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Arshad A, Tsirikos AI. Survival of patients with Duchenne muscular dystrophy who underwent spinal deformity correction. Dev Med Child Neurol 2024; 66:187-194. [PMID: 37482906 DOI: 10.1111/dmcn.15711] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/25/2023]
Abstract
AIM We investigated survival rates after scoliosis correction in individuals with Duchenne muscular dystrophy (DMD) and evaluated factors that can affect them. METHOD This was a retrospective cohort study from 2000 to 2022 with a minimum 2-year postoperative follow-up. We reviewed the hospital records/spinal radiographs and analysed data with XLSTAT. Kaplan-Meier and multivariate Cox regression survival analysis was performed. RESULTS Forty-three patients had a mean age at surgery of 14 years 5 months. Mean postoperative follow-up was 10 years 10 months. There was no operative or 30-day postoperative mortality in this group. Twenty-four patients died because of cardiorespiratory failure. Median survivorship was 14 years 2 months, with the longest observed survival being 22 years 6 months given the limitation of the length of postoperative follow-up. The degree of preoperative coronal imbalance and pelvic obliquity, as well as intraoperative blood loss, were factors that significantly affected survival. The impact of preoperative sagittal imbalance and extension of the fusion to the sacrum/pelvis trended towards significance. In contrast, age at surgery, preoperative/postoperative scoliosis, thoracic kyphosis, lumbar lordosis, scoliosis and pelvic obliquity flexibility or correction indices, postoperative coronal/sagittal balance, need of preoperative non-invasive ventilation, preoperative feeding disorders, development of surgical complications, and length of hospital and intensive care unit stay were exposure variables that did not affect postsurgical survival in patients with DMD. INTERPRETATION Survival of up to two decades or more was possible among young patients with DMD after scoliosis correction. This was affected by factors that related to disease and deformity severity, as well as surgical morbidity. WHAT THIS PAPER ADDS There was no operative or 30-day postoperative mortality in this group of patients with Duchenne muscular dystrophy (DMD) undergoing scoliosis correction. Survival probabilities at 5-year, 10-year, 15-year, and 20-year intervals post-surgery were 92%, 80%, 33%, and 12% respectively. Scoliosis surgery achieved good deformity correction and a balanced spine that was maintained at follow-up. Respiratory failure, severe pneumonia, and left ventricular failure were the leading causes of death in the study participants. Preoperative global coronal imbalance, pelvic obliquity, and intraoperative blood loss significantly predicted survival. Factors that affected survival after scoliosis surgery were associated with perioperative morbidity and disease or deformity severity in the DMD group.
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Affiliation(s)
- Ayesha Arshad
- Scottish National Spine Deformity Centre, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Athanasios I Tsirikos
- Scottish National Spine Deformity Centre, Royal Hospital for Children and Young People, Edinburgh, UK
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Fujimoto A, Mizuno K, Iwata Y, Yajima H, Nishida D, Komaki H, Ishiyama A, Mori-yoshimura M, Tachimori H, Kobayashi Y. Long-term Observation in Patients with Duchenne Muscular Dystrophy with Early Introduction of a Standing Program Using Knee-ankle-foot Orthoses. Prog Rehabil Med 2023; 8:20230038. [PMID: 37901357 PMCID: PMC10602754 DOI: 10.2490/prm.20230038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 10/11/2023] [Indexed: 10/31/2023] Open
Abstract
Objectives This study investigated the outcomes of the early introduction of a standing program for patients with Duchenne muscular dystrophy (DMD). Methods This was a retrospective observational study of 41 outpatients with DMD aged 15-20 years. We introduced the standing program using knee-ankle-foot orthoses (KAFO) to slow the progression of scoliosis when ankle dorsiflexion became less than 0° in the ambulatory period. Results Thirty-two patients with DMD were offered the standing program with KAFO; 12 continued the program until the age of 15 years (complete group) and 20 discontinued the program before the age of 15 years (incomplete group). The non-standing program group included 9 patients. The standing program with KAFO was significantly associated with the Cobb angle at the age of 15 years after adjustment for the duration of corticosteroid use and DMD mutation type (P=0.0004). At the age of 15 years, significant correlations were found between the ankle dorsiflexion range of motion (ROM) and non-ambulatory period (P=0.0010), non-ambulatory period and Cobb angle (P<0.0001), Cobb angle and percent predicted forced vital capacity (P=0.0004), and ankle dorsiflexion ROM and Cobb angle (P=0.0066). In the complete group, the age at ambulation loss (log-rank P=0.0015), scoliosis progression (log-rank P=0.0032), and pulmonary dysfunction (log-rank P=0.0006) were significantly higher than in the non-standing program group. Conclusions The early introduction of a standing program for DMD patients may prolong the ambulation period and slow the progression of scoliosis and pulmonary dysfunction.
