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Liang H, Shao Z, Shi Y, Wang X. Comparison of surgical and non-surgical treatment for scoliosis in Duchenne muscular dystrophy: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2025; 145:219. [PMID: 40167615 DOI: 10.1007/s00402-025-05811-1] [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: 11/25/2023] [Accepted: 03/05/2025] [Indexed: 04/02/2025]
Abstract
INTRODUCTION Duchenne muscular dystrophy (DMD) is a neuromuscular disease caused by dystrophin gene mutations, which not only causes severe physical and psychological damage to the patient but also imposes a considerable economic burden on society. However, whether to aggressively surgical treatment for progressive scoliosis of DMD remains a conundrum. Therefore, we aimed to systematically evaluate the efficacy and prognosis of surgical treatment for DMD-associated scoliosis. MATERIALS AND METHODS PubMed, Embase, The Cochrane Library, China National Knowledge Infrastructure database, Wanfang database, China Science and Technology Journal Database, and China Biomedical Literature Database were searched for literature from the time of database creation until November 2022. The inclusion parameters were as follows: number of survivors, frequency of complications, preoperative, postoperative, and final follow-up Cobb's angles. Data were analyzed using RevMan 5.4.1 and Stata 12.0. RESULTS Six studies were analyzed. Survival rates were higher [OR = 3.83, 95% CI (1.91, 7.66), p = 0.0001] and Cobb's angle improved [SMD, 1.79, 95% CI (150, 2.07), p < 0.00001] in the surgical group than in the non-surgical group. The non-surgical group had a lower complication rate than the surgical group did [OR = 8.75, 95% CI (1.02,75.08), p = 0.048]. CONCLUSIONS Notably, scoliosis-correction surgery improves patient survival. Besides, scoliosis-correction surgery provides patients with more stable Cobb angle. As expected, non-surgical treatment has the advantage of reducing the occurrence of complications.
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Affiliation(s)
- Haibo Liang
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Zhenxuan Shao
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
- The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Yifeng Shi
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Xiangyang Wang
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China.
- The Second Affiliated Hospital and Yuying Children's hospital of Wenzhou Medical University, 109 West Xueyuan Road, Wenzhou, 325027, China.
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Coughlin GH, Shah SA, Gupta A, Bauer JM. The use of skin traction as an intraoperative adjunct for correction during pediatric neuromuscular scoliosis correction. 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 2025; 34:602-609. [PMID: 39656310 DOI: 10.1007/s00586-024-08598-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 11/16/2024] [Accepted: 11/29/2024] [Indexed: 02/09/2025]
Abstract
PURPOSE Intraoperative traction can improve deformity correction during posterior spinal fusion (PSF). This is commonly done with invasive distal femoral or pelvic pins, or traction boots. The novel technique of intraoperative skin traction (ISkinT) avoids risks associated with intraoperative skeletal traction (ISkelT) or hyperlordosis with extended hip position. We aimed to describe ISkinT and assess its safety and efficacy in PSF in non-ambulatory scoliosis. METHODS Retrospective review of patients aged 10-21yo who underwent T2-pelvis PSF with ISkinT from 2017 to 2023. Demographics and radiographic measurements were statistically compared to a published cohort that used ISkelT. RESULTS 42 patients treated with ISkinT were included and compared to 41 patients treated with ISkelT. ISkinT was applied by a cranial attachment and an average of 12% body weight to the pelvis with the hips and knees flexed, using tape-rope-weight system with Trendelenburg assistance. The preop major Cobb was 90°±21° in the ISkinT cohort and 91°±17° in the ISkelT cohort (p = 0.743; d = 0.07), which corrected 75% in ISkinT and 53% in ISkelT (p < 0.0001; d = 1.3). Preop pelvic obliquity averaged 23°± 10° in ISkinT and 34°±14° in ISkelT that corrected 74% in ISkinT and 65% in ISkelT (p < 0.0001; d = 0.95). No intraop or postoperative skin traction-related complications occurred, including neuromonitoring complications (obtained in 88%). CONCLUSION In non-ambulatory neuromuscular pediatric scoliosis patients, ISkinT during PSF to the pelvis is a safe and effective technique for deformity correction. There were no associated complications and no difference of corrective capacity for ISkinT compared to ISkelT. ISkinT can be considered for T2-pelvis PSF for pediatric scoliosis.
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Affiliation(s)
| | - Suken A Shah
- Biostatistics, Epidemiology and Analytics in Research (BEAR) Core, Seattle Children's Hopsital, Seattle, WA, USA
| | - Apeksha Gupta
- Department of Orthopedics, Nemours Children's Hospital at AI duPont, Wilmington, DE, USA
| | - Jennifer M Bauer
- Department of Orthopaedic Surgery, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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Do SH, Bae S, Jo DJ, Choi HY. Distal Junctional Failure After Fusion Stopping at L5 in Patients With Adult Spinal Deformity: Incidence, Risk Factors, and Radiographic Criteria. Neurospine 2024; 21:856-864. [PMID: 39363465 PMCID: PMC11456928 DOI: 10.14245/ns.2448122.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 07/12/2024] [Accepted: 07/13/2024] [Indexed: 10/05/2024] Open
Abstract
OBJECTIVE To identify risk factors and establish radiographic criteria for distal junctional failure (DJF) in patients with adult spinal deformity (ASD), who underwent fusion surgery stopping at L5. METHODS This retrospective study was undertaken from January 2016 to December 2020. Patients with ASD who underwent fusion surgery (≥5 levels) stopping at L5 were analyzed. DJF was defined as symptomatic adjacent segment pathology at the lumbosacral junction necessitating consideration for revision surgery. Demographic data and radiographic measurements were compared between the DJF and non-DJF groups. Receiver operating characteristic curve analysis was performed to identify the radiographic cutoff value for DJF. RESULTS Among 76 patients, 16 (21.1%) experienced DJF. DJF was associated with older age, antidepressant/anxiolytic medication, longer level of fusions, and worse preoperative sagittal alignment. Antidepressant/anxiolytic medication (odds ratio, 5.60) and preoperative pelvic incidence (PI)-lumbar lordosis (LL) mismatch>40° (odds ratio, 5.87) were independent risk factors for DJF. Without both factors, the incidence of DJF has been greatly reduced (9.1%). Two radiographic criteria were determined for DJF: last distal junctional angle (DJA)>-5° and Δ last DJA-post DJA>5°. When both criteria were met, the sensitivity and specificity of the DJF were 93.3% and 91.7%, respectively. CONCLUSION Use of antidepressant/anxiolytic medication and preoperative PI-LL mismatch >40° were independent risk factors for DJF. DJF could be diagnosed using postoperative changes in the DJA. If both criteria were met, DJF could be strongly suggested.
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Affiliation(s)
- Sung Ho Do
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea
| | - Sungsoo Bae
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea
| | - Dae Jean Jo
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea
| | - Ho Yong Choi
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea
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Weintraub M, Gupta A, Khokhar A, Vives M, Kaushal N. Current Concepts in the Orthopaedic Management of Duchenne Muscular Dystrophy. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202407000-00011. [PMID: 38996213 PMCID: PMC11239163 DOI: 10.5435/jaaosglobal-d-24-00099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/21/2024] [Accepted: 05/22/2024] [Indexed: 07/14/2024]
Abstract
Duchenne muscular dystrophy (DMD), a genetic condition marked by progressive muscle degeneration, presents notable orthopaedic challenges, especially scoliosis, which deteriorates patients' quality of life by affecting sitting balance and complicating cardiac and respiratory functions. Current orthopaedic management strategies emphasize early intervention with corticosteroids to delay disease progression and the use of surgical spinal fusion to address severe scoliosis, aiming to enhance sitting balance, alleviate discomfort, and potentially extend patient lifespan. Despite advancements, optimal management requires ongoing research to refine therapeutic approaches, ensuring improved outcomes for patients with DMD. This review synthesizes recent findings on surgical and nonsurgical interventions, underscoring the importance of a multidisciplinary approach tailored to the dynamic needs of patients with DMD.
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Affiliation(s)
- Matthew Weintraub
- From the Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, NJ
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Gaumé M, Saghbiny E, Richard L, Thouement C, Vialle R, Miladi L. Pelvic Fixation Technique Using the Ilio-Sacral Screw for 173 Neuromuscular Scoliosis Patients. CHILDREN (BASEL, SWITZERLAND) 2024; 11:199. [PMID: 38397311 PMCID: PMC10887892 DOI: 10.3390/children11020199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024]
Abstract
Pelvic fixation remains one of the main challenging issues in non-ambulatory neuromuscular scoliosis (NMS) patients, between clinical effectiveness and a high complication rate. The objective of this multicenter and retrospective study was to evaluate the outcomes of a technique that was applied to treat 173 NMS patients. The technique is not well-known but promising; it uses the ilio-sacral screw, combined with either the posterior spinal fusion or fusionless bipolar technique, with a minimum follow-up of two years. The mean operative age of the patients was 13 ± 7 years. The mean preoperative main coronal curve was 64° and improved by a mean of -39° postoperatively. The mean preoperative pelvic obliquity was 23°, which improved by a mean of -14° postoperatively. No decrease in the frontal or sagittal correction was observed during the last follow-up. The sitting posture improved in all cases. Twenty-nine patients (17%) had a postoperative infection: twenty-six were treated with local debridement and antibiotics, and three required hardware removal. Fourteen mechanical complications (8%) occurred: screw malposition (n = 6), skin prominence (n = 1), and connector failure (n = 1). This type of surgery is associated with a high risk for infection. Comorbidities, rather than the surgery itself, were the main risk factors that led to complications. The ilio-sacral screw was reliable and effective in correcting pelvic obliquity in NMS patients. The introduction of intraoperative navigation should minimize the risk of screw misplacement and facilitate revision or primary fixation.
