The December 2023 Spine Roundup³⁶⁰ looks at: Does size matter in adolescent pedicle screws?; Effect of lumbar fusion and pelvic fixation rigidity on hip joint stress: a finite element analysis; Utility of ultrasonography in the diagnosis of lumbar spondylolysis in adolescent patients; Rett syndrome-associated scoliosis a national picture.

Objective: To evaluate per-operative and postoperative complications following surgical correction of neuromuscular scoliosis and assess the amount of radiological correction of Cobb’s angle and pelvic obliquity angle. Design: Retrospective study of 25 consecutive patients with neuromuscular scoliosis (10 Duchenne Muscular Dystrophy, 8 Cerebral palsy, 2 Neurofibromatosis, and 1 each of Spinal Muscular Atrophy, Friedrich’s Ataxia, Spina Bifida, Rett’s Syndrome and incarcerated hemi-vertibrae) who had surgical correction for their spinal disorders between 1999 and 2002. Background: Aims of surgical correction in neuromuscular scoliosis include improving sitting ability, cardio-respiratory function and cosmesis. Patients studied underwent a combination of anterior release, posterior spinal fusion and pelvic fixation. Due to the length and complexity of procedures many of these patients need two stage surgical procedures on two separate occasions to achieve this goal. However our practice is performing these two stage procedures in one sitting with post operative ITU support. Results: Patients were aged between 4 and 16 years of age with mean preoperative Cobb angles of 75.9° and pelvic obliquity of 18°. A mean correction of 55.8° of Cobb angle and 12° of Pelvic obliquity were achieved. We had mean operating time of 413 minutes with a mean blood loss of 50.2 ml/ Kg body weight. All patients were admitted to ITU post operatively with a mean stay in ITU of 5.8 days. All patients achieved clinical and radiological spinal fusion. Instrumentation had to be removed from one patient after fusion because of persistent infection. Conclusion: Surgery for Neuromuscular Scoliosis is time consuming and complicated. With anticipation of blood loss, complications and ITU support, we can successfully perform the two-stage procedure in one sitting

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Aims

It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis.

Aims

Severe spinal deformity in growing patients often requires surgical management. We describe the incidence of spinal deformity surgery in a National Health Service.

We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions.

We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations.

There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036).

In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

Cite this article: Bone Joint J 2014; 96-B:943–9.