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Affiliation(s)
- Akiko Fujimoto
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Katsuhiro Mizuno
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Rehabilitation Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Yasuyuki Iwata
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Rehabilitation, National Hakone Hospital, Odawara, Japan
| | - Hiroyuki Yajima
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Daisuke Nishida
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Rehabilitation Medicine, Tokai University School of Medicine, Isehara, Japan
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Komaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Akihiko Ishiyama
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Madoka Mori-yoshimura
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Hisateru Tachimori
- Endowed Course for Health System Innovation, Keio University School of Medicine, Tokyo, Japan
- Department of Clinical Data Science, Clinical Research and Education Promotion Division, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yoko Kobayashi
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Rehabilitation, National Hakone Hospital, Odawara, Japan
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Morales Ciancio RA, Gagliardi MJ, Tucker S, Ember T, Harris M, Broomfield E, Craven CL. Distal fusion in Duchenne scoliosis: the relevance of preoperative pelvic obliquity. A case series study. Spine Deform 2023; 11:1261-1270. [PMID: 37280469 DOI: 10.1007/s43390-023-00689-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 04/08/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE The aim of this study was to determine clinical and radiographic outcomes for Duchenne Muscular Dystrophy (DMD) patients who underwent posterior spinal fusion from T2/3 to L5 (without pelvic fixation), at this single centre. METHODS From January 2012 to January 2020, 29 consecutive DMD scoliosis patients underwent posterior spinal fusion using pedicle screws from T2/3 to L5 in a single center with a minimum of 3 years follow-up (FU). Radiologic measurements and chart review were performed. RESULTS Twenty nine patients aged 14 ± 1.5 years were included. No patient was lost to FU. All patients had significant correction in Cobb angle, pelvic obliquity (PO) and lumbar lordosis (LL), without loss of correction at last FU. The mean values for preoperative, immediate postoperative and last FU were CA 62o, 15o and 17o, PO: 21o, 8o and 9o; and LL 10o, -41o and -41o respectively. Correction in CA was independent of any variable analysed including implant density, rod diameter, traction, or bone density. Regarding PO, it was inversely related to age and independent of all other variables. Factors associated with postoperative complications were age and respiratory function. CONCLUSIONS It appears from our results that pelvic fixation might not always be required in DMD scoliosis surgery, when using pedicle screws with lowest instrumented vertebra at L5. However, larger preoperative PO values can be related with residual PO. It seems that probably related to the underlying condition, early surgery may decrease incidence of complications. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | | | - Stewart Tucker
- Orthopaedic and Spine Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Thomas Ember
- Orthopaedic and Spine Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Mark Harris
- Orthopaedic and Spine Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Edel Broomfield
- Orthopaedic and Spine Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Claudia L Craven
- Orthopaedic and Spine Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
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Roberts S, Arshad A, Tsirikos AI. Surgical and long-term functional outcomes of patients with Duchenne muscular dystrophy following spinal deformity correction. World J Orthop 2023; 14:411-426. [PMID: 37377990 PMCID: PMC10292064 DOI: 10.5312/wjo.v14.i6.411] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/29/2023] [Accepted: 05/15/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Life expectancy in patients with Duchenne muscular dystrophy (DMD) has improved due to advances in medical care. DMD patients develop progressive spinal deformity after loss of ambulatory function and onset of wheelchair dependence for mobility. There is limited published data on the effect of spinal deformity correction on long-term functional outcomes, quality of life (QoL), and satisfaction in DMD patients.
AIM To investigate the long-term functional outcomes following spinal deformity correction in DMD patients.
METHODS This was a retrospective cohort study from 2000-2022. Data was collected from hospital records and radiographs. At follow-up, patients completed the muscular dystrophy spine questionnaire (MDSQ). Statistical analysis was performed by linear regression analysis and ANOVA to analyse clinical and radiographic factors significantly associated with MDSQ scores.
RESULTS Forty-three patients were included with mean age 14.4 years at surgery. Spino-pelvic fusion was performed in 41.9% of patients. Mean surgical time was 352.1 min and mean blood loss was 36% of estimated total blood volume. Mean hospital stay was 14.1 d. Postoperative complications occurred in 25.6% of patients. Mean preoperative scoliosis was 58°, pelvic obliquity 16.4°, thoracic kyphosis 55.8°, lumbar lordosis 11.1°, coronal balance 3.8 cm, and sagittal balance + 6.1 cm. Mean surgical correction of scoliosis was 79.2% and of pelvic obliquity was 80.8%. Mean follow-up was 10.9 years (range: 2-22.5). Twenty-four patients had died at follow-up. Sixteen patients completed the MDSQ at mean age 25.4 years (range 15.2-37.3). Two patients were bed-ridden and 7 were on ventilatory support. Mean MDSQ total score was 38.1. All 16 patients were satisfied with the results of spinal surgery and would choose surgery again if offered. Most patients (87.5%) reported no severe back pain at follow-up. Factors significantly associated with functional outcomes (MDSQ total score) included greater duration of post-operative follow-up, age, scoliosis postoperatively, correction of scoliosis, increased lumbar lordosis postoperatively, and greater age at loss of independent ambulation.
CONCLUSION Spinal deformity correction in DMD patients leads to positive long-term effects on QoL and high patient satisfaction. These results support spinal deformity correction to improve long-term QoL in DMD patients.
