Correction Of Pelvic Obliquity Research Articles

Hip reduction surgery versus scoliosis correction in non-ambulant neuromuscular patients: which surgery is the first step?

Children and young adults with neuromuscular disorders have a high incidence of both spine and hip deformities. The aim of this study was to evaluate the outcome of either primary scoliosis or hip surgery in children and young adults with neuromuscular disorders. A retrospective study was conducted on all children and young adults with neuromuscular-related synchronous hip subluxation/dislocation and scoliosis undergoing hip or scoliosis surgery in our institution between 2012 and 2021 with a minimum follow-up of 24months. Demographic and operative data were collected; radiological parameters were measured preoperatively and postoperatively at final follow-up. Forty neuromuscular patients with synchronous hip displacement and scoliosis were included. Twenty patients with an average age of10.2years had hip correction surgery performed primarily, with a mean follow-up of 54.9 (24-96)months. The other 20 patients with an average age of 12.4years had scoliosis correction first, with a mean follow-up of 40 (24-60)months. In the "Hip first" group, pelvic obliquity, hip MP and Cobb angle were 16.8°, 71%, and 49°, respectively. At final follow-up, the mean pelvic obliquity and Cobb angles significantly progressed to 27.2° (p = 0.003) and 82.2° (p = 0.001), respectively. Eighteen patients (90%) required scoliosis correction after the hip surgery. In the "Scoliosis first" group, the mean pelvic obliquity, hip MP and Cobb angle were 21.2°, 49% and 65.5°, respectively. At final follow-up, both pelvic obliquity and Cobb angle significantly improved to 8.44° (p = 0.002) and 23.4° (p = 0.001), respectively. In 11/20 (55%) patients, the hip MP had significantly increased following the spinal surgery to 62% (p = 0.001), but only 5/20 (25%) patients underwent hip surgery after scoliosis correction. In neuromuscular patients presenting with synchronous hip displacement and scoliosis deformity, corrective scoliosis surgery is associated with a significant correction of pelvic obliquity and lower rates of secondary hip surgery. On the other hand, primary hip surgery does not reduce the risk of pelvic obliquity and scoliosis deformity progression.

Distal fusion level, complications, and reoperations in individuals with cerebral palsy undergoing surgery for scoliosis.

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. 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. 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). Maintained curve and pelvic obliquity correction with no significant difference in complication and reoperation rates were found irrespective of distal fusion level.

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

Nonrandomized controlled cohort. To compare early results between bipolar fusionless construct (BFC) and single posterior fusion (SPF) surgery in neuromuscular scoliosis (NMS). Surgical treatments for NMS have traditionally been characterized by high complication rates. A mini-invasive BFC was developed to reduce these risks while maintaining adequate curve reduction. There is, however, a current lack of studies comparing clinical and radiologic perioperative outcomes between both techniques. All patients surgically treated for NMS with to-pelvis construct between 2011 and 2021 at 2 centers were included and divided into 2 groups according to the surgical technique (BFC or SPF). Gender, age, main deformity region, etiology, preoperative and postoperative main curve magnitude and pelvic obliquity, surgery time, estimated blood loss and transfusion rates, length of hospital stay, the magnitude of main curve and pelvic obliquity correction, and early complications were compared. Quantitative data were compared through ANOVA or Mann-Whitney test. Analysis of qualitative outcomes was performed through Fisher exact test and logistic regressions. Kruskal-Wallis test was used to compare complications between groups. Eighty-nine NMS patients were included: 48 in the SPF group and 41 in the BFC group. Surgery time (203 vs. 241min), rate (32 vs. 52%) and severity of complications, unplanned returns to the operating room (15 vs. 39%), estimated blood loss (179 vs. 364 cc), and transfusion rates (27 vs. 73%) were lower in the BFC group ( P <0.05). There were no significant differences in age, maturity stage, preoperative curve magnitude, preoperative pelvic obliquity and postoperative curve, and pelvic obliquity correction between groups. BFC may be a safer and less invasive option for NMS surgical treatment, resulting in similar curve corrections while significantly decreasing the number and severity of complications as well as intraoperative blood loss when compared with SPF. Level -lll.

Role of intra-operative traction in deformity correction in neuromuscular scoliosis: a systematic review and meta-analysis.

