Surgery For Neuromuscular Scoliosis Research Articles

Evidence of spinal stiffening following fusionless bipolar fixation for neuromuscular scoliosis: a shear wave elastography assessment of lumbar annulus fibrosus.

There are no established criteria for stiffness after fusionless surgery for neuromuscular scoliosis (NMS). As a result, there is no consensus regarding the surgical strategy to propose at long-term follow-up. This study reports the first use of shear wave elastography for assessing the mechanical response of lumbar intervertebral discs (IVDs) after fusionless bipolar fixation (FBF) for NMS and compares them with healthy controls. The aim was to acquire evidence from the stiffness of the spine following FBF. Nineteen NMS operated on with FBF (18 ± 2y at last follow-up, 6 ± 1 y after surgery) were included prospectively. Preoperative Cobb was 89 ± 20° and 35 ± 1° at latest follow-up. All patients had reached skeletal maturity. Eighteen healthy patients (20 ± 4 y) were also included. Shear wave speed (SWS) was measured in the annulus fibrosus of L3L4, L4L5 and L5S1 IVDs and compared between the two groups. A measurement reliability was performed. In healthy subjects, average SWS (all disc levels pooled) was 7.5 ± 2.6m/s. In NMS patients, SWS was significantly higher at 9.9 ± 1.4m/s (p < 0.05). Differences were significant between L3L4 (9.3 ± 1.8m/s vs. 7.0 ± 2.5m/s, p = 0.004) and L4L5 (10.3 ± 2.3m/s vs. 7.1 ± 1.1m/s, p = 0.0006). No difference was observed for L5S1 (p = 0.2). No correlation was found with age at surgery, Cobb angle correction and age at the SWE measurement. This study shows a significant increase in disc stiffness at the end of growth for NMS patients treated by FBF. These findings are a useful adjunct to CT-scan in assessing stiffness of the spine allowing the avoidance of surgical final fusion at skeletal maturity.

Does the Intrathecal Baclofen Dose Need to Be Changed after Spinal Fusion Surgery for Neuromuscular Scoliosis?

Patients with cerebral palsy (CP) may receive intrathecal baclofen (ITB) to reduce muscle spasticity and dystonia. It can be challenging to identify the proper dose of ITB, and anecdotally these dosing needs may change after spinal fusion surgery. This study aimed to evaluate the need for changes in ITB dosing following a spinal fusion in pediatric neuromuscular scoliosis (NMS) patients and identify predisposing factors for those changes. This was a retrospective case-control study of NMS patients with an ITB pump who later received a spinal fusion surgery. Dosing changes and the indications for the changes were postoperatively noted. Demographics, preoperative factors, and surgical factors were evaluated for correlation with dosing changes. A total of 49 patients were included in this study. Most had no change in ITB dose (71.4%), and others required a change that averaged about 10%. Male patients, those with larger pumps, and those that had a longer hospital stay were more likely to require a decrease in dose. Complications were similar between groups. Three catheters were revised during surgery: two continued on the same dose and one required an increase in dose after surgery. Spinal fusion after ITB pump placement is feasible and safe. Most patients did not require dosing changes after spine fusion; however, careful evaluation postoperatively remains prudent.

Use of monopolar cautery in patient with a vagal nerve stimulator during neuromuscular scoliosis surgery.

It is a historic and common practice while performing spine surgery on patients with a VNS has been to have the patient's neurologist turn off the VNS generator in the pre-operative anesthetic care unit and to use bipolar rather than monopolar electrocautery. Here we report a case of a 16-year-old male patient with cerebral palsy and refractory epilepsy managed with an implanted VNS who had scoliosis surgery (and subsequent hip surgery) conducted with the use of monopolar cautery. Although VNS manufacturer guidelines suggest that monopolar cautery should be avoided, perioperative care providers should consider its selective use in high-risk instances (with greater risks of morbidity and mortality due to blood loss which outweigh the risk of surgical re-insertion of a VNS) such as cardiac or major orthopedic surgery. Considering the number of patients with VNS devices presenting for major orthopedic surgery is increasing, it is important to have an approach and strategy for perioperative management of VNS devices.

Anesthesia and Perioperative Management for Surgical Correction of Neuromuscular Scoliosis in Children: A Narrative Review.