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Affiliation(s)
- Mathilde Gaumé
- University Institute for Spine Surgery, Armand Trousseau Hospital, Sorbonne University, 26 Avenue du Dr Netter, 75012 Paris, France; (M.G.); (E.S.); (L.R.); (C.T.)
- Pediatric Orthopedic Surgery Department, Necker Hospital, APHP, University of Paris-Cité, 75015 Paris, France;
| | - Elie Saghbiny
- University Institute for Spine Surgery, Armand Trousseau Hospital, Sorbonne University, 26 Avenue du Dr Netter, 75012 Paris, France; (M.G.); (E.S.); (L.R.); (C.T.)
| | - Lou Richard
- University Institute for Spine Surgery, Armand Trousseau Hospital, Sorbonne University, 26 Avenue du Dr Netter, 75012 Paris, France; (M.G.); (E.S.); (L.R.); (C.T.)
| | - Clélia Thouement
- University Institute for Spine Surgery, Armand Trousseau Hospital, Sorbonne University, 26 Avenue du Dr Netter, 75012 Paris, France; (M.G.); (E.S.); (L.R.); (C.T.)
| | - Raphaël Vialle
- University Institute for Spine Surgery, Armand Trousseau Hospital, Sorbonne University, 26 Avenue du Dr Netter, 75012 Paris, France; (M.G.); (E.S.); (L.R.); (C.T.)
| | - Lotfi Miladi
- Pediatric Orthopedic Surgery Department, Necker Hospital, APHP, University of Paris-Cité, 75015 Paris, France;
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Green-Petersen I, Magnano L, Charalampidis A, Gerdhem P. Distal fusion level, complications, and reoperations in individuals with cerebral palsy undergoing surgery for scoliosis. 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 2023; 32:4037-4044. [PMID: 37656234 DOI: 10.1007/s00586-023-07907-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE To compare radiological outcome, complications and reoperations in individuals with cerebral palsy and scoliosis fused to the fifth lumbar vertebra (L5), the sacrum, or the ilia. METHODS 208 individuals were identified in the national quality registry Swespine. Lowest level of fusion was L5 in 58, the sacrum in 92, and the ilia in 58 individuals. A subanalysis on 58 matched pairs operated to L5 or the pelvis (sacrum = 42, ilia = 16) with similar pelvic obliquity (± 5°) was performed. RESULTS The median (interquartile range) follow-up for the last radiograph was 1.7 (1.7) years and for reoperations 6.0 (5.9) years. Preoperatively, median Cobb angle of the major curve was 65° (23°) in the L5 group, 68° (28°) in the sacrum group, and 78° (25°) in the ilia group (p = 0.006). Preoperative median pelvic obliquity according to Maloney was 16° (19°), 21° (13°), and 27° (28°), respectively (p = 0.004). Immediate postoperative Cobb angles were 28° (18°), 28° (16°), and 32° (25°), respectively (p = 0.11). Immediate postoperative pelvic obliquity was 7° (10°), 7° (8°), and 8° (10°), respectively (p = 0.28). The median change in pelvic obliquity from the first to the last postoperative radiograph was - 5° (7°), - 3° (6°), - 3° (6°), respectively (p = 0.55). 7 (12%), 11 (12%), and 7 (12%) patients required at least one reoperation (p = 1.0), respectively. In the matched analysis, no significant differences in the radiological outcomes were found (all p ≥ 0.38). CONCLUSIONS Maintained curve and pelvic obliquity correction with no significant difference in complication and reoperation rates were found irrespective of distal fusion level.
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Affiliation(s)
- I Green-Petersen
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - L Magnano
- Department of Trauma and Orthopaedics, Enna Hospital, Sicily, Italy
| | - A Charalampidis
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Reconstructive Orthopedics, Karolinska University Hospital, Stockholm, Sweden
| | - P Gerdhem
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
- Department of Orthopedics and Hand Surgery, Uppsala University Hospital, Uppsala, Sweden.
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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Taylor TN, Bridges CS, Nordstrom LA, Hanson DS, Gerow FT, Smith BG. Early Complications After Posterior Spinal Fusion in Patients With Rett Syndrome. J Pediatr Orthop 2023; 43:e326-e330. [PMID: 36882895 DOI: 10.1097/bpo.0000000000002384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND Neuromuscular scoliosis in Rett syndrome (RS) is common, progressive, and often requires posterior spinal fusion (PSF). While PSF is associated with improved overall outcomes, there is a paucity of information describing complications. We aimed to report the postoperative complications, readmissions, and reoperations for patients with RS undergoing PSF. METHODS Female pediatric patients with RS treated by PSF with segmental instrumentation, with or without concurrent pelvis fixation, during January 2012 to August 2022 were included. Preoperative patient characteristics, intraoperative data (estimated blood loss, cell saver, packed red blood cells transfused), postoperative complications according to the Modified Clavien-Dindo-Sink classification within 90 days, unplanned readmissions within 30 days, and unplanned reoperations within 90 days were recorded. RESULTS A total of 25 females were included. The mean (SD) age at surgery was 12.9 (1.8) years and the mean follow-up of 38.6 (24.9) months. The mean preoperative major coronal curve was 79 degrees (23 degrees) which decreased to 32 degrees (15 degrees) by the last follow-up ( P <0.001). The median estimated blood loss was 600 mL and length of stay was 7 days. There were 81 total postoperative complications (3.2 complications/patient). Eight (32%) had grade IVa complications (disseminated intravascular coagulopathy, hypotensive shock, respiratory failure, chronic urosepsis). Five (20%) patients experienced seizures, 48% had pulmonary complications, and 56% had gastrointestinal complications. There were 3 readmissions (12%) within 30 days for pneumonia and 2 (8%) reoperations (an incision and drainage and C2-T2 fusion for significant kyphosis) within 90 days. One patient also had their fusion extended to the pelvis 1 year later. There were more nonambulatory patients in the group fused to the pelvis, but otherwise no differences between those fused and unfused to the pelvis. CONCLUSIONS This is the largest review of early postoperative complications for patients with RS who underwent PSF. PSF effectively reduced the major coronal curve, but surgeons and families should be aware of a high postoperative seizure and respiratory complication rate, as well as 8% having reoperations within 90 days and 12% being readmitted within 30 days. LEVEL OF EVIDENCE Level IV-therapeutic study.