Intra-operative traction (IOT) has emerged as new modality for improving correction rates in scoliosis since it has the potential to reduce operative time and blood loss in neuromuscular scoliosis (NMS). The aim of this study is to describe the effects of IOT in deformity correction in NMS. The search was conducted in online electronic databases following the PRISMA guidelines. This review included studies on NMS which have described usage of IOT in deformity correction. Eight studies were included in analysis and review. There was low-to-moderate heterogeneity across the studies (I2 - 42.4 to 93.9%). All the studies used cranio-femoral traction for IOT. The final Cobb's angle in coronal plane was significantly lower in the traction group as compared to the non-traction group (SMD -0.36 95% CI -0.71 to 0). There was a trend towards better outcomes in final obliquity (SMD -0.78 95% CI -1.64 to 0.09), operative time (SMD -1.09 95% CI -2.25 to 0.08) and blood loss (SMD -0.86 95% CI significantly lower in the traction group as2.15 to 0.44) but did not reach statistical significance. IOT helped to achieve significant scoliotic curve correction in NMS compared to non-traction group. Despite the overall tendency of improved pelvic obliquity correction, reduced operative time and reduced blood loss as compared to a surgery without the use of IOT, it did not achieve statistical significance. Further studies which are prospective with a larger sample size and focussing on a particular etiology may be conducted which would validate the results. IV.

Perioperative complications after posterior spinal fusion versus minimally invasive fusionless surgery in neuromuscular scoliosis: a comparative study.

Early-onset scoliosis is a common deformity in neuromuscular disease. When conservative treatment becomes ineffective, several surgical options can be proposed. The most common technique is posterior spinal fusion (PSF) consisting of performing a multiple segmental instrumentation with pedicular screws on the full spine associated with decortication and bone graft. Minimally invasive fusionless surgery (MIFS) is an alternative to correct and fix definitively the spine without graft. The objective of this study was to compare early surgical inpatient period between PSF and MIFS in neuromuscular scoliosis. 140 NMS operated by PSF or MIFS between 2012 and 2017 was retrospectively reviewed. The following data were compared between groups: general characteristics (age, sex, etiology), preoperative preparation (halo traction, noninvasive ventilation or tracheostomy), Cobb angle and pelvic obliquity correction, use of drugs (vasopressor and/or inotropes, expansion fluids, transfusion and volumes), postoperative complications, and need of noninvasive ventilation. 75 patients were managed by PSF with a mean age of 14.3 ± 2.3y and 65 by MIFS with a mean age of 11.8 ± 3y. Average pelvic obliquity and major curve correction were similar postoperatively. Intraoperative blood transfusion was significantly more common in PSF group (OR, 14; 95% CI [6.3-33.0]). Vasopressors were used non-significantly more often in the PSF group and expansion fluids similar in the two groups. PSF group had more overall complications (OR, 4.6; 95% CI [2.3-9.8]), more infections (OR, 3.6; 95% CI [1.5-9.3]) and more hemodynamic complications (OR, 4.1; 95% CI [1.4-15.1]). Average intubation duration was 5days in the PSF and 4days in MIFS (p = 0.05). In this series of neuromuscular patients, the complication rate was reduced in MIFS comparatively to PSF, with lower blood transfusion and less infections.

Hip Displacement Does Not Change After Pelvic Obliquity Correction During Spinal Fusion in Children With Cerebral Palsy.

Children with cerebral palsy (CP) frequently develop both neuromuscular hip dysplasia and scoliosis, and occasionally, the timing of the worsening of both of these pathologies is concurrent. The question as to whether the hip or spine should be addressed first in CP remains controversial, with the majority of evidence being "expert opinion." The purpose of this project was to determine the impact of posterior spinal fusion (PSF) on the change in hip displacement for children with CP without previous reconstructive hip surgery. This was an Institutional Review Board-approved study that observed 67 patients from 2004 to 2018. Inclusion criteria included children with CP, 18 years of age and younger, Gross Motor Function Classification System IV and V, undergoing PSF at a single tertiary care children's hospital with a minimum 2-year follow-up. The primary outcome was the change in hip displacement as quantified by the migration percentage (MP). The hip with the highest MP (worst hip) at the spine preoperative analysis were included for analysis. Triradiate cartilage (TRC) status and pelvic obliquity correction were analyzed with multivariate analysis. Sixty-seven patients were included for analysis, with a mean age of 12.5±2.3 years. The mean major curve angle of the major curve was 77±23 degrees and the mean preoperative pelvic obliquity was 21±12 degrees. There was no statistically significant change in MP after PSF from a mean preoperative value of 41±27%, to a mean postoperative value of 41±29% at the last follow-up, (P=0.76) The mean follow-up time was 4.1±2.7 years. TRC status (P=0.52) and the severity of pelvic obliquity (P=0.10) did not statistically impact the change in MP after PSF. PSF did not influence-either negatively or positively-the progression of hip displacement in children with CP, regardless of pelvic obliquity correction or TRC status. The lack of deterioration in hip displacement post-PSF, however, may suggest a protective effect of spine surgery. Level III-retrospective cohort study.