Scoliosis is the most frequent spinal deformity in children. It is defined as a spine deviation of more than 10° in the frontal plane. Neuromuscular scoliosis is associated with a heterogeneous spectrum of muscular or neurological symptoms. Anesthesia and surgery for neuromuscular scoliosis have a higher risk of perioperative complications than for idiopathic scoliosis. However, patients and their relatives report improved quality of life after the surgery. The challenges for the anesthetic team result from the specifics of the anesthesia, the scoliosis surgery itself, or factors associated with neuromuscular disorders. This article includes details of preanesthetic evaluation, intraoperative management, and postoperative care in the intensive care unit from an anesthetic view. In summary, adequate care for patients who have neuromuscular scoliosis requires interdisciplinary cooperation. This comprehensive review covers information about the perioperative management of neuromuscular scoliosis for all healthcare providers who take care of these patients during the perioperative period, with an emphasis on anesthesia management.

Incisional Negative Pressure Wound Therapy Does Not Affect Deep Surgical Site Infection Rates in Neuromuscular Scoliosis Surgery.

Surgical site infection (SSI) is a devastating complication in patients with neuromuscular scoliosis (NMS) undergoing posterior spinal instrumented fusion (PSIF) for progressive scoliosis. Incisional negative pressure wound therapy (INPWT) has been used in other surgical fields to reduce SSI. Our purpose was to examine the prophylactic use of INPWT after NMS surgery to decrease SSI. At a single institution, 71 consecutive patients with NMS underwent PSIF from 2015 to 2019. Starting in 2017, all patients with NMS received INPWT postoperatively until discharge. Rates of deep SSI were compared between the two cohorts of patients. Additionally, patient demographic and operative factors such as American Society of Anesthesiologists score, number of levels instrumented, need for an anterior spinal release, need for spinal fusion to pelvis, blood loss, operative time, fluoroscopy time, length of stay, and transfusion requirement were analyzed for potential influence on deep SSI. There was no significant difference in deep SSI rates between patients who received INPWT (2 of 41) and those treated with a standard postoperative dressing (2 of 30; P=1.0). Although INPWT theoretically can stabilize the wound environment and prevent deep SSI, our findings do not support this. More research is needed to evaluate the efficacy of INPWT after PSIF for NMS. [Orthopedics. 2023;46(6):373-378.].

Surgical complications in neuromuscular scoliosis surgery: Systematic review and meta-analysis of the last ten years

Surgical complications in neuromuscular scoliosis surgery: Systematic review and meta-analysis of the last ten years

Hemodynamic Consideration in Intraoperative Neurophysiological Monitoring in Neuromuscular Scoliosis Surgery.

To prove the hypothesis that the parameters of intraoperative neurophysiological monitoring (IONM) during will be more deteriorated in neuromuscular scoliosis (NMS) than in adolescentidiopathic scoliosis (AIS). This retrospective study reviewed the data of 69 patients (NMS=32, AIS=37) who underwent scoliosis surgery under IONM. The amplitude of motor evoked potentials (MEPs), and the amplitude and the latency of somatosensory evoked potentials (SEPs) were examined. Demographic, preoperative, perioperative and postoperative data were analyzed to determine whether they affected the IONM parameters for each group. Of the items analyzed, the bleeding amount was the only significant risk factor for SEP latency deterioration in the NMS group only. The amplitude of SEP and MEP did not correlate with the hemodynamic parameters. The NMS/AIS ratios of the bleeding-related parameters were higher in the order of bleeding amount/weight (2.62, p<0.01), bleeding amount/body mass index (2.13, p<0.01), and bleeding amount (1.56, p<0.01). This study suggests that SEP latency is more vulnerable than SEP or MEP amplitude in ischemic conditions during scoliosis surgery. In NMS patients, it should be considered that the bleeding amount can have a critical effect on intraoperative electrophysiological deterioration.

Transition of Caregiver Perceptions after Pediatric Neuromuscular Scoliosis Surgery.

Introduction Spinal fusion for children with neuromuscular scoliosis has been known to improve sitting balance and quality of life as well as for high caregiver satisfaction. However, most studies performed were single surveys, and it remains unclear whether high satisfaction levels are maintained. Thus, in this article, we report the short- and medium-term improvements in caregiver standing assessment after neuromuscular scoliosis surgery in children with Gross Motor Function Classification System (GMFCS) level IV or V. Methods In total, 18 patients with GMFCS levels IV and V were included in this study. The underlying diseases were typical cerebral palsy in 12 cases, chromosomal abnormalities in 5 cases, and congenital myopathy in 1 case. The median age at the time of surgery was 14.5 years. The medians for the first and second follow-up surveys were after 1.4 and 5.9 years, respectively. All the patients had undergone posterior spinal fusion, whereas 12 had undergone pelvic fixation. These patients were assessed using a caregiver questionnaire, in addition to patient demographic data and radiographic assessments. Results The median BMI was 15.4 kg/m2 preoperatively, 16.6 kg/m2 at the first survey, and 17.1 kg/m2 at the second survey. The main Cobb angles were 97.5°, 36.5°, and 37.0° and the spino-pelvic obliquity angles were 22.5°, 6.0°, and 6.5° preoperatively, at the first survey and at the second survey, respectively. In the questionnaire, most domains were rated similarly in the first and second surveys, but the ratings for the “children's QOL” and “digestion and defecation” domains were noted to increase, while that for the “transfer” and “satisfaction with treatment” domains have decreased. Conclusions Neuromuscular scoliosis surgery in children has been associated with extremely high treatment satisfaction in the early postoperative period. However, some caregivers showed a decline in the “transfer” and “treatment satisfaction” domains over time.