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Badin D, Baldwin KD, Cahill PJ, Spiegel DA, Shah SA, Yaszay B, Newton PO, Sponseller PD. When to Perform Fusion Short of the Pelvis in Patients with Cerebral Palsy?: Indications and Outcomes. JB JS Open Access 2023; 8:JBJSOA-D-22-00123. [PMID: 37073271 PMCID: PMC10106181 DOI: 10.2106/jbjs.oa.22.00123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
Patients with scoliosis secondary to cerebral palsy (CP) are often treated with posterior spinal fusion (PSF) with or without pelvic fixation. We sought to establish criteria to guide the decision of whether or not to perform fusion "short of the pelvis" in this population, and to assess differences in outcomes. Methods Using 2 prospective databases, we analyzed 87 pediatric patients who underwent PSF short of the pelvis from 2008 to 2015 to treat CP-related scoliosis and who had ≥2 years of follow-up. Preoperative radiographic and clinical variables were analyzed for associations with unsatisfactory correction (defined as pelvic obliquity of ≥10°, distal implant dislodgement, and/or reoperation for increasing deformity at 2- or 5-year follow-up). Continuous variables were dichotomized using the Youden index, and a multivariable model of predictors of unsatisfactory correction was created using backward stepwise selection. Finally, radiographic, health-related quality-of-life, and clinical outcomes of patients with fusion short of the pelvis who had neither of the 2 factors associated with unsatisfactory outcomes were compared with those of 2 matched-control groups. Results Deformity correction was unsatisfactory in 29 of 87 patients with fusion short of the pelvis. The final model included preoperative pelvic obliquity of ≥17° (odds ratio [OR], 6.8; 95% confidence interval [CI], 2.3 to 19.7; p < 0.01) and dependent sitting status (OR, 3.2; 95% CI, 1.1 to 9.9; p = 0.04) as predictors of unsatisfactory correction. The predicted probability of unsatisfactory correction increased from 10% when neither of these factors was present to a predicated probability of 27% to 44% when 1 was present and to 72% when both were present. Among matched patients with these factors who had fusion to the pelvis, there was no association with unsatisfactory correction. Patients with independent sitting status and pelvic obliquity of <17° who had fusion short of the pelvis had significantly lower blood loss and hospital length of stay, and better 2-year health-related quality-of-life scores compared with matched controls with fusion to the pelvis. Conclusions In patients with scoliosis secondary to CP, pelvic obliquity of <17° and independent sitting status are associated with a low risk of unsatisfactory correction and better 2-year outcomes when fusion short of the pelvis is performed. These may be used as preoperative criteria to guide the decision of whether to perform fusion short of the pelvis in patients with CP. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel Badin
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Keith D. Baldwin
- Division of Orthopedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Patrick J. Cahill
- Division of Orthopedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David A. Spiegel
- Division of Orthopedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Suken A. Shah
- Department of Orthopedic Surgery, Nemours Children’s Hospital, Wilmington, Delaware
| | - Burt Yaszay
- Department of Orthopedics and Sports Medicine, Seattle Children’s Hospital and University of Washington, Seattle, Washington
| | - Peter O. Newton
- Department of Orthopedics, Rady Children’s Hospital and University of California-San Diego Medical Center, San Diego, California
| | - Paul D. Sponseller
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
- Email for corresponding author:
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Weissmann KA, Barrios C, Lafage V, Lafage R, Costa MA, Álvarez D, Huaiquilaf CM, Ang B, Schulz RG. Vertebral Coplanar Alignment Technique Versus Bilateral Apical Vertebral Derotation Technique in Neuromuscular Scoliosis. Global Spine J 2023; 13:104-112. [PMID: 33557621 PMCID: PMC9837503 DOI: 10.1177/2192568221992313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
STUDY DESIGN Single-center retrospective analysis of prospectively collected data. OBJECTIVE Our aim was to compare the correction capacity in 3 planes of the VCA technique versus the AD technique in neuromuscular scoliosis patients. METHODS We analized patients with neuromuscular scoliosis that underwent posterior spinal fusion from 2013 to 2017 using 2 different techniques for correction: vertebral coplanar alignment (VCA) that takes into consideration the fact that the medial cortex is more resistant than the lateral cortex, with more anchor points for better distribution of forces and ligamentotaxis and the more widely spread apical derotation (AD) technique. Clinical, surgical, and radiographic information of patients operated on with the AD technique were compared to those operated on with the VCA technique in the coronal, sagittal and axial plane at pre-op, immediate post-op, and 2 year follow-up. RESULTS 64 patients met inclusion criteria, 34 patients underwent the VCA technique and 30 patients underwent the AD technique. The 2 cohorts did not differ in terms of demographics, clinical presentation or preoperative alignment. There were no significant differences in the correction ability between both techniques regarding curve magnitude, apical vertebral rotation, or pelvic obliquity. There was a significant decrease in thoracic kyphosis in the AD group compared to the VCA group in the immediate postop period (4.2 ± 26.6º for VCA and 13.2 ± 21.3º for AD (p = 0.048)). CONCLUSION Both apical derotation technique and vertebral coplanar alignment allow for correction in the 3 planes for patients with neuromuscular scoliosis. VCA is a less hypokyphosing technique than AD.
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Affiliation(s)
- Karen A. Weissmann
- School of Doctorate, Valencia Catholic
University Sant Vincent Martyr, Valencia, Spain,Department of Orthopedics and
Traumatology, University of Chile, San Miguel, Región Metropolitana, Chile,Karen A. Weissmann, MD, School of Doctorate,
Valencia Catholic University Sant Vincent Martyr, Valencia, Spain; Department of
Orthopedics and Traumatology, University of Chile, Area Sur. Gran Avenida Jose
Miguel Carrera, 3100, San Miguel, Región Metropolitana, Chile.
;
| | - Carlos Barrios
- Institute for Research on
Musculoskeletal Disorders, Valencia Catholic University Sant Vincent Martyr,
Valencia, Spain
| | - Virginie Lafage
- Department of Orthopedic Surgery,
Hospital for Special Surgery, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery,
Hospital for Special Surgery, New York, NY, USA
| | | | - Diego Álvarez
- Hospital Exequiel González Cortés,
Redsalud, Santiago, Chile
| | | | - Bryan Ang
- Weill Cornell School of Medicine, New
York, NY, USA
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Soini V, Raitio A, Helenius I, Helenius L, Syvänen J. A retrospective cohort study of bleeding characteristics and hidden blood loss after segmental pedicle screw instrumentation in neuromuscular scoliosis as compared with adolescent idiopathic scoliosis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 12:100190. [PMID: 36561891 PMCID: PMC9763505 DOI: 10.1016/j.xnsj.2022.100190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/09/2022]
Abstract
Background Progressive scoliosis in neuromuscular patients often requires a long instrumented spinal fusion. Previous studies have shown larger intraoperative blood loss in these patients than those with adolescent idiopathic scoliosis (AIS), but the total blood loss composed of visible and hidden blood loss has not been described in this patient population. The aim of our study was to investigate the bleeding characteristics and hidden blood loss related to spinal fusion in neuromuscular scoliosis (NMS) as compared to AIS patients. Methods A retrospective cohort study with prospective data collection of NMS patients undergoing segmental pedicle screw instrumentation at a university hospital between 2009 and 2021. A comprehensive statistical analysis was performed regarding intra- and postoperative blood loss compared to patient characteristics such as age and diagnosis. Hidden blood loss was estimated and compared to the total blood loss. We standardized amount of bleeding with patient weight and fusion level for further analysis. Consecutive AIS patients served as a control population. Eighty-one consecutive patients with NMS (mean age 15.2 years, 37 females) were included and their bleeding characters were compared with 199 AIS patients (mean age 15.8 years, 143 females). The primary outcome was total blood loss including intraoperative, 24-hour drain output and hidden blood loss. Secondary outcome measures included requirement for blood transfusion. Results Neuromuscular patients had a significantly larger total blood loss with mean values of 1914 mL in the NMS and 1357 mL in the AIS groups, respectively (p<0.001). The hidden blood loss was also significantly larger in NMS than in AIS group (566 ± 533 mL vs. 398 ±411 mL, p=0.0332). Neuromuscular scoliosis was also associated with significantly greater weight and levels of fused adjusted intraoperative bleeding (1.79 ml/kg/fused level in NMS vs. 0.87 ml/kg/fused level in AIS vs. p< 0.0001) and hidden blood loss (1.00 ml/kg/levels fused vs. 0.65 ml/kg/fused levels, p=0.053). NMS diagnosis was also a risk factor for greater hidden blood loss in multivariable analysis (p=0.0011). 24-hour drain output was similar in the NMS and AIS groups. Male gender was a risk factor for greater hidden blood loss in the NMS group (p=0.0429). Fifty-nine (73%) NMS and 27 (14%) AIS patients received allogenic red blood cell infusions perioperatively (p<0.001). Conclusions Hidden blood loss constitutes one-third of total blood loss in children undergoing segmental pedicle screw instrumentation for neuromuscular scoliosis. Hidden blood loss is significantly greater in the neuromuscular as compared with idiopathic scoliosis. Hidden blood loss should be considered in the perioperative management of NMS.
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Affiliation(s)
- Venla Soini
- Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, 20520, Turku, Finland,Department of Surgery, Vaasa Central Hospital, Wellbeing Services County of Ostrobothnia, Vaasa, Finland
| | - Arimatias Raitio
- Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, 20520, Turku, Finland
| | - Ilkka Helenius
- Department of Orthopaedics and Traumatology, University of Helsinki, and Helsinki University Hospital, Finland,Department of Paediatric Orthopaedic Surgery, Helsinki New Children's Hospital, Helsinki, Finland
| | - Linda Helenius
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland
| | - Johanna Syvänen
- Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, 20520, Turku, Finland,Corresponding author at: Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, FI-20520 Turku, Finland.
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11
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Strom SF, Hess MC, Jardaly AH, Conklin MJ, Gilbert SR. Is it necessary to fuse to the pelvis when correcting scoliosis in cerebral palsy? World J Orthop 2022; 13:365-372. [PMID: 35582151 PMCID: PMC9048500 DOI: 10.5312/wjo.v13.i4.365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/30/2021] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Neuromuscular scoliosis is commonly associated with a large pelvic obliquity. Scoliosis in children with cerebral palsy is most commonly managed with posterior spinal instrumentation and fusion. While consensus is reached regarding the proximal starting point of fusion, controversy exists as to whether the distal level of spinal fusion should include the pelvis to correct the pelvic obliquity.
AIM To assess the role of pelvic fusion in posterior spinal instrumentation and fusion, particularly it impact on pelvic obliquity correction, and to assess if the rate of complications differed as a function of pelvic fusion.