Surgical treatment of spinal deformities in spinal muscular atrophy: a single-center experience from China.

To report the clinical characteristics and surgical outcomes of scoliosis in patients with spinal muscular atrophy (SMA) from Mainland China. Nineteen patients were retrospectively analyzed. Demographic, anthropometric and respiratory parameters were collected preoperatively. Surgical program was analyzed. Radiographic data were measured perioperatively. Motor status, ventilation support, sitting ability and respiratory symptoms were evaluated preoperatively and at final follow-up. Age at surgery was 17.08 (12.83, 20.08) years. More than 40% of patients were diagnosed with low weight. Pulmonary dysfunction was observed in all patients. All patients received posterior spinal fusion (PSF). Sacroiliac fixation with sacral-2 alar iliac technique was used in 16 patients. Major curve correction rate was 54.87 ± 16.14%. Pelvic obliquity correction rate was 63.84 ± 23.70%. T1-T12 height, space-available-for-lung ratio and thoracic transverse diameter were increased (p < 0.001). Percentage of patients capable of sitting independently increased from 26.32% preoperatively to 73.68% at final follow-up. Cumulative scores of sitting-related items in muscular dystrophy spine questionnaire improved from 19.11 ± 5.40 preoperatively to 26.21 ± 5.20 at final follow-up. Total scores of symptomatic domains in St. George's Respiratory Questionnaire decreased from 4 (2, 12) preoperatively to 1 (0, 3) at final follow-up. SMA patients in China always present severe scoliosis at late adolescence, accompanied with high proportion of low weight and pulmonary dysfunction. PSF is effective for the correction of scoliosis and pelvic obliquity and the improvement of thoracic morphology. Sitting ability and respiratory symptoms were improved postoperatively.

Sacral-Alar-Iliac (SAI) Fixation in Children With Spine Deformity: Minimum 10-Year Follow-Up.

Sacral-alar-iliac (SAI) screws are utilized to achieve pelvic fixation in spine deformity patients. The primary purpose of this study is to investigate the long-term outcomes of pediatric patients with scoliosis treated with posterior spinal fusion and SAI fixation at 10-year clinical and radiographic follow-up. We reviewed the clinical and radiographic records of patients aged 18 years or below treated for scoliosis with posterior spinal fusion using SAI fixation. Pelvic obliquity and the major coronal curve were determined at the preoperative visit and 6-week, 1-year, 5-year, and 10-year postoperative visits. SAI screw-specific data collected included screw dimensions, rate of screw revision, pain at the SAI screw sites, presence of lucency >2 mm around the screw, screw loosening or breaking, and deep surgical site infections. Ninety-seven of 151 patients (75%) were included. The average age at index surgery was 13.5±3.1 years, and the most common diagnosis was cerebral palsy (67%). The mean duration of follow-up was 11±3 years. The mean pelvic obliquity measured 20±8.0 degrees preoperatively, and 8.7±4.0 degrees at the 10-year follow-up. There were no significant difference in pelvic obliquity when comparing the 10-year follow-up visit with the 6-week postoperative follow-up. Average screw dimensions were 8.4×68.8 mm. By the 10-year follow-up, 4 patients (4%) had at least 1 SAI screw-related complication. Of these patients, 2 (2%) had pain at 1 SAI screw, 4 (4%) had lucency around the screw, and 3 (3%) had broken or loose screws. Two (2%) required SAI screw revision because of late deep wound infection, and underwent exchange with a longer screw. There were no intrapelvic protrusions, vascular, or neurological complications. SAI screws are a safe and effective method for pelvic fixation in children with spinal deformity. The outcomes at ≥10 years are satisfactory, with low rates of long-term complications and excellent postoperative correction and subsequent maintenance of coronal curvature and pelvic obliquity over time. Level IV.