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Affiliation(s)
- Simon Roberts
- Department of Spinal Surgery, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, United Kingdom
| | - Ayesha Arshad
- Scottish National Spine Deformity Centre, Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, United Kingdom
| | - Athanasios I Tsirikos
- Scottish National Spine Deformity Centre, Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, United Kingdom
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Yoon JA, Park HE, Kim J, Son J, Shin YB. Corticosteroid use and bone health management for Duchenne muscular dystrophy in South Korea. Sci Rep 2022; 12:11300. [PMID: 35788153 PMCID: PMC9253151 DOI: 10.1038/s41598-022-15510-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/24/2022] [Indexed: 11/09/2022] Open
Abstract
This study aimed to determine the current corticosteroid use and bone health management status of patients with Duchenne muscular dystrophy (DMD) in South Korea. This is a national population-based study utilized information from the databased of Korean National Health Insurance Database. Database regarding bone status, spine radiography findings, bone mineral density, and laboratory test results were obtained, as well as the proportion of patients with spine and lower limb prostheses, occurrence of scoliosis, and age at scoliosis surgery. Deflazacort dose in the ambulant group (aged < 15 years) increased by age and year. The maintenance dose of prednisolone and deflazacort for the 15–19 years group decreased by year. Among the patients, 12.47% underwent spine radiography, 23.11% underwent dual-energy X-ray absorptiometry, and 22.7% underwent vitamin D tests. Moreover, 40.9% of the patients were prescribed vitamin D at a mean age of 14.6 ± 6.1 years, while 10.22% were prescribed bisphosphonate at 17.92 ± 3.4 years. Further, 16.1% of the patients underwent posterior spinal instrumentation and fusion at 14.4 ± 2.3 years and 5.3% underwent anterior spinal instrumentation and fusion at 14.4 ± 2.3 years. Ankle–foot orthosis and spine orthosis prescriptions were noted in 4.91% and 1.84% of patients, respectively. In this our study, the current corticosteroid use and bone health management status of DMD in South Korea has been presented. The dose prescription for corticosteroid and bone health monitoring did not reach to current recommendation.
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Affiliation(s)
- Jin A Yoon
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-Ro Seo-Gu, Busan, 602-739, Republic of Korea
| | - Ho Eun Park
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-Ro Seo-Gu, Busan, 602-739, Republic of Korea
| | - Jinmi Kim
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jungmin Son
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Yong Beom Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-Ro Seo-Gu, Busan, 602-739, Republic of Korea.
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Protocol-driven early tracheal extubation in patients with flaccid neuromuscular scoliosis and pre-existing lung disease. Spine Deform 2022; 10:689-696. [PMID: 35067898 DOI: 10.1007/s43390-021-00411-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 09/05/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To review the results of a postoperative respiratory pathway for patients with muscular dystrophy (MD) and spinal muscular atrophy (SMA) undergoing spinal surgery. METHODS With IRB approval, a retrospective review was done on all patients with SMA and MD undergoing spinal surgery on a neuromuscular protocol. Baseline demographics, perioperative results, and long-term outcomes were collected. Per the protocol, patients remained intubated after surgery and were transported to the intensive care unit (ICU) for extubation. We present the results of protocol implementation and compare patients with MD to those with SMA. RESULTS Twenty-four patients were treated using the protocol. Average age was 13.1 years. Severe restrictive lung disease was present in 75% of patients. Nocturnal BiPAP was required in 68% of patients. Average number of instrumented levels was 17. All patients were immediately extubated upon entering the ICU. There were three respiratory complications and only was patient was re-intubated. Average ICU stay was 1.8 days and average hospital length of stay was 6.7 days. No differences in postoperative inspiratory or expiratory positive airway pressures were observed between the MD and SMA groups. CONCLUSION Through a multidisciplinary neuromuscular protocol, excellent clinical outcomes were achieved in patients with neuromuscular scoliosis and restrictive lung disease, with complication rates and length of stay significantly lower than previously published data. LEVEL OF EVIDENCE IV.
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Lehovsky K. In children with cerebral palsy, does spinal fusion surgery for scoliosis improve lung function? Arch Dis Child 2021; 106:1231-1233. [PMID: 34407955 DOI: 10.1136/archdischild-2021-322600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/29/2021] [Indexed: 11/03/2022]
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Comparison of survival analysis between surgical and non-surgical treatments in Duchenne muscular dystrophy scoliosis. Spine J 2020; 20:1840-1849. [PMID: 32535073 DOI: 10.1016/j.spinee.2020.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/18/2020] [Accepted: 06/04/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There are still controversies about the effects of spinal surgeries for Duchenne muscular dystrophy (DMD) scoliosis on functional outcome, respiratory function, and the survival rate. PURPOSE The purpose of this retrospective investigation was to compare the clinical course over time between the patients who were treated surgically and those who were treated nonsurgically. Through this comparison, we tried to determine how surgical treatment could affect the functional status, pulmonary function, and survival rate in patients with DMD scoliosis. STUDY DESIGN/SETTING Single-center retrospective cohort study. PATIENT SAMPLE We reviewed the clinical data of 199 male patients with DMD scoliosis who were followed up at our center for an average of 6.4 years between 2003 and 2017. OUTCOME MEASURES The basic radiologic parameters evaluated include the Cobb angle and pelvic obliquity on a whole spine X-ray. Further, the Swinyard scale for functional status, forced vital capacity (FVC) for respiratory function, and mortality were compared between the surgical group and nonsurgical group. METHODS The radiologic parameters and Swinyard scale stage were compared between the surgical group and nonsurgical group at baseline and 2, 5, and 10 years. For the FVC, serial changes every year were investigated in both groups. Mortality was surveyed between the surgical group and nonsurgical group. RESULTS Of the 199 patients, 99 patients underwent the instrumented spinal fusion surgery and 100 patients in the nonsurgical group opted for conservative management. Radiologic results of the two groups were not different at baseline, but during the follow-up periods, the surgical group demonstrated better Cobb angles and pelvic obliquities. The surgical group showed a better functional status than did the nonsurgical group (6.7±0.9 versus [vs.] 7.2±0.7, p<.001). These functional differences between the groups were continuously observed during the follow-up period. Similarly, the FVC at baseline was higher in the surgical group than in the nonsurgical group (1005.7±421.4 mL vs. 787.3±574.1 mL, p=.005). Although FVC in the nonsurgical group consistently decreased during the follow-up (4.8% decrease/year), FVC in the surgical group increased up to the 2-year follow-up period compared with the baseline value and decreased during the follow-up period (2.8% decrease/year). Mortality was higher in the nonsurgical group than in the surgical group (n=22/100, 22.0% vs. n=8/99, 8.1%; p<.001) during an average follow-up duration of 6.4 years. Mean survival was longer in the surgical group than in the nonsurgical group (12.2 years vs. 8.3 years, hazard ratio=2.43, p=.02). CONCLUSIONS Spinal surgery for DMD scoliosis improved the FVC for approximately 2 years postoperatively compared to non-surgical treatment. The surgical group had a better functional status and FVC at baseline than the non-surgical group. The positive effect of surgical treatment on the FVC is owing to scoliosis correction, which delayed the decrease of FVC and consequently extended the survival rate of the patients with DMD scoliosis.