METHODS This was a retrospective, cohort study in which we reviewed the medical records of children with cerebral palsy scoliosis treated with posterior instrumentation and fusion at a single institution. Minimum follow-up was six months. Patients were stratified into two groups: Those who were fused to the pelvis and those fused to L4/L5. The major outcomes were complications and radiographic parameters. The former were stratified into major and minor complications, and the latter consisted of preoperative and final Cobb angles, L5-S1 tilt and pelvic obliquity.
RESULTS The study included 47 patients. The correction of the L5 tilt was 60% in patients fused to the pelvis and 67% in patients fused to L4/L5 (P = 0.22). The pelvic obliquity was corrected by 43% and 36% in each group, respectively (P = 0.12). Regarding complications, patients fused to the pelvis had more total complications as compared to the other group (63.0% vs 30%, respectively, P = 0.025). After adjusting for differences in radiographic parameters (lumbar curve, L5 tilt, and pelvic obliquity), these patients had a 79% increased chance of developing complications (Relative risk = 1.79; 95%CI: 1.011-3.41).
CONCLUSION Including the pelvis in the distal level of fusion for cerebral palsy scoliosis places patients at an increased risk of postoperative complications. The added value that pelvic fusion offers in terms of correcting pelvic obliquity is not clear, as these patients had similar percent correction of their pelvic obliquity and L5 tilt compared to children whose fusion was stopped at L4/L5. Therefore, in a select patient population, spinal fusion can be stopped at the distal lumbar levels without adversely affecting the surgical outcomes.
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Affiliation(s)
- Shane F Strom
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Al 35294, United States
| | - Matthew C Hess
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Al 35294, United States
| | - Achraf H Jardaly
- Department of Orthopaedics, The Hughston Clinic/Hughston Foundation, Columbus, GA 31908, United States
| | - Michael J Conklin
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Al 35294, United States
| | - Shawn R Gilbert
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Al 35294, United States
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12
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Nunes BL, Zanotto DS, Lima CC, Senna G, Silva LTPE, Nascimento JE, Reis CD, Fontes BPC. ANALYSIS OF PATIENTS SUBMITTED TO SURGICAL TREATMENT FOR NEUROMUSCULAR SCOLIOSIS WITH AND WITHOUT INTRAOPERATIVE TRACTION. COLUNA/COLUMNA 2022. [DOI: 10.1590/s1808-185120222103262614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objectives: To compare the surgical treatment of neuromuscular scoliosis (NMS) with and without intraoperative skull-skeletal traction (ISST) in terms of the degree of curve correction, surgical time, hospitalization time, screw density, use of blood products,and complications. Methods: A comparative retrospective study, in which we analyzed the medical records and radiographs of 17 patients who underwent surgical treatment for neuromuscular scoliosis (NMS). They were divided into two groups, with 9 and 8 patients operated with and without ISST, respectively, at a referral hospital specialized in the treatment of spinal deformitiesfrom 2019 to 2021. The categorical variables were analyzed using the Chi-squared test. Results: Among the 17 patients included in the study, there was a higher prevalence of women in the group without ISST (6 and 2) and of men in group with ISST (5 and 3). The ages of the patients in the two groups ranged from 8-19 years and from 11-29 years, respectively. The screw density used in the traction group averaged 66.33%±8.49 and 82.63%±17.25 in the non-traction group, a statistically significant differencewith a P-value of 0.036. The average percent correction was 76.81%±15.61 in the traction group as compared to an average of 66.39%±12.99 in the non-traction group. In addition, there were complications in 1 patient in each of the groups. Conclusions: Surgical treatment for NMS with ISST allows surgery using fewer blood products to maintain the same hematimetric level in the postoperative period. ISST also allows the use of a lower screw density to correct more severe deformities. Level of evidence III; Comparative retrospective study.
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13
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Douleh DG, Greig D, Thompson R, Garg S. When Should Instrumentation to the Pelvis be Considered in Minimally Ambulatory Adolescents With Neuromuscular Scoliosis? J Pediatr Orthop 2021; 41:S53-S58. [PMID: 34096538 PMCID: PMC10364839 DOI: 10.1097/bpo.0000000000001821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The goal of neuromuscular scoliosis (NMS) surgery is to improve sitting balance, facilitate daily care, and alleviate pain. In nonambulatory patients, where sitting balance is key, fusion to the pelvis is usually required. However, in minimally ambulatory patients, fusion to the pelvis remains controversial, and there is considerable practice variability in this patient population. The purpose of this study is to evaluate and summarize the available evidence regarding fusion constructs in minimally ambulatory patients with NMS and to provide expert opinion regarding when fusion to the pelvis should be considered. METHODS A search of the English literature was performed using PubMed to identify papers pertaining to patients with NMS treated with instrumented posterior spinal fusion. Papers published before 2000, case reports, and level V evidence were excluded. RESULTS The authors identified 8 studies for review. The majority included both nonambulatory and minimally ambulatory patients. Structured review of the literature demonstrated fusion to the pelvis may allow for greater curve and pelvic obliquity correction, but it is also associated with increased blood loss and operative time. There is no evidence that fusing to the pelvis decreases ambulatory status in minimally ambulatory patients. CONCLUSIONS In minimally ambulatory patients with NMS, fusion short of the pelvis may be considered in patients with adequate head control without the presence of hip subluxation or dislocation and when pelvic obliquity is <15 degrees. Fusion to the pelvis is recommended in patients who do not meet these criteria.
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Affiliation(s)
- Diana G. Douleh
- Department of Orthopedics, Anschutz Medical Campus, Aurora, CO
| | - Danielle Greig
- Department of Orthopedics, University of California Los Angeles, Los Angeles, CA
| | - Rachel Thompson
- Department of Orthopedics, University of California Los Angeles, Los Angeles, CA
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14
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Faldini C, Viroli G, Fiore M, Barile F, Manzetti M, Merlini L, Ruffilli A. Surgical treatment of scoliosis in Ullrich Congenital Muscular Dystrophy: a case series of 3 patients. Intractable Rare Dis Res 2021; 10:75-80. [PMID: 33996351 PMCID: PMC8122316 DOI: 10.5582/irdr.2020.03162] [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] [Indexed: 11/05/2022] Open
Abstract
Scoliosis in Ullrich Congenital Muscular Dystrophy (UCMD) is very common, with a reported incidence of more than 50%, and it is rapidly progressive. There are no previous studies which specifically focus on scoliosis surgery in UCMD patients. This article reports three cases of scoliosis surgery in UCMD, focusing on operative course, clinical and radiological results achieved, fusion area and complications, with a 2-year follow-up. The surgical technique adopted for vertebral arthrodesis included: high-density pedicle screw systems, asymmetric rods contouring and direct vertebral rotation. The summary results shown a significative correction of the coronal deformity, with a reduction of the mean Cobb angle from 49° to 25° post-operatively. Mean pelvic tilt remained stable, while L5-tilt showed a decrease from 10° to 6°. Mean screw density was 1.92. None of the patients required extended fixation to S2. No major complications were reported, and patients maintained their pre-operative walking ability. All the patients reported a subjective improvement in quality of life, with a better sitting comfort. In conclusion, posterior spinal fusion with high-density pedicle screw systems and direct vertebral rotation may be safe and effective in surgical correction of scoliosis in UCMD. If pelvic obliquity and L5-tilt are less than 15°, could be possible to achieve an optimal spinal and pelvic balance even without sacral or pelvic fixation.
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Affiliation(s)
- Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli (IOR), Bologna, Italy
| | - Giovanni Viroli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli (IOR), Bologna, Italy
| | - Michele Fiore
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli (IOR), Bologna, Italy
- Address correspondence to:Michele Fiore, 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli (IOR), via G. C. Pupilli 1, 40136, Bologna, Italy. E-mail:
| | - Francesca Barile
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli (IOR), Bologna, Italy
| | - Marco Manzetti
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli (IOR), Bologna, Italy
| | - Luciano Merlini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Alberto Ruffilli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli (IOR), Bologna, Italy
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15
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Intraoperative traction in neuromuscular scoliosis surgery improves major curve correction when fusing to L5. Spine Deform 2021; 9:769-776. [PMID: 33464552 DOI: 10.1007/s43390-020-00268-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intraoperative traction has shown improved curve correction in neuromuscular scoliosis surgery. It is found to be superior to anterior release in terms of correction of both main curve and pelvic obliquity. No previous study has examined the effect of intraoperative traction in patients without pelvic fixation. METHOD This retrospective study included 40 non-ambulatory (GMFCS 4 or above) patients with neuromuscular scoliosis undergoing surgery with bilateral segmental pedicle screw instrumentation to L5. Twenty-two consecutive patients had intraoperative Gardner-Wells tongs and skin traction (traction group), while the remaining did not (non-traction group). Inclusion criteria were minimum 2-year follow-up, complete medical records and radiographs. Main curve (MC), pelvic obliquity (POB), T1 tilt, kyphosis, rotation, coronal and sagittal balance and preoperative bending radiographs were measured and analyzed in all patients. RESULTS Both groups demonstrated roughly 60% MC correction. Preoperative MC was larger in the traction group [97° (49-126) vs. 83° (40-134); P = 0.03]. The measured correction index was almost twice as large in the traction group (1.9 vs. 1.1; P = 0.001). Mean [IQR] 2-year POB was 14° [7-40] in the traction group compared to 16° [4-60] in the non-traction group (P = 0.59). Eleven patients (50%) in the traction group compared to only four (22%) in the non-traction group had a POB within 10° at 2-year follow up (RR: 2.1; 95% CI 0.8-5.2). We found no difference in kyphosis or remaining radiographic parameters. No traction-related complications were recorded. CONCLUSION In patients with neuromuscular scoliosis undergoing instrumented fusion to the L5, we found that intraoperative traction increased the degree of MC correction and patients were more likely to achieve POB below 10° without any effects on sagittal parameters or without any detectable significant reduction on rotation.