Is it necessary to fuse to the pelvis when correcting scoliosis in cerebral palsy?

BACKGROUNDNeuromuscular 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. AIMTo 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. METHODSThis 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.RESULTSThe 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). CONCLUSIONIncluding 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.

Predicting the impact of intraoperative halo-femoral traction from preoperative imaging in neuromuscular scoliosis.

Intraoperative traction (ITx) has been demonstrated to be a useful adjunct intervention at the time of posterior spinal fusion (PSF) for the treatment of severe neuromuscular scoliosis (NMS) to improve the coronal spinal deformity and pelvic obliquity. The purpose of this study is to determine if preoperative flexibility radiographs can predict the amount of spinal deformity and pelvic obliquity correction at final follow-up. This was a retrospective analysis of a single-surgeon series who underwent PSF to the pelvis with adjunct ITx for NMS. Database query identified 76 NMS patients, of which 41 met inclusion criteria. Demographic, radiographic and operative data were analyzed. Of the 41 study patients, 56% (n = 23) were male and mean age at surgery was 13.6years. Mean follow-up of 4.1years (minimum follow-up 2years). 35 patients had cerebral palsy, 5 patients were syndromic, and 1 patient had myelomeningocele. The average preoperative weight was 35kg and all were wheelchair ambulators. Total traction applied on average was 49% of the preoperative body weight. Mean preoperative coronal deformity was 91° which improved to 43° at final follow-up (53% correction). Push-supine imaging had the strongest correlation to major coronal deformity outcome at final follow-up (r2 = 0.87, p ≤ 0.0001). Compared to push-supine imaging, there was a mean greater coronal deformity correction of 18 ± 10° (p ≤ 0.0001) at final follow-up. To predict the final coronal deformity, the regression equation was final Cobb angle = 1.13085 + preop push-supine Cobb angle × 0.68830. Mean preoperative pelvic obliquity was 34° which improved to 12° at final follow-up (65% correction). Push-supine imaging had the strongest correlation to pelvic obliquity outcome at final follow-up (r2 = 0.59, p = 0.0001). Compared to push-supine imaging, there was a mean greater pelvic obliquity correction of 3 ± 10° (p = 0.0857) at final follow-up. The regression equation was final POB = 6.42096 + preop push-supine POB × 0.36675. Mean preoperative kyphosis was 70° and 52° at final follow-up (26% correction). The results of this study demonstrated for preoperative planning that the push-supine flexibility radiograph is most predictive of the coronal deformity and of the pelvic obliquity correction. At final follow-up in this NMS population, there was a mean greater improvement of 18° for coronal deformity versus preoperative push-supine imaging and 3° for pelvic obliquity versus preoperative push-supine imaging. At the time of PSF, ITx is an effective adjunct technique to improve coronal deformity and POB for NMS producing 53% coronal correction, 65% POB correction, and 26% kyphosis correction. IV.

A Modified Self-Growing Rod Technique for Treatment of Early-Onset Scoliosis.