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Intraoperative neurophysiological monitoring during scoliosis surgery in patients with Duchenne muscular dystrophy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2029-2035. [PMID: 32440770 DOI: 10.1007/s00586-020-06458-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 05/10/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Little is known about the reliability and value of intraoperative neurophysiological monitoring (IONM) in patients with Duchenne muscular dystrophy (DMD) undergoing scoliosis correction surgery. The aim of this study was to investigate the feasibility of IONM and the cortical excitability in these patients. METHODS Fifteen patients with DMD and scoliosis and 15 patients with adolescent idiopathic scoliosis (AIS) underwent scoliosis correction surgery with the use of IONM. IONM consisted of transcranial electrical stimulation motor evoked potential (Tc-MEP) and somatosensory evoked potential (SSEP) monitoring. The highest Tc-MEP amplitudes were collected to test the feasibility. Preoperative compound muscle action potentials (CMAPs) and transcranial magnetic stimulation (TMS)-MEPs were recorded to test the cortical excitability. SSEPs were scored as elicitable or not elicitable. RESULTS Tc-MEP amplitudes were significantly lower in the DMD group for both the gastrocnemius and tibialis anterior muscles. However, the abductor hallucis muscle had similar amplitudes in both the DMD as the AIS group. TMS/CMAP and Tc-MEP/CMAP ratios were similar in the DMD and AIS group (P = 0.126 and P = 0.792 respectively). CONCLUSIONS Tc-MEP and SSEP monitoring is feasible, particularly when Tc-MEPs are recorded from the abductor hallucis muscle in patients with DMD. Similar TMS/CMAP and Tc-MEP/CMAP ratios show that there were no differences observed in cortical excitability between the groups. IONM seems a feasible and valuable neurophysiological tool to signal possible surgically induced damage to the spinal cord during scoliosis correction surgery in patients with DMD.
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Farber HJ, Phillips WA, Kocab KL, Hanson DS, Heydemann JA, Dahl BT, Spoede ET, Jefferson LS. Impact of scoliosis surgery on pulmonary function in patients with muscular dystrophies and spinal muscular atrophy. Pediatr Pulmonol 2020; 55:1037-1042. [PMID: 32012473 DOI: 10.1002/ppul.24664] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 01/13/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Scoliosis is a common complication of severe neuromuscular diseases. The aim of this study is to determine the impact of posterior spinal fusion on pulmonary function parameters in patients with severe neuromuscular disease at our medical center. METHODS Retrospective chart review of all patients with severe neuromuscular disease who had posterior spinal fusion between 2012 and 2017 at Texas Children's Hospital. Patients with growing rods, brain injury or malformation, and/or spina bifida were excluded. Pulmonary function measures before and after spinal surgery were determined. RESULTS A total of 20 eligible patients were identified, 7 with Duchenne muscular dystrophy, 6 with spinal muscular atrophy, 3 with merosin deficient muscular dystrophy, 2 with Charcot-Marie-Tooth, 1 with central core disease, and 1 with dystroglycanopathy. The mean change in vital capacity from pre- to postspine surgery was a loss of 0.63 L for the spinal muscular atrophy patients, a loss of 0.36 L for the Duchenne muscular dystrophy patients, and a gain of 0.23 L for the merosin deficient patients. The difference between spinal muscular atrophy and merosin deficient patients was statistically significant (P = .02) CONCLUSION: In this single-center retrospective study, we found that after spine surgery for scoliosis, all patients with spinal muscular atrophy and most patients with Duchenne muscular dystrophy lost vital capacity, while the patients with merosin deficient muscular dystrophy gained vital capacity. These differences were not associated with differences is respiratory strength, body mass index, or surgical outcomes.