S2-Alar-iliac screw fixation for paediatric neuromuscular scoliosis: Preliminary results after two years

BackgroundCorrecting pelvic obliquity is among the main goals of surgery for neuromuscular scoliosis. Spino-pelvic fixation must be stable and capable of withstanding the considerable mechanical forces applied at the lumbo-sacral junction. Selection of the best anchoring option is therefore crucial. S2-alar-iliac (S2AI) screws, which are used in adults, are less often chosen in the French paediatric spinal-surgery community. The objective of this study was to report our preliminary experience with S2AI screws used in the treatment of paediatric patients with neuromuscular scoliosis. HypothesisPelvic anchoring by means of S2AI screws is reliable and technically feasible in non-ambulatory children with neuromuscular scoliosis. Materials and methodsConsecutive non-ambulatory patients who underwent scoliosis surgery with S2AI screw fixation to the pelvis between 2016 and 2018 were retrospectively included. The surgical procedure consisted in either posterior spinal fusion (PSF) or magnetic growing rod (MGR) implantation. In all patients, radiographs were obtained before surgery, within 3 months after surgery, and at last follow-up; and low-dose computed tomography (CT) was performed before and after surgery. ResultsWe included 25 patients with a mean age of 13.8±4.0 years, 18 managed by PSF and 7 by MGRs. Screw diameters ranged from 7.5 to 9.5mm and all screws were at least 60mm in length. The diameters and lengths were the same on both sides in 16 (89%) patients in the PSF group and in all patients in the MGR group. At last follow-up after a mean of 35.5±3.0 months, pelvic obliquity was corrected in all 23 patients with this abnormality before surgery. Complications consisted of lateral cortical screw breakthrough in 8 (32% of screws) patients and screw malposition in 2 (8% of screws) patients. No clinically significant complications related to the fixation material were recorded. DiscussionThe results of our study demonstrate the feasibility of S2AI screw fixation in paediatric patients with neuromuscular scoliosis. Pelvic asymmetry and dysmorphism do not contra-indicate the procedure but must be evaluated before surgery. Further work is needed to assess the potential long-term consequences on pain and growth of screw passage through the sacro-iliac joints. Level of evidenceIV, retrospective study.

Clinical Issues in Indication, Correction, and Outcomes of the Surgery for Neuromuscular Scoliosis: Narrative Review in Pedicle Screw Era.

Surgical treatment for neuromuscular scoliosis has evolved with pedicle screw instrumentation and the improvement of perioperative management. We aimed to review recent papers related to posterior surgical correction with a pedicle screw system for neuromuscular scoliosis, particularly cerebral palsy and muscular dystrophy, in terms of indication, correction method, and outcomes. The most remarkable change was the posterior-only operation with all-pedicle screw fixations. With this change, operation time, blood loss, and postoperative complications decreased. Furthermore, spinal osteotomy could be performed with the pedicle screw system for severe scoliosis. S2-alar-iliac screws demonstrated favorable outcomes in terms of stability and complication, but a question remains about saving the mobile segment for sitting balance, interaction between the hip and spine, effect to the sagittal balance, and proximal junctional problem. The quality of life improvement was more definite in patients with cerebral palsy. The improvement of respiratory function in Duchenne muscular dystrophy was not certain, although an increase of spinal height, thoracic cavity size, and absolute forced vital capacity have been reported. Further prospective studies or randomized clinical trials are needed to evaluate the long-term outcomes of lumbosacral fixation, preservation of the lumbosacral joint, or functional improvement considering the different etiology.

Does nutrition consultation in the year leading up to neuromuscular scoliosis surgery result in significant weight gain, or just a larger magnitude curve?