The patient is positioned prone on a radiolucent table, and the spine is prepared and draped in a standard fashion. A posterior midline skin incision is made from the upper to the lower instrumented level. Subperiosteal exposure of the spine is carried out, ensuring that capsules of the facet joints are spared. Pedicle screws are inserted bilaterally at the cranial and caudal ends of the instrumentation. Fixation with pedicle screws of at least 3 levels at the top and bottom end is usually advised; in nonambulatory patients with pelvic obliquity, caudal fixation can be extended to the pelvis with bilateral iliac screws. Sublaminar wires are positioned bilaterally at every level between the cranial and caudal ends of the instrumentation and are passed as medially as possible to avoid damage to the facet joints. Four 5-mm cobalt-chromium rods are cut, contoured, and inserted at each end of the construct. Ipsilateral rods are secured with use of sublaminar wires, making sure that they overlap over a sufficient length to allow for the remaining spinal growth. Correction of the deformity is achieved with use of a combination of cantilever maneuvers and apical translation by progressive and sequential tightening of the sublaminar wires. The wound is closed in layers over a subfascial drain. The patient is allowed free mobilization after surgery. No postoperative brace is required. Nonoperative alternative treatment for EOS includes serial cast immobilization and bracing4. Alternative surgical treatments include traditional growing rods5, magnetically controlled growing rods6, the vertical expandable prosthetic titanium rib-expansion technique7, and the Shilla technique8. The use of compression-based systems (i.e., staples or tether)9 or early limited fusion has also been reported by other authors. The main advantage of our technique is that it relies on physiological spinal growth and does not require surgery or external devices for rod lengthening, which is particularly beneficial in frail patients with a neuromuscular disease in whom repeated surgery is not advised. Segmental fixation by sublaminar wires allows good control of the deformity apex during growth. Concerns regarding early fusion of the spine have not been confirmed in our mid-term follow-up study10. This technique allows correction of the deformity and continuous spinal growth in the years following surgery. At 6.0 years postoperatively, the average main curve correction was reported to be 61% and the average pelvic obliquity correction was 69%. The spine was reported to lengthen an average of 40.9 mm (range, 14.0 to 84.0 mm) immediately postoperatively, and the T1-S1 segment was reported to continue growing at 10.5 mm/year (range, 3.6 to 16.5 mm/year) thereafter10. The most common complication is rod breakage at the thoracolumbar junction, which seems to be more common in patients with idiopathic or cerebral palsy EOS and during the pubertal growth spurt10. Subperiosteal exposure of the spine should be carried out, making sure to preserve facet joints in the unfused area of the spine.Achieve segmental fixation with use of sublaminar wires at every level and pedicle screws at the top and bottom ends of the instrumentation.If pelvic imbalance is present and the patient is nonambulatory, pelvic fixation with iliac screws is advised.First round correction of the deformity is achieved with a cantilever technique; correction fine-tuning can be performed by tightening sublaminar wires.Consider utilizing thicker rods in cases of idiopathic or cerebral palsy EOS. EOS = early-onset scoliosisAP = anteroposteriorEV = end vertebraSSEP = somatosensory evoked potentialsMEP = motor evoked potentialsPJK = proximal junctional kyphosisSMA = spinal muscular atrophyCP = cerebral palsyPACU = post-anesthesia care unit.

Minimally Invasive Fusionless Surgery for Scoliosis in Spinal Muscular Atrophy: Long-term Follow-up Results in a Series of 59 Patients.

Treatment of spinal muscular atrophy (SMA) scoliosis has evolved in the last decade, with the emergence of fusionless surgical techniques that allow correction of the deformity before the end of growth spurt. These techniques are expected to delay definitive spine fusion and preserve trunk growth. The aim was to evaluate long-term clinical, radiologic, and respiratory outcomes of a minimally invasive fusionless surgery (MIFLS) in SMA scoliosis. All children affected with SMA scoliosis who underwent MIFLS in our department from 2011 to 2019 were included. The instrumentation consisted in a bilateral sliding rod construct from T1 to the sacrum, anchored proximally by double-hook claws and distally by iliosacral screws. Clinical, genetic, respiratory and radiographic data were retrospectively reviewed. A patient's satisfaction survey was performed. A total of 59 children with genetic confirmation of SMA (9SMA1c, 47SMA2, and 3SMA3) underwent MIFLS at a mean age of 11±1.9 years. All of them were nonwalker at the time of surgery. Twenty-six were treated with intrathecal Nusinersen. Mean follow-up was 5.2 years (2 to 9.6 y). Mean major coronal curve improved from 79±15 to 41±16 degrees and pelvic obliquity decreased from 24±11 to 5.9±4 degrees. Mean space available for lung improved from 77% to 93%. Mechanical or infectious complications occurred in 9 patients, with removal of the implant in 1. 6 children required unplanned surgeries. Postoperative bracing was needed in 13 children. Mean gain weight 3 years after the first surgery was 6 kg. 91.5% of patients had a positive satisfaction of the surgery. There was no significant impact in respiratory function postoperatively. Only 30 children required rod lengthening procedures, with a mean interval between procedures of 1.9 years (0.5 to 3.7 y). No arthrodesis was required at last follow-up in any patient. Bipolar MIFLS in SMA preserves spinal and thoracic growth without interference with respiratory function. It provides a significant correction of spinal deformity and pelvic obliquity, having a reduced rate of complications. The correction of spinal deformity was maintained at long term, not requiring definitive fusion at the end of growth. Level IV.