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Affiliation(s)
- Harold J Farber
- Section of Pulmonology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - William A Phillips
- Department of Orthopedic Surgery, Texas Children's Hospital Orthopedic Surgery Service, Baylor College of Medicine, Houston, Texas
| | - Kenneth L Kocab
- Outcomes and Impact Service, Texas Children's Hospital, Houston, Texas
| | - Darrell S Hanson
- Department of Orthopedic Surgery, Houston Methodist Hospital, Texas Children's Hospital Orthopedic Surgery Service, Houston, Texas
| | - John A Heydemann
- Department of Orthopedic Surgery, Texas Children's Hospital Orthopedic Surgery Service, Baylor College of Medicine, Houston, Texas
| | - Benny T Dahl
- Department of Orthopedic Surgery, Texas Children's Hospital Orthopedic Surgery Service, Baylor College of Medicine, Houston, Texas
| | | | - Larry S Jefferson
- Section of Pulmonology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Flotats-Bastardas M, Ebrahimi-Fakhari D, Bernert G, Ziegler A, Schlachter K, Poryo M, Hahn A, Meyer S. [Non-ambulatory patients with Duchenne muscular dystrophy : Recommendations for monitoring disease progression and course of treatment]. DER NERVENARZT 2019; 90:817-823. [PMID: 31270551 DOI: 10.1007/s00115-019-0754-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is a severe X‑linked recessive neuromuscular disorder. In children without corticosteroid therapy, progressive muscular weakness is associated with loss of ambulation on average by the age of 9.5 years. OBJECTIVE, MATERIAL AND METHODS On the basis of current guidelines, a group of experts in this field defined a number of clinical parameters and examinations that should be performed on a regular basis to assess changes over time in non-ambulant patients. RESULTS AND CONCLUSION To assess function of the upper extremities the Brooke upper extremity functional rating scale or the performance of upper limb test should be used. For assessment of pulmonary function measurement of forced vital capacity (FVC) is recommended. The extent of cardiac involvement can best be evaluated using cardiac magnetic resonance imaging (MRI), measurement of the ejection fraction (EF) and the left ventricular shortening fraction (LVSF) by echocardiography. The pediatric quality of life inventory should be used for assessment of quality of life. In addition, the body mass index (BMI), the number of infections and need for in-hospital treatment as well as early detection of orthopedic problems, most importantly the development of scoliosis should be monitored. After transition from pediatric to adult care DMD patients should be primarily cared for by adult neurologists and specialists in pulmonary and cardiac medicine.
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Affiliation(s)
- Marina Flotats-Bastardas
- Klinik für Allgemeine Pädiatrie und Neonatologie, Sektion Neuropädiatrie, Universitätsklinikum des Saarlandes, Geb. 9, 66421, Homburg, Deutschland
| | - Daniel Ebrahimi-Fakhari
- Klinik für Allgemeine Pädiatrie und Neonatologie, Sektion Neuropädiatrie, Universitätsklinikum des Saarlandes, Geb. 9, 66421, Homburg, Deutschland
| | - Günther Bernert
- Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef-Spital mit Gottfried von Preyer'schem Kinderspital, Wien, Österreich
| | - Andreas Ziegler
- Sektion für Neuropädiatrie und Stoffwechselmedizin, Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Kurt Schlachter
- Klinik für Kinder- und Jugendheilkunde, Landeskrankenhaus Bregenz, Bregenz, Österreich
| | - Martin Poryo
- Klinik für Pädiatrische Kardiologie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Andreas Hahn
- Abteilung Kinderneurologie, Sozialpädiatrie und Epileptologie, Universitätskinderklinik Gießen, Gießen, Deutschland
| | - Sascha Meyer
- Klinik für Allgemeine Pädiatrie und Neonatologie, Sektion Neuropädiatrie, Universitätsklinikum des Saarlandes, Geb. 9, 66421, Homburg, Deutschland.
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Choi YA, Shin HI, Shin HI. Scoliosis in Duchenne muscular dystrophy children is fully reducible in the initial stage, and becomes structural over time. BMC Musculoskelet Disord 2019; 20:277. [PMID: 31170965 PMCID: PMC6555713 DOI: 10.1186/s12891-019-2661-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with Duchenne muscular dystrophy (DMD) often develop scoliosis that progresses rapidly after loss of ambulation. Management of scoliosis is crucial because it affects both life expectancy and quality of life of patients with DMD. Spinal orthosis attempts to prevent or delay scoliosis using spinal support at three points of the controlling mechanism; the curve should be flattened by the pressure. Therefore, it is assumed that spine flexibility could be a significant influencing factor for the effectiveness of braces. Hence, we attempted to investigate the flexibility of scoliosis in non-ambulant patients with DMD. METHODS We reviewed the medical records of 273 boys who were genetically identified as having DMD, and finally, 50 boys with serial records of radiographs after loss of ambulation were finally enrolled. And among them, only 31 patients developed scoliosis. Spine radiographs in sitting and supine positions were also reviewed to obtain Cobb angle, curve flexibility, and pelvic obliquity. Flexibilities (%) were calculated by the difference in angles between the sitting and supine positions divided by the angle at the sitting position, multiplied by 100. RESULTS Among 31 boys who had scoliosis, all but 2 boys with curves went through a sequential course of 1) no scoliosis, 2) nonstructural scoliosis, when scoliosis was only measurable in the sitting position, and 3) structural scoliosis, when scoliosis was also detectable in the supine position. Flexibility decreased each year after detection of scoliosis in those who developed scoliosis the first year, from 75.5 ± 5.0% to 57.1 ± 10.5% and to 49.1 ± 10.0% (mean ± standard deviation). Spinal flexibility was significantly correlated with curve magnitude of scoliosis in both sitting and supine position (p < 0.05, respectively). CONCLUSIONS There is a period of fully reducible curve in DMD patients at the initial stage of scoliosis. Afterward, as spinal curve progresses, flexibility decreases over time. To detect the scoliosis when the curve is fully reducible, scoliosis curve in DMD patients should be evaluated dynamically, including radiographs of at least in two different positions.