Patients with neuromuscular scoliosis undergoing posterior instrumented spinal fusion can be underweight, malnourished, and have higher complication rates. A nutrition consult is common in this population and it is unclear if weight gain occurs from the consult or surgery. The purpose of the study was to determine if nutrition consultation in the year prior to spinal fusion resulted in significant differences in weight gain or percentile on the CP growth chart. The secondary aim was to determine if there would be deformity progression during that time. Retrospective chart and radiograph review was performed for all patients with neuromuscular spinal deformity treated with posterior instrumented spinal fusion at one institution between January 1, 2009 and August 1, 2015. Inclusion criteria included < 20years old, diagnosis of neuromuscular scoliosis, and 1-year pre-operative percentile on the CP growth chart < 50. Patient demographics, GMFCS level, weight, percentile on appropriate CP growth chart, major curve and pelvic obliquity at 1 year pre-operatively and at surgery were recorded. Sixty-eight patients met inclusion criteria. Thirty-seven patients had a nutrition appointment within 1year pre-operatively, 31 patients did not. There were no significant differences between the groups when comparing increase in weight (p = 0.9), percentile on CP growth charts (p = 0.3), major deformity (p = 0.1), and pelvic obliquity (p = 0.2). Overall, there was a mean 3.2kg weight gain, 5.2% increase on CP growth charts, 40° increase in major curve, and 5° worsening of pelvic obliquity in the year before surgery. There was an average overall increase in the pre-operative albumin value, but this was not different between groups (p = 0.6). Children who were tube fed gained on average 10.8 percentiles on the CP growth chart, whereas children without gained only 0.5 percentiles (p = 0.002). Nutrition consultations in the year preceding posterior instrumented spinal fusion do not lead to weight optimization prior to surgery in comparison to patients without nutrition consults. Gastrostomy tubes were found to be helpful for weight optimization and should be considered as an alternative nutrition option in pre-operative planning in underweight patients. III-therapeutic study: retrospective comparative study.

Gastrostomy Tubes in Patients With Cerebral Palsy Undergoing Surgery—Usually an Ally, but the Devil Is In the Details

In this issue of JPOSNA, Dr. Shiver et al. review data about the role of an enterostomy feeding tube (gastrostomy/G-tube, jejunostomy/J-tube, or gastro-jejunostomy/G-J tube) in patients with cerebral palsy undergoing spinal surgery for neuromuscular scoliosis.1 The authors quite rightly comment that spinal surgery in these patients represents a significant intervention that may result in a number of respiratory, gastrointestinal, and infectious complications. These complications can have a tremendous medical, social, and psychological impact on the patient and the patient’s family, so understanding a particular patient’s risk factors before surgery is an important part of preoperative planning. As pediatric hospitalists who often co-manage these patients at our institution—including seeing these patients preoperatively with an emphasis on their nutritional status2—we greatly appreciate the opportunity to comment on this paper.

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.

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.

Traction Films- Can They Help Predict Final Radiographic Outcomes of Surgery for Neuromuscular Scoliosis?

Traction Films- Can They Help Predict Final Radiographic Outcomes of Surgery for Neuromuscular Scoliosis?

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.

EPIDEMIOLOGICAL PROFILE AND OUTCOMES IN POSTOPERATIVE NEUROMUSCULAR ESCOLIOSIS

ABSTRACT Objective To outline the epidemiological profile and identify the hospital outcomes of patients submitted to neuromuscular scoliosis correction surgery. Methods This was a descriptive study that included 50 patients hospitalized following surgery for neuromuscular scoliosis in a tertiary-level hospital in São Paulo from January 2017 to July 2017. The variables were collected retrospectively from the patients’ medical records: age, sex, main diagnosis, length of hospital stay, duration of surgery, hospital complications, and mobility. Results Surgeries were performed in boys and girls in similar proportions, adolescents, many with cerebral palsy (42%), with mean hospital stay of 10.8 days. Fifty-two percent presented some complication, such as constipation. Infection of the surgical site was present in 12% of the sample. Forty-two percent had moderate to intense pain and only 2% did not achieve the proposed mobility goals. Conclusion We observed that the epidemiological profile presented data consistent with the scarce literature available, while the definitions of complications, incidence, and hospital outcomes available in the literature were varied quite a bit from the findings in this study. Level of evidence III; Retrospective study.

