045). CONCLUSÕES: a instrumentação com parafusos pediculares mostrou correção da escoliose semelhante à fixação com Luque-Galveston e maior poder de correção da obliquidade pélvica no tratamento das deformidades neuromuscluares.

Surgical complications in neuromuscular scoliosis operated with posterior- only approach using pedicle screw fixation

Background

There are no reports describing complications with posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) using pedicle screw fixation in patients with neuromuscular scoliosis.

Methods

Fifty neuromuscular patients (18 cerebral palsy, 18 Duchenne muscular dystrophy, 8 spinal muscular atrophy and 6 others) were divided in two groups according to severity of curves; group I (< 90°) and group II (> 90°). All underwent PSF and SSI with pedicle screw fixation. There were no anterior procedures. Perioperative (within three months of surgery) and postoperative (after three months of surgery) complications were retrospectively reviewed.

Results

There were fifty (37 perioperative, 13 postoperative) complications. Hemo/pneumothorax, pleural effusion, pulmonary edema requiring ICU care, complete spinal cord injury, deep wound infection and death were major complications; while atelectesis, pneumonia, mild pleural effusion, UTI, ileus, vomiting, gastritis, tingling sensation or radiating pain in lower limb, superficial infection and wound dehiscence were minor complications. Regarding perioperative complications, 34(68%) patients had at least one major or one minor complication. There were 16 patients with pulmonary, 14 with abdominal, 3 with wound related, 2 with neurological and 1 cardiovascular complications, respectively. There were two deaths, one due to cardiac arrest and other due to hypovolemic shock. Regarding postoperative complications 7 patients had coccygodynia, 3 had screw head prominence, 2 had bed sore and 1 had implant loosening, respectively. There was a significant relationship between age and increased intraoperative blood loss (p = 0.024). However it did not increased complications or need for ICU care. Similarly intraoperative blood loss > 3500 ml, severity of curve or need of pelvic fixation did not increase the complication rate or need for ICU. DMD patients had higher chances of coccygodynia postoperatively.

Conclusion

Although posterior-only approach using pedicle screw fixation had good correction rate, complications were similar to previous reports. There were few unusual complications like coccygodynia.

Surgery for scoliosis in Duchenne muscular dystrophy

BACKGROUND

Scoliosis in people with Duchenne muscular dystrophy is usually progressive and treated with surgery. However, it is unclear whether the existing evidence is sufficiently scientifically rigorous to support a recommendation for spinal surgery for most people with Duchenne muscular dystrophy and scoliosis.

OBJECTIVES

The objectives of this systematic review were to determine the effectiveness and safety of spinal surgery in Duchenne muscular dystrophy patients with scoliosis. We intended to test whether spinal surgery is effective in increasing life expectancy, improving respiratory function, improving quality of life and overall functioning; and whether spinal surgery is associated with severe adverse effects.

SEARCH STRATEGY

We searched the specialized registers of the Cochrane Neuromuscular Disease Group and Cochrane Back Group, the Cochrane Central Register of Controlled Trials (January 2006), MEDLINE (January 1966 to January 2006), EMBASE (January 1980 to January 2006), Dissertation Abstracts International (1861 to Jan 2006), CINAHL (January 1982 to January 2006), and the National Institute of Health Clinical Trials Database (January 2006). No language restrictions were imposed.

SELECTION CRITERIA

Controlled clinical trials using random or quasi-random allocation of treatment evaluating all forms of spinal surgery for scoliosis in patients with Duchenne muscular dystrophy were to be included in the review. The control interventions would have been no treatment, non-operative treatment, or a different form of spinal surgery.

DATA COLLECTION AND ANALYSIS

Two authors examined the search results and evaluated the study characteristics against inclusion criteria to decide which ones would be included in the review.

MAIN RESULTS

A total of 402 studies were identified from electronic searching. Thirty-six studies were relevant but none met the inclusion criteria for the review, because they were not clinical trials but prospective or retrospective reviews of case series.

AUTHORS' CONCLUSIONS

Since there were no randomized controlled clinical trials available to evaluate the effectiveness of scoliosis surgery in people with Duchenne muscular dystrophy, no evidence-based recommendation can be made for clinical practice. Patients should be informed about the uncertainty of benefits and potential risks of surgery for scoliosis. Randomized controlled trials are needed to investigate the effectiveness of scoliosis surgery, in terms of patients' quality of life, functional status, respiratory function and life expectancy.