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Affiliation(s)
- Young-Ah Choi
- Department of Rehabilitation Medicine, Incheon St. Mary’s Hospital 59, Dongsu-ro, Bupyeong-gu, Incheon, 21431 Korea
| | - Hyung-Ik Shin
- Seoul National University Hospital, Department of Rehabilitation Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744 Korea
| | - Hyun Iee Shin
- Seoul National University Hospital, Department of Rehabilitation Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744 Korea
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Carmen L, Maria V, Morales-Medina JC, Vallelunga A, Palmieri B, Iannitti T. Role of proteoglycans and glycosaminoglycans in Duchenne muscular dystrophy. Glycobiology 2019; 29:110-123. [PMID: 29924302 DOI: 10.1093/glycob/cwy058] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 06/18/2018] [Indexed: 12/25/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is an inherited fatal X-linked myogenic disorder with a prevalence of 1 in 3500 male live births. It affects voluntary muscles, and heart and breathing muscles. DMD is characterized by continuous degeneration and regeneration cycles resulting in extensive fibrosis and a progressive reduction in muscle mass. Since the identification of a reduction in dystrophin protein as the cause of this disorder, numerous innovative and experimental therapies, focusing on increasing the levels of dystrophin, have been proposed, but the clinical improvement has been unsatisfactory. Dystrophin forms the dystrophin-associated glycoprotein complex and its proteins have been studied as a promising novel therapeutic target to treat DMD. Among these proteins, cell surface glycosaminoglycans (GAGs) are found almost ubiquitously on the surface and in the extracellular matrix (ECM) of mammalian cells. These macromolecules interact with numerous ligands, including ECM constituents, adhesion molecules and growth factors that play a crucial role in muscle development and maintenance. In this article, we have reviewed in vitro, in vivo and clinical studies focused on the functional role of GAGs in the pathophysiology of DMD with the final aim of summarizing the state of the art of GAG dysregulation within the ECM in DMD and discussing future therapeutic perspectives.
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Affiliation(s)
- Laurino Carmen
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy
| | - Vadala' Maria
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy
| | - Julio Cesar Morales-Medina
- Centro de Investigación en Reproducción Animal, CINVESTAV-Universidad Autónoma de Tlaxcala, CP, AP 62, Mexico
| | - Annamaria Vallelunga
- Department of Medicine and Surgery, Centre for Neurodegenerative Diseases (CEMAND), University of Salerno, Salerno, Italy
| | - Beniamino Palmieri
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy
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Apkon SD, Alman B, Birnkrant DJ, Fitch R, Lark R, Mackenzie W, Weidner N, Sussman M. Orthopedic and Surgical Management of the Patient With Duchenne Muscular Dystrophy. Pediatrics 2018; 142:S82-S89. [PMID: 30275252 DOI: 10.1542/peds.2018-0333j] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 11/24/2022] Open
Abstract
Orthopedic care is an important aspect of the overall management of patients with Duchenne muscular dystrophy (DMD). In addition to progressive muscle weakness and loss of function, patients may develop joint contractures, scoliosis, and osteoporosis, causing fractures; all of these necessitate intervention by a multidisciplinary team including an orthopedic surgeon as well as rehabilitation specialists such as physio- and occupational therapists. The causes of these musculoskeletal complications are multifactorial and are related to primary effects on the muscles from the disease itself, secondary effects from weak muscles, and the related side effects of treatments, such as glucocorticoid use that affect bone strength. The musculoskeletal manifestations of DMD change over time as the disease progresses, and therefore, musculoskeletal management needs change throughout the life span of an individual with DMD. In this review, we target pediatricians, neurologists, orthopedic surgeons, rehabilitation physicians, anesthesiologists, and other individuals involved in the management of patients with DMD by providing specific recommendations to guide clinical practice related to orthopedic issues and surgical management in this setting.
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Affiliation(s)
- Susan D Apkon
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, Washington;
| | - Ben Alman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - David J Birnkrant
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Robert Fitch
- Duke University Health System, Department of Orthopedic Surgery, Durham, North Carolina
| | - Robert Lark
- Duke University Health System, Department of Orthopedic Surgery, Durham, North Carolina
| | | | - Norbert Weidner
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
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Birnkrant DJ, Bushby K, Bann CM, Alman BA, Apkon SD, Blackwell A, Case LE, Cripe L, Hadjiyannakis S, Olson AK, Sheehan DW, Bolen J, Weber DR, Ward LM. Diagnosis and management of Duchenne muscular dystrophy, part 2: respiratory, cardiac, bone health, and orthopaedic management. Lancet Neurol 2018; 17:347-361. [PMID: 29395990 DOI: 10.1016/s1474-4422(18)30025-5] [Citation(s) in RCA: 550] [Impact Index Per Article: 91.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 10/30/2017] [Accepted: 01/12/2018] [Indexed: 02/07/2023]
Abstract
A coordinated, multidisciplinary approach to care is essential for optimum management of the primary manifestations and secondary complications of Duchenne muscular dystrophy (DMD). Contemporary care has been shaped by the availability of more sensitive diagnostic techniques and the earlier use of therapeutic interventions, which have the potential to improve patients' duration and quality of life. In part 2 of this update of the DMD care considerations, we present the latest recommendations for respiratory, cardiac, bone health and osteoporosis, and orthopaedic and surgical management for boys and men with DMD. Additionally, we provide guidance on cardiac management for female carriers of a disease-causing mutation. The new care considerations acknowledge the effects of long-term glucocorticoid use on the natural history of DMD, and the need for care guidance across the lifespan as patients live longer. The management of DMD looks set to change substantially as new genetic and molecular therapies become available.