When Should Instrumentation to the Pelvis be Considered in Minimally Ambulatory Adolescents With Neuromuscular Scoliosis?

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. 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. 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. 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.

Minimally Invasive Surgery for Neuromuscular Scoliosis: Results and Complications at a Minimal Follow-up of 5 Years.

A prospective study. The aim of this study was to report the results of an alternative technique to growing rods (GR) for neuromuscular scoliosis using a minimally invasive fusionless surgery with a minimum of 5 years' follow-up. Conservative treatment is not effective in progressive neuromuscular scoliosis. Early surgery using GR is increasingly advocated to control the deformity while preserving spinal and thoracic growth before arthrodesis. These techniques still provide a high rate of complications. The technique relies on a bilateral double rod sliding instrumentation anchored proximally by four hooks claws and distally to the pelvis by iliosacral screws through a minimally invasive approach. The clinical and radiological outcomes of 100 consecutive patients with neuromuscular scoliosis who underwent this fusionless surgery with a minimum follow-up of 5 years were reviewed. 6.5 ± 0.7 years after initial surgery, six patients were lost of follow-up and 11 died of unrelated raison. Of the 83 remaining patients at latest follow-up, mean Cobb angle was stable to 35.0° which correspond to 61% correction of the initial deformation. Mean pelvic obliquity was 29.6° (0.3°-80.0°) preoperatively and 7.2 (0.2°-23.5°) at latest follow-up. Correction of the hyper kyphosis remained stable. Skeletal maturitywas reached in 42 of 83 patients (50.6%). None of these patients has required spinal fusion. The global complication rate was 31.3%. The outcomes of this minimally invasive fusionless technique at 5 years follow-up showed a stable correction of spinal deformities and pelvic obliquity over time, with a reduced rate of complication. The arthrodesis was not required for all patients at skeletal maturity. This technique could be a good alternative to arthrodesis for neuromuscular scoliosis.Level of Evidence: 3.

Surgical pathway proposal for severe paralytic scoliosis in adolescents with myelomeningocele.

The increased life expectancy of patients with myelomeningocele led to the necessity of new management for addressing complex spine deformities with severe pelvic obliquity. Tethered cord release (TCR) and spinal fusion were described as treatment options. However, nowadays, the surgical strategy is not well defined and high rates of mechanical failures and complications are reported. Our aim was to propose a new two-stage surgical pathway to treat a selected group of severe myelomeningocele scoliosis. This is a retrospective series of myelomeningocele scoliosis in paralytic adolescent patients treated with concurrent TCR and posterior spinal fusion (PSF), followed by delayed anterior fusion (ASF) through minimally invasive lateral approach. Inclusion criteria were as follows: evolutive scoliosis in tethered cord syndrome and paraplegia, main curve >70°, pelvic obliquity >20°, and age between 10 and 18 years. Clinical, surgical, and radiographic parameters were evaluated preoperatively and at a mean follow-up (FU) of 2.8 years. Six patients out of 58 met the inclusion criteria and were included in the study (mean age 12.3 years old). The mean curve and pelvic obliquity correction were 68.8% and 82%, respectively. No loss of correction was recorded at FU. One case of cerebrospinal fluid leakage requiring revision surgery was recorded. To the best of our knowledge, this is the first study proposing a two-stage surgical pathway for severe MMC spinopelvic deformity treatment. Concurrent TCR and PSF with delayed minimally invasive ASF permitted to minimize complications providing good fusion rates without loss of correction and implant failure.

Intraoperative traction in neuromuscular scoliosis surgery improves major curve correction when fusing to L5.

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. 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. 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. 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.

Spinal Fusion with Sacral Alar Iliac Pelvic Fixation in Severe Neuromuscular Scoliosis.