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16
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Metoki Y, Iwase D, Fukushima K, Uchiyama K, Saito W, Takaso M. Hip Dislocation After Correction for Scoliosis in an Adolescent with Angelman Syndrome: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00042. [PMID: 33878039 DOI: 10.2106/jbjs.cc.20.00959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Although scoliosis is common in Angelman syndrome (AS), there are no reports of hip dislocation as a complication of scoliosis surgery. We experienced a case of hip dislocation after posterior spinal instrumentation and fusion from T4 to L5 because of scoliosis progression in an adolescent girl with AS. Postoperatively, posterior dislocation of the left hip occurred; after closed reduction, instability remained. Thus, periacetabular osteotomy was performed (left hip), with good clinical outcomes. CONCLUSION Especially in cases of abnormal muscle tone, a loss of spinal flexibility because of extensive spinal fixation may result in secondary pathologies of the hip joint.
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Affiliation(s)
- Yukie Metoki
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara City, Kanagawa, Japan
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Saito W, Inoue G, Shirasawa E, Imura T, Nakazawa T, Miyagi M, Kawakubo A, Uchida K, Kotani T, Akazawa T, Takaso M. Limitations of posterior spinal fusion to L5 for flaccid neuromuscular scoliosis focusing on pelvic obliquity. Spine Deform 2021; 9:559-565. [PMID: 33006744 DOI: 10.1007/s43390-020-00214-1] [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: 06/13/2020] [Accepted: 09/21/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective comparison based on the degree of pelvic obliquity (PO). PURPOSE To assess the controversial indications for and limitations of ending the instrumentation for posterior spinal fusion (PSF) at L5 in patients with flaccid neuromuscular scoliosis (fNMS). METHODS We reviewed the cases of 45 patients with progressive spinal deformity as a result of fNMS treated by PSF to L5 and followed for an average of 4 years postoperatively with adequate clinical and radiological data. Anterior-posterior and lateral whole spine radiographs were evaluated. We divided patients into two groups based on the degree of pelvic obliquity (PO) at the final follow-up. Radiographic data from the two groups were analyzed to identify the indications and limitations of this surgical method focusing on PO. RESULTS Preoperatively, there were significant differences between the two groups in Cobb angle, PO, thoracolumbar kyphosis, and lumbar lordosis (LL) while sitting; Cobb angle and LL while supine (Supine Cobb, and Supine LL); and major curve flexibility. Multivariate logistic regression analysis identified Supine Cobb and Supine LL as independent risk factors for residual PO at the final follow-up (Supine Cobb: odds ratio, 1.1; 95% confidence interval 1.0-1.2, Supine LL: odds ratio, 0.9; 95% confidence interval 0.8-1.0). CONCLUSION Patients with larger preoperative Cobb angle and smaller LL while supine may not achieve adequate spine and pelvic correction and this may lead to deterioration in the PO over time, even after spinal fusion ending at L5.
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Affiliation(s)
- Wataru Saito
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Eiki Shirasawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Takayuki Imura
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Toshiyuki Nakazawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masayuki Miyagi
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Ayumu Kawakubo
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Kentaro Uchida
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Toshiaki Kotani
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tsutomu Akazawa
- Department of Orthopedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
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18
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Stiel N, Özden J, Ridderbusch K, Moritz M, Kunkel P, Gulati A, Hagemann C, Mladenov K, Stuecker R, Spiro AS. Pedicle screw instrumentation with or without pelvic fixation in neuromuscular scoliosis: Outcome and complications in a series of 37 patients with a minimum 2-year follow-up. Surgeon 2020; 18:e7-e12. [DOI: 10.1016/j.surge.2019.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/20/2019] [Accepted: 11/24/2019] [Indexed: 11/30/2022]
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Tøndevold N, Lastikka M, Andersen T, Gehrchen M, Helenius I. Should instrumented spinal fusion in nonambulatory children with neuromuscular scoliosis be extended to L5 or the pelvis? Bone Joint J 2020; 102-B:261-267. [DOI: 10.1302/0301-620x.102b2.bjj-2019-0772.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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. Methods In all, 91 nonambulatory patients with neuromuscular scoliosis were included. All underwent surgery using bilateral, segmental, pedicle screw instrumentation. A total of 40 patients underwent fusion to L5 and 51 had their fixation extended to the pelvis. The two groups were assessed for differences in terms of clinical and radiological findings, as well as complications. Results The main curve (MC) was a mean of 90° (40° to 141°) preoperatively and 46° (15° to 82°) at two-year follow-up in the L5 group, and 82° (33° to 116°) and 19° (1° to 60°) in the pelvic group (p < 0.001 at follow-up). Correction of MC and pelvic obliquity (POB) were statistically greater in the pelvic group (p < 0.001). There was no statistically significant difference in the operating time, blood loss, or complications. Loss of MC correction (> 10°) was more common in patients fixated to the pelvis (23% vs 3%; p = 0.032), while loss of pelvic obliquity correction was more frequent in the L5 group (25% vs 0%; p = 0.007). Risk factors for loss of correction (either POB or MC) included preoperative coronal imbalance (> 50 mm, odds ratio (OR) 11.5, 95%confidence interval (CI) 2.0 to 65; p = 0.006) and postoperative sagittal imbalance (> 25 mm, OR 11.0, 95% CI1.9 to 65; p = 0.008). Conclusion We found that patients undergoing pelvic fixation had a greater correction of MC and POB. The rate of complications was not different. Preoperative coronal and postoperative sagittal imbalance were associated with increased risks of loss of correction, regardless of extent of fixation. Therefore, we recommend pelvic fixation in all nonambulatory children with neuromuscular scoliosis where coronal or sagittal imbalance are present preoperatively. Cite this article: Bone Joint J 2020;102-B(2):261–267.
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Affiliation(s)
- Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Markus Lastikka
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Thomas Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ilkka Helenius
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
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20
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Schur M, Andras LM, Murgai R, Siddiqui AA, Gonsalves NR, Sponseller PD, Emans JB, Vitale MG, Skaggs DL. Pelvic Obliquity Correction in Distraction-Based Growth Friendly Implants. Spine Deform 2019; 7:985-991. [PMID: 31732012 DOI: 10.1016/j.jspd.2019.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 02/25/2019] [Accepted: 03/15/2019] [Indexed: 11/17/2022]
Abstract
DESIGN Multicenter retrospective review. OBJECTIVE To evaluate radiographic outcomes and complication rates of patients treated with distraction based implants and pelvic fixation with either screws (sacral-alar-iliac [SAI] screws or iliac screws) or hooks (S hook iliac fixation). SUMMARY OF BACKGROUND DATA Multiple options exist for pelvic fixation in distraction-based growing rod systems; however, limited comparative data are available. METHODS Early-onset scoliosis (EOS) patients of all diagnoses with distraction-based implants that had pelvic fixation from 2000 to 2013 were reviewed from two EOS multicenter databases. Patients were divided into two groups by type of pelvic fixation: (1) screw group (SAI screws or iliac screws) or (2) S hooks. Exclusion criteria were as follows: index instrumentation ≥10 years old and follow up <2 years. A total of 153 patients met the inclusion criteria. Mean age at index surgery was 6.1 years (range 1.0-9.9 years) and mean follow-up was 4.9 years. RESULTS Pelvic fixation in the 153 patients was as follows: screw group = 42 and S hook group = 111. When comparing patients with >20° of initial pelvic obliquity, the screw group had significantly more correction; mean 26° ± 13° for the screw group versus mean 17° ± 7° in the S hook group (p = .039). There was no significant difference in change in T1-S1 length (40 vs. 39 mm, p = .89) or correction of Cobb angle (30° vs. 24°, p = .24). The total complication rate for the screw group was 14% (6/42) versus 25% (28/111) in the S hook group, though this did not achieve significance (p = .25). The most common complications were device migration (13), implant failure (8), and implant prominence (4) for S hooks and implant failure (3), implant prominence (2), and device migration (1) for the screw group. CONCLUSION In distraction-based growth-friendly constructs, pelvic fixation with screws achieved better correction of pelvic obliquity than S hooks. Complications were almost twice as common with S hooks than screws, though this did not reach statistical significance.