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Affiliation(s)
- David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Katharine Bushby
- John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Carla M Bann
- RTI International, Research Triangle Park, NC, USA
| | - Benjamin A Alman
- Department of Orthopaedic Surgery, Duke University School of Medicine and Health System, Durham, NC, USA
| | - Susan D Apkon
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Laura E Case
- Doctor of Physical Therapy Division, Department of Orthopaedics, Duke University School of Medicine, Durham, NC, USA
| | - Linda Cripe
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Stasia Hadjiyannakis
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, and University of Ottawa, Ottawa, ON, Canada
| | - Aaron K Olson
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Daniel W Sheehan
- John R Oishei Children's Hospital, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Julie Bolen
- Rare Disorders and Health Outcomes Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - David R Weber
- Division of Endocrinology and Diabetes, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Leanne M Ward
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, and University of Ottawa, Ottawa, ON, Canada
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Hino K, Fukuda M, Morino T, Ogata T, Ito M, Ishii E. Spinal fusion in a patient with Fukuyama congenital muscular dystrophy. Brain Dev 2017; 39:613-616. [PMID: 28318781 DOI: 10.1016/j.braindev.2017.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/02/2017] [Accepted: 02/10/2017] [Indexed: 11/30/2022]
Abstract
Many studies have evaluated surgical treatments for spinal deformities in patients with neuromuscular disease. However, few reports have described patients with Fukuyama congenital muscular dystrophy (FCMD). A 13-year-old boy with FCMD was unable to sit for long periods or sleep in the supine position because of progressive scoliosis. His Cobb angle worsened from 27° to 41° in 5months. He underwent standard posterior spinal fusion and pedicle-screw-alone fixation from T5 to S1. Postoperatively, his Cobb angle improved from 41° to 25° without exacerbation for 2years. After the surgery, he was able to sit for longer periods without pain, and he and his family were satisfied with the efficacy of the spinal fusion. Some patients with mild FCMD can sit at the age of puberty, but progression to scoliosis is possible. Therefore, spinal fusion for progressive scoliosis in patients with FCMD should be considered.
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Affiliation(s)
- Kaori Hino
- Department of Pediatrics, Ehime University Graduate School of Medicine, Japan.
| | - Mitsumasa Fukuda
- Department of Pediatrics, Ehime University Graduate School of Medicine, Japan
| | - Tadao Morino
- Department of Orthopedics, Ehime University Graduate School of Medicine, Japan
| | - Tadanori Ogata
- Department of Orthopedics, Ehime University Graduate School of Medicine, Japan
| | - Masanori Ito
- Department of Pediatrics, Ehime University Graduate School of Medicine, Japan
| | - Eiichi Ishii
- Department of Pediatrics, Ehime University Graduate School of Medicine, Japan
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Chua K, Lau LL, Hui JHP, Lee EH. Neuromuscular scoliosis: how decision making and treatment are different. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Roberts SB, Tsirikos AI. Factors influencing the evaluation and management of neuromuscular scoliosis: A review of the literature. J Back Musculoskelet Rehabil 2016; 29:613-623. [PMID: 26966821 DOI: 10.3233/bmr-160675] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Neuromuscular scoliosis (NMS) is the second most prevalent spinal deformity (after idiopathic scoliosis) and is usually first identified during early childhood. Cerebral palsy (CP) is the most common cause of NMS, followed by Duchenne muscular dystrophy (DMD). Progressive spinal deformity causes difficulty with daily care, walking and sitting, and can lead to back and rib pain, cardiac and pulmonary complications, altered seizure thresholds, and skin compromise. Early referral to specialist spinal services and early diagnosis of NMS is essential to ensure appropriate multidisciplinary patient management. The most important goals for patients are preservation of function, facilitation of daily care, and alleviation of pain. Non-operative management includes observation or bracing for less severe and flexible deformity in young patients as a temporising measure to provide postural support. Surgical correction and stabilisation of NMS is considered for patients with a deformity >40-50°, but may be performed for less severe deformity in patients with DMD. Post-operative intensive care, early mobilisation and nutritional supplementation aim to minimise the rate of post-surgical complications, which are relatively common in this patient group. However, surgical management of NMS is associated with good long-term outcomes and high satisfaction rates for patients, their relatives and carers.