319. Minimally invasive surgery for neuromuscular scoliosis: a case control study of 140 consecutive patients

BACKGROUND CONTEXT Minimally invasive surgery (MIS) has been shown to have benefits in adolescent idiopathic scoliosis (AIS) and adult scoliosis with regards to estimated blood loss (EBL), transfusion rate, pain, narcotic usage and hospital stay. These benefits are ideal for neuromuscular scoliosis (NMS) patients, who generally have larger and stiffer curves which are at risk of progression, even with bracing. PURPOSE The purpose of this study was to report a consecutive case series of NMS patients undergoing MIS or standard PSF. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE A total of 37 NMS patients treated with MIS and 103 NMS patients treated with PSF. OUTCOME MEASURES Pre- and postoperative Cobb angle, pre- and postoperative kyphosis, pre- and postoperative pelvic obliquity, perioperative complications, surgery time, EBL, transfusion rates, ICU length of stay, hospital length of stay. METHODS We retrospectively collected data of 37 consecutive patients with neuromuscular scoliosis treated with MIS using 1 incision and a muscle-splitting approach by 2 senior surgeons from 2013-2018. 103 NMS patients treated with standard PSF and pedicle screw constructs were retrospectively reviewed in comparison. RESULTS In the MIS group, respectively the control group, the mean Cobb angle was corrected from 69.9° vs 67.7° to 29.4° vs 25.4° with a mean correction of 59% vs 63%, (p CONCLUSIONS The use of MIS for patients with neuromuscular scoliosis results in a significant correction of spinal deformity, with a low EBL, a significantly lower rate of need for allogenic blood transfusion, and a shorter LOS. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Intra-operative computed tomography guided navigation for pediatric pelvic instrumentation: A technique guide.

Pelvic instrumentation for neuromuscular scoliosis has been part of neuromuscular scoliosis surgery since the era of the Luque Galveston construct. Unit Rod (Medtronic Sofamor-Danek, Nashville, TN) instrumentation brought with it the concept of cantilever correction by placing the implants in the pelvis and then gradually bringing the rod to the spine by sequentially tightening the sublaminar wires, with the goal of creating a level pelvis over a straight spine. More recently surgeons have utilized pedicle screw constructs in which the corrective strategies have varied. Challenges with pelvic fixation using iliac screws linked to the spinal rod have led to the development of the S2-alar-iliac technique (S2AI) in which the spinal rod connects to the pelvic screw. The screw is placed in the S2 ala, crosses the sacro-iliac joint and into the ilium through a large column of supra-acetabular bone. This column is the same area used for anterior inferior iliac spine external fixation frames used in trauma surgery. S2AI screw placement can be technically difficult and can require experienced radiology technologists to provide the appropriate views. Additionally, although the technique was originally described being placed via freehand technique with intra-operative flouroscopy, the freehand technique suffers from the anatomic anomalies present in the pelvis in neuromuscular scoliosis. As such, we prefer to place them using intra-operative navigation for all pediatric spinal deformity cases. Below in detail we report our intra-operative technique and an illustrative case example.

Perioperative complications and risk factors in neuromuscular scoliosis surgery.

OBJECTIVE High rates of perioperative complications are associated with deformity correction in neuromuscular scoliosis. The current study aimed to evaluate complications associated with surgical correction of neuromuscular scoliosis and to characterize potential risk factors. METHODS Data were retrospectively collected from a single-center cohort of 102 consecutive patients who underwent spinal fusions for neuromuscular scoliosis between January 2008 and December 2016 and who had a minimum of 6 months of follow-up. A subgroup analysis was performed on data from patients who had at least 2 years of follow-up. Univariate and multivariate regression analyses, as well as binary correlational models and Student t-tests, were employed for further statistical analysis. RESULTS The present cohort had 53 boys and 49 girls with a mean age at surgery of 14.0 years (± 2.7 SD, range 7.5-19.5 years). The most prevalent diagnoses were cerebral palsy (26.5%), spinal cord injury (24.5%), and neurofibromatosis (10.8%). Analysis reflected an overall perioperative complication rate of 27% (37 complications in 27 patients), 81.1% of which constituted major complications (n = 30) compared to a rate of 18.9% for minor complications (n = 7). Complications were predicted by nonambulatory status (p = 0.037), increased intraoperative blood loss (p = 0.012), increased intraoperative time (p = 0.046), greater pelvic obliquity at follow-up (p = 0.028), and greater magnitude of sagittal profile at follow-up (p = 0.048). Pulmonary comorbidity (p = 0.001), previous operations (p = 0.013), history of seizures (p = 0.046), diagnosis of myelomeningocele (p = 0.046), increase in weight postoperatively (p < 0.005), and increased lumbar lordosis at follow-up (p = 0.015) were identified as risk factors for perioperative infection. CONCLUSIONS These results suggest that in neuromuscular scoliosis, patients with preexisting pulmonary compromise and greater intraoperative blood loss have the greatest risk of experiencing a major perioperative complication following surgical deformity correction.