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Affiliation(s)
- Mathew Schur
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Rajan Murgai
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Ali A Siddiqui
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Nicholas R Gonsalves
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Paul D Sponseller
- Division of Pediatric Orthopaedics, Johns Hopkins Children's Center, 1800 Orleans St, Baltimore, MD 21287, USA
| | - John B Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Michael G Vitale
- Columbia University Medical Center, Morgan Stanley Children's Hospital of New York - Presbyterian, 3959 Broadway, New York, NY 10032, USA
| | - David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA.
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The modified Kostuik transilial bar technique has acceptable results in neuromuscular spinal deformity correction. J Pediatr Orthop B 2019; 28:385-392. [PMID: 30855544 DOI: 10.1097/bpb.0000000000000626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study is to evaluate the results of the modified Kostuik transilial bar technique for neuromuscular scoliosis (NS). We reviewed the records of 21 patients treated for NS with this instrumentation. There were 14 females and seven males, with an average age of 15.6 years (range: 9-21 years). We determined patients' demographics, correction ratio of both curve and pelvic obliquity, loss of correction, screw loosening at first sacral vertebra, and clinical outcomes. Mean follow-up was 56 months (range: 34-96 months). There were no reoperations, no screw breakage, and no significant loss of correction. The mean preoperative coronal Cobb angle was 71.4°±8.7°, the initial postoperative measurements had a mean Cobb angle of 19.2°±7.2°, and at the last follow-up, the mean Cobb angle was 23.6°±6.9° (P<0.001). Pelvic obliquity decreased from 27.7°±12.4° to 9.1°±5.3° at follow-up and to 11.9°±6.3° at the last follow-up (P<0.001). The preoperative pelvic obliquity angle was significantly higher at the patients with screw loosening (P=0.016). There was one established as well as one possible pseudoarthrosis in our patients. The new technique does appear to possibly become an alternative to conventional lumbosacral fixation techniques. Integration of the bar with pipe-type connector onto the long spinal instrumentation with oblique connectors can prevent the most unenviable complications such as wide exposure, hardware prominence, reoperation, and pseudoarthrosis.
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Brasil Neto CG, Ávila LM, Grimm DH, Aguiar CAD, Rocha LEMD. USE OF ALAR-ILIAC S2 SCREW TECHNIQUE IN SCOLIOSIS SECONDARY TO MYELOMENINGOCELE. COLUNA/COLUMNA 2019. [DOI: 10.1590/s1808-185120191802195897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: To evaluate retrospectively the results related to the use of pelvic fixation with alar-iliac S2 screw in individuals with myelomeningocele. Methods: Retrospective study of cases surgically treated with this technique, between January 2015 and March 2018 at the Pequeno Principe Children's Hospital. Radiographic images and clinical records were analyzed in search of complications. Results: Twelve patients with mean age of 13.3 years were treated at the time of surgery. The mean follow-up was 11.5 months. The mean of the highest magnitude curve measured by the Cobb angle in the preoperative period was 83.8°; while in the last postoperative follow-up was 29.5° (correction of 65%). The mean pelvic obliquity was 23.1° in the preoperative period and in the postoperative was 7.1° (correction of 69%). Only 2 cases (17%) with complications associated with material failure at the level of sacroiliac fixation, due to the unilateral release of the head of the polyaxial S2 iliac screw. Conclusions: The technique of pelvic fixation in the scoliosis secondary to myelomeningocele with the use of S2 alar-iliac screws has shown satisfactory results, with only two complications (17%) directly related to pelvic fixation in the operated cases. Level of Evidence IV; Series of Cases.
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Affiliation(s)
- Coracy Gonçalves Brasil Neto
- Hospital Evangélico de Curitiba, Brazil; Hospital Infantil Pequeno Príncipe, Brazil; Hospital São Vicente de Curitiba, Brazil
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Abstract
STUDY DESIGN Retrospective study of prospectively collected data. OBJECTIVE To identify risk factors for the development of any major complication after elective posterior lumbar fusion (PLF). SUMMARY OF BACKGROUND DATA PLF is one of the most performed fusion techniques with utilization rates increasing by 356% between 1993 and 2001. Surgical and anesthetic advances have made the option of surgery more accessible for elderly patients with a larger comorbidity burden. Identifying risk factors for the development of major complications after elective PLF is important for patient risk stratification and patient safety efforts. METHODS The 2011 to 2014 American College of Surgeon's National Surgical Quality Improvement Program database was queried using Current Procedural Terminology codes 22612, 22630, and 22633. Patients were divided into two cohorts based on the development of any major complication. Bivariate and multivariate logistic regression analyses were employed to identify predictors for the development of ≥ 1, ≥ 2, and ≥ 3 major complications. RESULTS A total of 7761 patients met the inclusion criteria for the study of which, 2055 (26.5%) patients developed one major complication, 249 (3.2%) patients developed two major complications, and 151 (1.9%) patients developed three major complications. The most common complication was intra/postoperative red blood cell transfusion (23.2%). Three multivariate logistic regression models were employed to identify factors associated with ≥ 1, ≥ 2, and ≥ 3 major complications. Patient variables present across all three models were osteotomy, pelvic fixation, operation time ≥4 hours, bleeding disorder, and American Society of Anesthesiology Class ≥ 3. CONCLUSION Several risk factors were identified for the development of major complications after elective PLF. Identification of these factors can improve the selection of appropriate surgical candidates, patient risk stratification, and patient postoperative safety. LEVEL OF EVIDENCE 3.
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The Thoracic Lordosis Correction Improves Sacral Slope and Walking Ability in Neuromuscular Scoliosis. Clin Spine Surg 2016; 29:E413-20. [PMID: 27171667 DOI: 10.1097/bsd.0b013e318294368e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To report on neuromuscular patients with preserved walking ability, but forward bending of the body due to thoracic lordosis, and to suggest thoracic lordosis correction as the surgical treatment. SUMMARY OF BACKGROUND DATA It is an established fact that lumbar lordosis or pelvic parameter is directly related to thoracic sagittal balance. However, the reverse relationship has not been fully defined yet. Loss of thoracic kyphosis results in positive sagittal balance, which causes walking difficulty. Neuromuscular patients with thoracic lordosis have not been reported yet, and there have been no reports on their surgical treatments. METHODS This study analyzed 8 patients treated with thoracic lordosis correction surgery. Every patient was diagnosed with muscular dystrophy. In thoracic lordosis correction surgery, anterior release was performed in the first stage and posterior segmental instrumentation was performed in the second stage. Radiographic parameters were compared and walking ability was evaluated with gait analysis. All patients were classified according to the modified Rancho Los Amigos Hospital system preoperatively and 2 years postoperatively to evaluate functional ability. The average follow-up period was 2.9 years. RESULTS Before surgery, the mean thoracic sagittal alignment was -2.1-degree lordosis, the mean Cobb angle and sacral slope increased to 36.3 and 56.6 degrees, respectively. The anterior pelvic tilt in gait analysis was 29.3 degrees. At last follow-up after surgery, the mean thoracic sagittal alignment changed to 12.6-degree kyphosis, and the Cobb angle and sacral slope decreased to 18.9 and 39.5 degrees, respectively. Lumbar lordosis and the sacral slope showed significant positive correlation (P<0.001). The improvement in thoracic lordosis showed a significant correlation to the preoperative flexibility of the major curve (P=0.028). The anterior pelvic tilt in gait analysis improved to 15.4 degrees. The functional ability improved in 2 (50%) of 4 patients in class 2 and maintained in remaining 6 patients 2 years after surgery. CONCLUSIONS Thoracic lordosis correction surgery in neuromuscular scoliosis patients with thoracic lordosis improved the sacral slope in the standing position and the anterior pelvic tilt in gait. Sagittal imbalance was compensated by the spinopelvic mechanism, and back and hip extensor muscles seem to play a major role in this compensation.
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Moghimi MH, Reitman CA. Perioperative complications associated with spine surgery in patients with established spinal cord injury. Spine J 2016; 16:552-7. [PMID: 24952256 DOI: 10.1016/j.spinee.2014.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 04/23/2014] [Accepted: 06/11/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Only a small percentage of patients with spinal cord injury (SCI) require consideration for reconstructive surgery after their initial injury. For those who do, perioperative complications can be frequent and significant. There has been very little published literature examining treatment of these patients and essentially nothing to guide the surgeon in perioperative decision making and management. PURPOSE To identify some of the common challenges associated with surgery in this patient population and review the literature to highlight the perioperative concerns in patients with chronic SCI. STUDY DESIGN Review article. METHODS A primary PubMed literature search was performed and reviewed for patients with chronic SCI with emphasis on the complications and difficulties encountered during surgical treatment of patients with chronic SCI. RESULTS For those who do proceed with surgery in this patient population, preoperative nutrition, bone density, and skin should be evaluated and optimized. Preoperative inferior vena cava filters should be considered. The integrity of the reconstruction will be extensively challenged. In addition, augmented fixation and bracing should be contemplated. CONCLUSIONS Patients with chronic SCI who require spinal reconstruction provide many unique challenges. Indications for surgery must be strong as perioperative complications can be frequent and long-term outcomes unpredictable. Close monitoring for postoperative complications is essential.