We demonstrate how to perform posterior spinal fusion with SAI pelvic fixation in a patient with cerebral palsy. In correcting the scoliosis, we utilize the segmental 3-dimensional technique, which includes compression, distraction, transverse approximation to 1 rod at a time, and derotation around 2 rods. We also demonstrate SAI pelvic fixation with identification of the screw starting point on the lateral-caudal border of the first sacral foramen and trajectory toward the anterior inferior iliac spine. Nonoperative alternatives include bracing, trunk support, contouring of sitting surfaces (such as wheelchairs), and physical therapy to slow curve progression during growth periods and delay the need for surgical treatment3,4. Decision-making is shared with the family following education about the risks and benefits. Families who are satisfied with the function of the child at baseline should not be persuaded into pursuing surgical treatment. Neuromuscular scoliosis can include difficulty sitting secondary to increased pelvic obliquity, along with poor trunk control and balance. Surgical intervention is considered in patients with curves exceeding approximately 50°, as these curves will often continue to progress even after maturity5. In patients with neuromuscular scoliosis, indications for pelvic fixation include pelvic obliquity of >15°, poor control of the trunk as indicated by lack of independent sitting or standing, and location of the apex of the curve in the lumbar spine. SAI screws are utilized as a low-profile option for pelvic fixation to avoid implant prominence and an increased risk of skin breakdown and infection, which are associated with traditional sacroiliac screws2,6. Miyanji et al. reported quality outcomes in patients with cerebral palsy and Gross Motor Function Classification Scores of ≥41. In that study, caregivers completed a validated disease-specific questionnaire grading the health-related quality of life of the patient preoperatively and at 1, 2, and 5 years postoperatively. Complication data were prospectively collected for each patient and preoperative outcome scores were compared at each of the postoperative time points. Survey scores at 1, 2, and 5 years postoperatively were significantly higher compared with baseline preoperative values.Sponseller et al. compared the 2-year postoperative radiographic parameters of 32 pediatric patients who underwent SAI fixation and 27 patients who underwent pelvic fixation with the sacroiliac technique2. Among patients who underwent SAI fixation, the mean correction of pelvic obliquity was 20° ± 11° (70% correction) and the mean Cobb angle 42° ± 25° (67%). Among patients who underwent pelvic fixation with the sacroiliac technique, those values were 10° ± 9° (50%) and 46° ± 16° (60%), respectively. SAI screws provided significantly better pelvic obliquity correction (p = 0.002) but no difference in Cobb correction or complications compared with other traditional techniques. Family discussion prior to surgical treatment is paramount.Perform preoperative neurologic examination7.Examine the cranium carefully for a ventriculoperitoneal shunt or prior cranial reconstruction prior to cranial traction.Transcranial neuromonitoring may be useful. Use descending neural motor evoked potentials when no signals from transcranial monitoring are obtained8.Sink the SAI screw until it lines up with the S1 screw. Bury the SAI screw so it is not prominent.Measure rods longer in order to ensure adequate length for compression and distraction in correction of the pelvic obliquity.Use a T-square to verify adequate spinopelvic alignment9.Postoperatively, the use of incisional vacuum-assisted closure can decrease soiling in these patients. SAI = Sacral alar iliacCP = Cerebral palsyAIS = Adolescent idiopathic scoliosisSMA = Spinal muscular atrophyIONM = Intraoperative neuromonitoringGMFCS = Gross Motor Functional Classification SystemDNMEP = Descending neural motor evoked potentialTXA = Tranexamic acidFFP = Fresh frozen plasmaASIS = Anterior superior iliac spineAIIS = Anterior inferior iliac spinePJK = Proximal junctional kyphosis.

BMI change following spinal fusion for neuromuscular scoliosis surgery.

Retrospective descriptive, multi-center study. We hypothesize that a post-operative weight gain will result in patients who are underweight prior to surgery. Cachexia and low body mass index is common among children with cerebral palsy (CP). Many interventions are undertaken to assist the child in nourishment and to obtain a more normal body mass. Additionally, scoliosis is common among children with CP. In our practice we have noted weight gain post operatively in severely underweight children after spinal fusion. We underwent a retrospective review of a CP cohort from a multicenter prospective registry. Percentiles on the CP specific growth chart for which each child belonged were plotted based on the patients' age, weight, gender, GMFCS level, and tube feeding status. We then assessed percentile change in patients between pre-op visit, 1year, 2years and for those with available data, 5years follow up visits. Patients with under two years of follow up, patients with GMFCS III and below, and patients without weight data were excluded. We identified a total of 211 potentially eligible patients from a multicenter prospective registry. 109 had complete 2years data to analyze and 37 patients had full 5years data to analyze. We found that patients under the 50th percentile pre-operatively increased their percentile on the CP growth chart for weight 12.1 percentiles (95% CI 6.7, 17.5 p value < 0.001) whereas patients that began at the 50th percentile or above on average lost 2.2 percentiles (95% CI -6.8, 2.3) though the change was not statistically significant (p value 0.330). These changes appeared stable at 5years. Although regression analysis showed that Cobb correction and pelvic obliquity correction, and hyperlordosis were not independent predictors of the change, we noted that patients with residual curves after surgery of 40° or more experienced 13.3 percentile less weight gain than those with better corrections. Patients with CP are at risk for cachexia, malnutrition, reflux and other GI disorders. Data presented here suggests that corrective spinal surgery may improve weight percentile in patients who start out at 50th percentile and lower. Patients with 40° or greater of residual scoliosis may benefit less from spinal fusion than those with a better correction. II; Prognostic retrospective cohort study.