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Abstract
BACKGROUND Patients with neuromuscular scoliosis (NMS) can pose treatment challenges related to medical comorbidities and altered spinopelvic anatomy. We reviewed the recent literature regarding evaluation and management of NMS patients and explored areas where further research is needed. METHODS We searched the PubMed database for all papers related to the treatment of NMS published from January 1, 2011 through July 31, 2014, yielding 70 papers. RESULTS A total of 39 papers contributed compelling new findings. Steroid treatment has been most promising in patients with Duchenne muscular dystrophy, leading to a significantly lower death rate, better pulmonary function, and longer independent ambulation. Growing rods in early-onset NMS were shown to result in significant improvements in major Cobb angles and pelvic obliquity, with low complication rates in patients with spinal muscular atrophy but high infection rates in those with cerebral palsy. Early reports of magnetic growing rods in NMS patients are favorable. Intraoperative neural monitoring is variable in this patient population; however, use of transcranial motor-evoked potentials in NMS patients seems to be safe. Blood loss is the highest in NMS patients when compared with all other diagnostic categories. However, tranexamic acid seems to significantly lower intraoperative blood loss. In a multicenter study, patients diagnosed with NMS had the highest surgical-site infection rate at 13.1%. Best-practice guidelines have been created regarding prevention of infection in NMS patients. Preoperative nutritional optimization and postoperative nutritional supplementation seem to help with lowering the infection rate in these patients. CONCLUSIONS There have been major advances in the management of NMS patients, but many challenges remain. Further multicenter studies and randomized clinical trials are needed, particularly in the areas of infection prophylaxis, nutritional optimization, improvement in intraoperative neural monitoring, and prevention of proximal junctional kyphosis. LEVEL OF EVIDENCE Level 4-literature review.
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Archer JE, Gardner AC, Roper HP, Chikermane AA, Tatman AJ. Duchenne muscular dystrophy: the management of scoliosis. JOURNAL OF SPINE SURGERY 2016; 2:185-194. [PMID: 27757431 DOI: 10.21037/jss.2016.08.05] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This study summaries the current management of scoliosis in patients with Duchenne Muscular Dystrophy. A literature review of Medline was performed and the collected articles critically appraised. This literature is discussed to give an overview of the current management of scoliosis within Duchenne Muscular Dystrophy. Importantly, improvements in respiratory care, the use of steroids and improving surgical techniques have allowed patients to maintain quality of life and improved life expectancy in this patient group.
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Affiliation(s)
- James E Archer
- The Royal Orthopaedic Hospital, Northfield, Birmingham, West Midlands, UK; ; Heartlands Hospital, Bordesley Green East, Birmingham, West Midlands, UK
| | - Adrian C Gardner
- The Royal Orthopaedic Hospital, Northfield, Birmingham, West Midlands, UK
| | - Helen P Roper
- Heartlands Hospital, Bordesley Green East, Birmingham, West Midlands, UK
| | | | - Andrew J Tatman
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham, UK
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The lifetime risk of pneumonia in patients with neuromuscular scoliosis at a mean age of 21 years: the role of spinal deformity surgery. J Child Orthop 2015; 9:357-64. [PMID: 26350797 PMCID: PMC4619373 DOI: 10.1007/s11832-015-0682-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/27/2015] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Patients with neuromuscular disorders often have an increased risk of pneumonia and decreased lung function, which may further be compromised by scoliosis. Scoliosis surgery may improve pulmonary function in otherwise healthy patients, but no study has evaluated its effect on the risk of pneumonia in patients with neuromuscular scoliosis (NMS). METHODS The patient charts of 42 patients (mean age 14.6 years) who had undergone surgery for severe NMS (mean scoliosis 86°) were retrospectively reviewed from birth to a mean of 6.1 years (range 2.8-9.5) after scoliosis surgery. The main outcome was radiographically confirmed pneumonia as a primary cause for hospitalization. We excluded postoperative (3 months) pneumonia from the analyses. RESULTS The lifetime annual incidence of pneumonia was 8.0/100 before and 13.4/100 after scoliosis surgery (p > 0.10). The mean number of hospital days per year due to pneumonia were 0.59 (SD 2.3) before scoliosis surgery and 2.24 (SD 6.9) after surgery (p > 0.10). Multivariate analysis demonstrated that lifetime risk factors for pneumonia were epilepsy (RR 15.2, 95 % CI 1.3-176.8, p = 0.027), non-cerebral palsy (CP) etiology (RR = 10.2, 95 % CI 3.2-32.7, p < 0.001) and major scoliosis (main curve >70°; RR = 11.3, 95 % CI 1.8-70.7, p = 0.01). CONCLUSIONS Epilepsy, non-CP etiology and major scoliosis are significant risk factors for pneumonia in patients with NMS. Scoliosis surgery does not decrease the incidence of pneumonia in patients with severe NMS. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Abstract
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.
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Affiliation(s)
- Daniel KL Cheuk
- The University of Hong Kong, Queen Mary HospitalDepartment of Pediatrics and Adolescent MedicinePokfulam RoadHong Kong SARChina
| | - Virginia Wong
- The University of Hong Kong, Queen Mary HospitalDepartment of Pediatrics and Adolescent MedicinePokfulam RoadHong KongChina
| | - Elizabeth Wraige
- Evelina Children's Hospital, St Thomas' HospitalDepartment of Paediatric NeurologyLambeth Palace RoadLondonUKSE1 7EH
| | - Peter Baxter
- Sheffield Children's HospitalRyegate Children's CentreWestern BankSheffieldSouth YorkshireUKS10 2TH
| | - Ashley Cole
- Sheffield Children's HospitalOrthopaedics DepartmentWestern BankSheffieldUKS10 2TH
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