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Affiliation(s)
- Michael H Moghimi
- Department of Orthopedic Surgery, Baylor College of Medicine, 6620 Main St, Ste 1325, Houston, TX 77030, USA
| | - Charles A Reitman
- Department of Orthopedic Surgery, Baylor College of Medicine, 7200 Cambridge, Floor 10A, Houston, TX 77030, USA.
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Nedelcu T, Georgescu I. Evaluation of the Unit Rod surgical instrumentation in Duchenne scoliosis. A retrospective study. J Med Life 2016; 9:437-443. [PMID: 27928452 PMCID: PMC5141408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The article represents a retrospective clinical and radiological study. Objectives. Evaluating the safety and efficiency of the surgical treatment by using the Unit Rod for scoliosis in adolescents and children presenting Duchenne's muscular dystrophy. Summary. Surgical management of myopathic scoliosis still causes controversies regarding the timing of surgery (patient's age), the pelvic inclusion in the arthrodesis or the advantages of surgery over the conservatory treatment. The patients are very fragile and a long surgery with massive blood loss could lead to serious complications. Unit Rod instrumentation is simple, confers excellent stability and has a low rate of complications. Methods. This is a retrospective clinical and radiological study with a medium follow-up of 6.9 years including 13 patients diagnosed with Duchenne myopathy. All investigated patients were non-ambulatory at the time of surgery and have been treated by the Unit Rod technique at the University Hospital of Rouen between 2002 and 2008. Spinal fusion was, in all cases, realized from T2 to pelvis. Galveston technique of pelvic fixation and Luque's sublaminar wire instrumentation of the spine were used. Results. The results obtained with this treatment and post-surgery complications were analyzed and compared with those from literature. The advantages of this technique consist mostly in a good and stable pelvic fixation, a short interventional time, a minimal blood loss and few complications. Cobb angle correction is similar to that obtained by other surgical procedures. Conclusions. Using the Unit Rod instrumentation of scoliosis in Duchenne's muscular dystrophy is safe, has excellent outcomes, brings post-surgery improvements, and has minor intra and post-surgery complications. The low cost of this treatment could make it a first choice for medical health systems with financial problems.
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Affiliation(s)
- T Nedelcu
- Paediatric Orthopaedics Department, General Hospital, Le Havre, France
| | - I Georgescu
- Paediatric Orthopaedics Department, Paediatric Physical Rehabilitation Centre
Bois Larris, Lamorlaye, France
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Cheuk DKL, Wong V, Wraige E, Baxter P, Cole A, Cochrane Neuromuscular Group. Surgery for scoliosis in Duchenne muscular dystrophy. Cochrane Database Syst Rev 2015; 2015:CD005375. [PMID: 26423318 PMCID: PMC7273403 DOI: 10.1002/14651858.cd005375.pub4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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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Cawley DT, Carmody O, Dodds MK, McCormack D. Early limited instrumentation of scoliosis in Duchenne muscular dystrophy: is a single-rod construct sufficient? Spine J 2015; 15:2166-71. [PMID: 26070283 DOI: 10.1016/j.spinee.2015.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 05/02/2015] [Accepted: 06/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Correction of scoliotic deformity in Duchenne muscular dystrophy (DMD) is performed to maintain adequate seating posture and facilitate comfort. Delaying surgery can predispose to greater morbidity as DMD exhibits progressive cardiorespiratory compromise. Early limited instrumentation may provide a solution to optimize patients with this condition. PURPOSE The aim was to assess outcomes for a cohort of DMD patients who had posterior single-rod instrumentation and bilateral spinal fusion of their neuromuscular scoliotic deformity. STUDY DESIGN This was a retrospective cohort study. PATIENT SAMPLE Forty-one consecutive patients were included. OUTCOME MEASURES Perioperative morbidity, seating outcomes, pulmonary function, deformity correction, and instrumentation integrity were assessed. METHODS Clinical and radiographic review was performed. RESULTS No perioperative mortality or neurologic deterioration was encountered. Total surgical time was 96 minutes, mean total blood loss was 2.3l, mean intensive care unit stay was 41 hours, and overall length of stay was 11 days. Mean Cobb angle improved from 24.3° to 15.6°, pelvic obliquity improved from 7° preoperatively to 5° postoperatively. Three patients had failure of fixation at a mean of 3.5 years. Forced vital capacity was 60% preoperatively and 56% at 1 year, forced expiratory volume/1 second was 67% and 62% at 1 year postoperatively. Seating and posture was satisfactory in all these patients. CONCLUSIONS The authors advocate early operative intervention using a limited instrumentation technique in patients with DMD to maintain seating balance and minimize perioperative morbidity.
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Affiliation(s)
- Derek T Cawley
- Department of Trauma & Orthopaedic Surgery, The Children's University Hospital, Temple St, Dublin 1, Ireland
| | - Olan Carmody
- Department of Trauma & Orthopaedic Surgery, The Children's University Hospital, Temple St, Dublin 1, Ireland
| | - Michael K Dodds
- Department of Trauma & Orthopaedic Surgery, The Children's University Hospital, Temple St, Dublin 1, Ireland
| | - Damian McCormack
- Department of Trauma & Orthopaedic Surgery, The Children's University Hospital, Temple St, Dublin 1, Ireland.
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Desrochers-Perrault F, Aubin CE, Wang X, Schwend RM. Biomechanical analysis of iliac screw fixation in spinal deformity instrumentation. Clin Biomech (Bristol, Avon) 2014; 29:614-21. [PMID: 24906687 DOI: 10.1016/j.clinbiomech.2014.04.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 03/28/2014] [Accepted: 04/28/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND High rates of iliac screw fixation failures have been reported in spinopelvic instrumentations. The objective was to assess the iliac screw loads as functions of instrumentation variables. METHODS Spinopelvic instrumentations of six neuromuscular scoliosis were simulated using patient-specific modeling techniques to evaluate the intra- and postoperative iliac screw loads as functions of instrumentation variables: the combined use of sacral screws, the uses of lateral offset connectors and cross-rod connectors, and the iliac screw insertion point and trajectory. FINDINGS Sacral screws, lateral connectors and the iliac screw insertion point had significant effects on iliac screw axial forces (69-297N) and toggle moments (0.8-2.9Nm) (p<0.05). The addition of sacral screws made the iliac screw forces lower for some functional loads but higher for other functional loads, and resulted in an increase of intraoperative screw forces when attaching the rods onto these additional screws. When lateral offset connectors were used, the toggle moments were 16% and 25% higher, respectively for the left and right sides. Inserting iliac through the sacrum resulted in 17% lower toggle moment compared to insertion through the iliac crest. Cross-rod connectors had no significant effect on the intraoperative iliac screw forces. Postoperative functional loading had an important effect (additional 34% screw axial force and 18% toggle moment). INTERPRETATION It is possible to reduce the iliac screw loads by adapting instrumentation variables and strategies. Reducing the loads could decrease the risk of failure associated with iliac screw fixations.
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Affiliation(s)
- Frederique Desrochers-Perrault
- Polytechnique Montreal, Department of Mechanical Engineering, P.O. Box 6079, Station "Centre-ville", Montreal, Quebec H3C 3A7, Canada; Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada
| | - Carl-Eric Aubin
- Polytechnique Montreal, Department of Mechanical Engineering, P.O. Box 6079, Station "Centre-ville", Montreal, Quebec H3C 3A7, Canada; Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada.
| | - Xiaoyu Wang
- Polytechnique Montreal, Department of Mechanical Engineering, P.O. Box 6079, Station "Centre-ville", Montreal, Quebec H3C 3A7, Canada; Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada
| | - Richard M Schwend
- Children's Mercy Hospital, 2401, Gillham Rd., Kansas City, MO 64108, USA
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Effects of surgical correction of neuromuscular scoliosis on gastric myoelectrical activity, emptying, and upper gastrointestinal symptoms. J Pediatr Gastroenterol Nutr 2014; 58:38-45. [PMID: 23942003 DOI: 10.1097/mpg.0b013e3182a7dac4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Gastrointestinal complications are frequent after surgical correction of neuromuscular scoliosis, but the effects of scoliosis surgery on gastric function and upper gastrointestinal symptoms over the long term are unknown. METHODS Thirty-one children (16 spastic, 15 flaccid patients) who underwent surgical correction of neuromuscular scoliosis were included in a prospective follow-up study. Median (range) age at surgery was 14.9 (5-20) years and follow-up time 4.3 (2-8) years. Electrogastrography (n=28), gastric emptying scintigraphy (n=17), and structured upper gastrointestinal symptoms questionnaire (n=26) were evaluated before and after surgery. The results were related to patients' clinical state, type and extent of corrective spinal surgery, and gastrointestinal complications. RESULTS The median main scoliosis curve of 81 degrees (51-129 degrees) was corrected to 25 degrees (1.0-85 degrees) after surgery. In electrogastrogram, power ratio increased from preoperative 1.4 (0.30-11) to postoperative 6.2 (1.2-26) in the spastic group (P=0.008), whereas in the flaccid group, power ratio remained unchanged at 2.2 (0.1-17). Patients with prolonged postoperative paralytic ileus had the most substantial increase in gastric power ratio (P=0.038). Correction of sagittal spinal balance correlated with increased postprandial normogastric activity after surgery (R=0.459; P=0.004). The gastric emptying results, upper gastrointestinal symptoms, and body mass index were not significantly altered after scoliosis surgery. CONCLUSIONS Gastric myoelectrical power increased after surgical correction of spastic neuromuscular scoliosis and was associated with prolonged postoperative paralytic ileus. Correction of poor, stooped spinal balance improved gastric myoelectrical activity. The net effect of scoliosis surgery on gastric emptying, upper gastrointestinal symptoms, and clinical nutritional state was minimal.