Spine deformities in patients with cerebral palsy; the role of the pelvis.

IntroductionProgressive neuromuscular spinal deformities with pelvic obliquity and loss of sitting balance are typical features of severely affected patients with cerebral palsy. The pelvis represents the key bone between the spine and the lower extremity when it comes to deciding whether and when to operate and if spine or hip surgery first is beneficial. The pelvis can be looked at as the lowest vertebra and as the rooftop of the lower extremities.Biomechanical considerationsTo allow for a normal spinal shape, the pelvis needs to be horizontal in the frontal plane and mildly anterior tilted in the sagittal plane, less for sitting and more for standing. Any abnormal pelvic position requires spinal compensation and challenges the equilibrium control of the individual. Both anatomical neighbourhoods – the spine and the hip joints — have to be considered when spinal deformities, hip instability and contractures evolve, in conservative therapy (bracing, physiotherapy, seating in the wheelchair) and when surgical interventions are weighed out against each other.Surgical considerationsMultiple anatomical factors such as sagittal profile and pelvic orientiation, pelvic transverse plane asymmetries and lumbosacral malformations have to be considered in case the pelvis is instrumented with sacral and iliac screws. Rotational deformities and asymmetries of the pelvic bones make the safe insertion of long screws challenging. Advantages of primary pelvic fixation include correction of pelvic obliquity, especially considering the lever arm of the whole spinal construct. The risk of revision surgery due to progression of distal curves is also reduced. Disadvantages of pelvic fixation include the complexity of the additional intervention, which may result in longer operating times, increased risk of blood loss, infection and hardware malpositioning.

Clinical Effectiveness of S2-Alar Iliac Screws in Spinopelvic Fixation in Pediatric Neuromuscular Scoliosis: Systematic Literature Review.

Study Design:Systematic literature review.Objectives:To comprehensively review the S2-alar iliac (S2-AI) screw technique for pelvic fixation in pediatric neuromuscular scoliosis.Methods:Articles identified from the PubMed and EMBASE databases were reviewed for relevance and applicability, and the studies were summarized.Results:Eight articles met the inclusion criteria. A total of 277 pediatric patients underwent spinopelvic fixation using S2-AI fixation for neuromuscular scoliosis; the mean follow-up was 3 years (range = 0.75-6 years). Six articles had level III evidence (5 retrospective cohort studies, 1 observational study), and 2 articles had level IV evidence (case series). Wound complications occurred in 34 (12.2%) patients. Instrumentation complications occurred in 36 patients (13.0%), including lucency around the screw (6.5%), screw fracture (3.6%), disengaging of the set/screw or rod from the tulip head (2.8%), and screw displacement (0.7%). Three patients (1.1%) required reoperation for instrumentation failures. The overall reoperation rate—including 3 hardware replacements and 3 cases of L5-S1 pseudarthrosis—was 2.1%. The mean Cobb angle correction was 51.4°, and the mean pelvic obliquity correction was 14.8°; deformity correction was maintained at 3- and 5-year follow-ups. There were 10 (3.6%) cases of implant prominence/implant-related pain, 1 case of sacroiliac joint pain (resolved with longer screw placement), and no major neurological or vascular complications secondary to S2-AI screw placement.Conclusions:This review suggests that the use of S2-AI screws in pediatric neuromuscular scoliosis is efficacious with a reasonable safety profile and provides a useful technique for pelvic fixation in children with scoliosis.