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Gressot LV, Patel AJ, Hwang SW, Fulkerson DH, Jea A. Iliac screw placement in neuromuscular scoliosis using anatomical landmarks and uniplanar anteroposterior fluoroscopic imaging with postoperative CT confirmation. J Neurosurg Pediatr 2014; 13:54-61. [PMID: 24266682 DOI: 10.3171/2013.10.peds13300] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Neuromuscular scoliosis is a challenging pathology to treat. Surgical correction can involve long fusion constructs extending to the pelvis. The deformity inherent in these patients makes it difficult to obtain adequate lateral intraoperative radiographs for traditional image-guided placement of iliac screws. METHODS A clinical and radiographic assessment of 14 patients with neuromuscular spinal deformity was conducted. From 2007 to 2013, 12 of these patients (mean age 14.25 years, range 10-20 years) underwent long spinal instrumentation (mean 15 levels, range 10-18 levels) and fusion to the pelvis, and 2 underwent placement of a growing rod construct with iliac screw placement at a single institution. The average length of follow-up was 33.7 months (range 6-64 months). Iliac screws were placed after identifying the posterior superior iliac spine and using only anteroposterior fluoroscopy (view of the inlet of the pelvis), rather than the technique of direct palpation of the sciatic notch. The accuracy of iliac screw placement was assessed with routine postoperative CT. RESULTS A total of 12 patients had 24 screws placed as part of a long-segment fusion to the pelvis, and 2 patients had two iliac screws placed as part of a growing rod construct for neuromuscular scoliosis. There were no iliac screw misplacements, and no complications directly related to the technique of iliac screw placement. For cases of definitive fusion (n = 12), the average coronal Cobb angle of patients with neuromuscular spinal deformity measured 62° before surgery and 44.3° immediately after surgery. The average preoperative thoracic kyphosis and lumbar sagittal lordosis measured 37.3° and 60.7°, respectively. Immediately after surgery, the thoracic and lumbar angles measured 30° and 41.1°, respectively. At last follow-up, the average coronal Cobb angle was maintained at 45.1°, and the thoracic and lumbar sagittal angles were maintained at 32.8° and 45.3°, respectively. CONCLUSIONS A less invasive technique for iliac screw placement can be performed safely with a low likelihood of screw misplacement. This technique offers the biomechanical advantages of iliac fixation without the soft tissue exposure typically needed for safe screw insertion. The technique relies on identification of the posterior superior iliac spine and high quality anteroposterior fluoroscopic imaging for a view of the pelvic inlet.
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Affiliation(s)
- Loyola V Gressot
- Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Multiaxial high-modularity spinopelvis (HMSP) fixation device in neuromuscular scoliosis: a comparative study. 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 2013; 23:543-9. [PMID: 24346017 DOI: 10.1007/s00586-013-3048-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 09/25/2013] [Accepted: 09/25/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare radiological and clinical results in patients operated for neuromuscular scoliosis with pelvic fixation using high-modularity spinopelvic screw (HMSP) designed by authors. METHODS Of 54 patients with neuromuscular scoliosis, group 1 comprised of 27 patients with conventional pelvic fixation; and group 2 comprised of 27 patients using HMSP. Results were evaluated radiologically and functionally. We compared preoperative and postoperative complications, especially the loosening or breakage of spinopelvis fixation device, failure of fixation, and the change of shadow around the spinopelvis fixation device. RESULTS There was no difference of correctional power, preoperative average Cobb's angle of each group was 79.8 and 75 to postoperative 30.2 and 28.3 (P < 0.05). Pelvic obliquity improved from average 18.3°-8.9° in group I and average 24.3°-12.5° in group II (P < 0.05). However, there was no difference between two groups (P > 0.05). Average blood loss was 2,698 ml in group 1 and 2,414.8 ml in group 2 (P > 0.05). Average operative time was 360 min in group 1 and 332 min in group 2 (P = 0.30). There was no difference found between two groups regarding gait and functional evaluation. On the all cases of group 1 and 2, the change of shadow around the spinopelvis fixation device was observed. There was one case of the fracture of spinopelvis fixation device in group I. CONCLUSION There was no difference of Cobb's angle and correctional power between the groups using HMSP when compared with the group using standard spinopelvis fixation device. Therefore, HMSP can be used more effectively in case of neuromuscular scoliosis.
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Abstract
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.
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Affiliation(s)
- Daniel K L Cheuk
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
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Abstract
BACKGROUND Correcting pelvic obliquity and improving sitting balance in neuromuscular scoliosis often requires fixation to the pelvis. We describe the use of a T square instrument to assist intraoperatively in evaluating the alignment of these curves and achieving balance in the coronal plane. METHODS The T square instrument was constructed with a vertical limb perpendicular to 2 horizontal limbs in a T formation. At the conclusion of the instrumentation and preliminary reduction maneuvers, the T square was positioned with the horizontal limbs parallel to the pelvis and the vertical limb in line with the central sacral line. If the spine and pelvis were well balanced, fluoroscopic images demonstrated that the superior aspect of the vertical limb of the T square was crossing the vertebral body of T1. If this was not shown, then some combination of compression, distraction, or a change in the contouring of the rods was performed until this balance was achieved. RESULTS In this series, we describe case examples in which the T square has been successfully used to aid in achieving balance in the coronal plane. This technique helps to overcome the challenges with positioning and imaging often encountered in managing these long, rigid curves. The T square is a useful adjunct in balancing posterior spinal fusions and evaluating the correction of pelvic obliquity in cases of neuromuscular scoliosis. CONCLUSIONS This novel, yet simple, T square technique can be used for any method of posterior spinal fusion with lumbopelvic fixation to assist in the intraoperative evaluation and achievement of balance in the coronal plane and has become routine at our institution. LEVEL OF EVIDENCE IV.
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Dayer R, Ouellet JA, Saran N. Pelvic fixation for neuromuscular scoliosis deformity correction. Curr Rev Musculoskelet Med 2012; 5:91-101. [PMID: 22430864 DOI: 10.1007/s12178-012-9122-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Pelvic fixation is most frequently indicated in the pediatric population for the treatment of neuromuscular scoliosis with significant pelvic obliquity. Neuromuscular scoliosis surgery is associated with a high risk of complications, and this is further increased by extension of fusion to the sacrum. Numerous techniques have been described for pelvic fixation associated with a long spine fusion each with its own set of specific benefits and risks. This article reviews the contemporary surgical techniques of pelvic fixation used to extend a spine fusion to the sacrum and pelvis focusing on the management of neuromuscular scoliosis, including their biomechanical rationale, results, and complications.
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Affiliation(s)
- Romain Dayer
- Division of Pediatric Orthopaedics, Child and Adolescent Department, University Hospitals of Geneva, Rue Willy Donzé 6, 1211, Genève 14, Switzerland,
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Abstract
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.
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Zahi R, Vialle R, Abelin K, Mary P, Khouri N, Damsin JP. Spinopelvic fixation with iliosacral screws in neuromuscular spinal deformities: results in a prospective cohort of 62 patients. Childs Nerv Syst 2010; 26:81-6. [PMID: 19629492 DOI: 10.1007/s00381-009-0966-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Redoine Zahi
- Department of Paediatric Orthopaedics, Armand Trousseau Hospital, Pierre and Marie Curie Paris6 University, Paris Cedex 12, France
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Cheuk DKL, Wong V, Wraige E, Baxter P, Cole A, N'Diaye T, Mayowe V. Surgery for scoliosis in Duchenne muscular dystrophy. Cochrane Database Syst Rev 2007:CD005375. [PMID: 17253553 DOI: 10.1002/14651858.cd005375.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- D K L Cheuk
- University of Hong Kong, Department of Pediatrics and Adolescent Medicine, Pokfulam Road, Hong Kong, China.
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