Neuromuscular Scoliosis Patients Research Articles

The effect of antibiotic-impregnated calcium sulfate beads and Medical Optimization Clinic attendance on the acute surgical site infection rate in high-risk pediatric neuromuscular and syndromic scoliosis patients.

Neuromuscular and syndromic (NMS) scoliosis patients are at higher risk of acute surgical site infections (SSIs). Despite following POSNA's endorsed consensus-based guidelines for SSI prevention, our institutional rates of acute SSI have varied dramatically. This variability drove simultaneous strategies to lower SSI rates: the creation of a preoperative Medical Optimization Clinic (MOC) and use of antibiotic-impregnated (Abx-I) calcium sulfate beads. Patients undergoing index PSF at a single institution between 2016 and 2022 were retrospectively reviewed. Patients with ≥ 2 risk factors were included: (1) BMI < 18.5 or > 25; (2) incontinence; (3) instrumentation to pelvis; (4) non-verbal; (5) GMFCS IV/V. SSI was defined as deep infection within 90days. We compared patients who attended MOC and received Abx-I (MOC + Abx-I) to those receiving neither intervention (control) nor a single intervention. 282 patients were included. The overall infection rate was 4.26%. Higher GMFCS (p = 0.0147), non-verbal status (p = 0.0048), and longer fusions (p = 0.0298) were independently associated with infection rate. Despite the MOC + Abx-I group having larger Cobb angles (88° ± 26°), higher GMFCS levels (4.5 ± 0.9), ASA class (3 ± 0.4), and more frequent instrumentation to the pelvis (85%), they had the lowest infection rate (2.13%) when compared to the control (4.2%) or single intervention groups (5.7%, 4.6%) (p = 0.9). The study examined the modern infection rate of NMS patients following the implementation of two interventions: MOC and Abx-I. Despite having higher risk factors (curves (88°), GMFCS level (4.5), ASA class (3), higher % instrumentation to the pelvis (85%)), the patients treated with both interventions demonstrated the lowest infection rate (2.13%).

Pelvic Fixation Technique Using the Ilio-Sacral Screw for 173 Neuromuscular Scoliosis Patients.

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.

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.

Rett Syndrome-Associated Scoliosis: Analysis of National Trends and Treatment Patterns of a Rare Indication for Posterior Instrumented Fusion.

Retrospective database cohort study. To evaluate U.S. treatment trends and inpatient outcomes for children undergoing posterior spinal fusion (PSF) for Rett syndrome (RTT)-associated scoliosis (RAS). RTT is a rare, sporadic neurodevelopmental disorder presenting in childhood with developmental regression, ataxia, and seizures. RAS occurs in 50% to 80% of cases of RTT, but little is known about the case volume and perioperative experience for children undergoing PSF. Using the International Classification of Diseases Ninth and 10th revision codes in the national Kids' Inpatient Database, we identified children with RTT who underwent PSF from 2000 to 2019. Annual case volumes were analyzed. Clinical characteristics and outcomes were compared with those of a cohort of patients with neuromuscular scoliosis (NMS). Among 220 patients with RAS, 216 (98.2%) were females (mean age at surgery: 12.3±3.3yr). Surgical case incidence steadily increased over 19 years, with more RAS admissions in the South (31.4%). Overall, patients with RAS demonstrated a higher mean Elixhauser Comorbidity Index score (2 vs . 1, P < 0.001) and had more perioperative complications (41.4% vs . 18%, P < 0.001) than patients with NMS. RTT diagnosis independently predicted higher odds of any complications (odds ratio: 1.98, P < 0.001) and increased length of stay (odds ratio: 1.18, P = 0.009) for admissions for PSF. Surgical treatment for RAS is rare but increased over a 19-year period. Cases appear to be clustering by region, with the highest proportion in the South. The higher Elixhauser Comorbidity Index in RAS patients predicted higher costs, longer hospital stays, more complications (particularly respiratory), and more nonroutine discharge disposition than in other patients with NMS. RTT was independently associated with higher odds of complications and longer length of stay. Because RAS cases appear to be increasing in number, future studies should emphasize methods to reduce morbidity and investigate deformity-specific metrics to help better understand this population.

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.

Clinical and radiological efficacy of spino-pelvic fixation in the treatment of neuromuscular scoliosis

Pelvic fixation is performed to obtain proper coronal and sagittal alignment when the pelvic obliquity is more than 15º in patients with neuromuscular scoliosis (NMS). Since many NMS patients were wheelchair or bed-ridden status, there has been controversy on the effect of pelvic fixation. Therefore, the purpose of this study is to analyze the effects of pelvic fixation on correction of spinal deformity and quality of life (QoL) in NMS patients. A total of 77 NMS patients who underwent deformity correction were divided into three groups and retrospectively analyzed preoperatively, postoperatively, and at 2-year follow-up: pelvic fixation group (Group A, n = 16), fixed to S1 (Group B, n = 33), and fixed to L5 (Group C, n = 28). The correction rate of scoliosis was 60.0%, 58.0%, and 56.7% in groups A, B, and C, respectively, with no statistical difference (P > 0.05). The correction rate of pelvic obliquity was 61.3%, 42.8%, and 57.5% in respective groups A, B, and C, with no significance (P > 0.05). The correction loss of scoliosis and pelvic obliquity showed no statistical significance between three groups for 2-year follow-up (all Ps > 0.05). There were no significant differences regarding clinical outcomes and postoperative complications among the three groups (all Ps > 0.05). Therefore, pelvic fixation using iliac screws is not substantially influencing radiological and clinical outcomes in the patients with NMS.

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.

Posterior Spinal Fusion Surgery for Neuromuscular Disease Patients with Severe Scoliosis Whose Cobb Angle Was over 100 Degrees.

Background and objectives: Patients with neuromuscular diseases usually have progressive neuromuscular scoliosis (NMS), requiring invasive surgery. Some patients present with severe scoliosis at the time of consultation and are difficult to treat. Posterior spinal fusion (PSF) surgery combined with anterior release and pre- or intraoperative traction would be effective for severe spinal deformities but would be invasive. This study aimed to evaluate the outcomes of PSF-only surgery for patients with severe NMS with a Cobb angle > 100°. Materials and Methods: Thirty NMS patients (13 boys and 17 girls; mean age 13.8 years) who underwent PSF-only surgery for scoliosis with a Cobb angle > 100° were included. We reviewed the lower instrumented vertebra (LIV), duration of surgery, blood loss, perioperative complications, preoperative clinical findings, and radiographic findings, including Cobb angle and pelvic obliquity (PO) in the sitting position pre- and postoperatively. The correction rate and correction loss of the Cobb angle and PO were also calculated. Results: The mean duration of surgery was 338 min, intraoperative blood loss was 1440 mL, preoperative %VC was 34.1%, FEV1.0 (%) was 91.5%, and EF was 66.1%. There were eight cases of perioperative complications. The Cobb angle and PO correction rates were 48.5% and 42.0%, respectively. We divided the patients into two groups: the L5 group, in which the LIV was L5, and the pelvis group, in which the LIV was the pelvis. The duration of surgery and PO correction rate in the pelvis group were significantly higher than those in the L5 group. Conclusions: Patients with severe NMS demonstrated severe preoperative restrictive ventilatory impairments. PSF surgery without anterior release or any intra-/preoperative traction showed satisfactory outcomes, including acceptable scoliosis correction and improved clinical findings, even in patients with extremely severe NMS. Instrumentation and fusion to the pelvis for severe scoliosis in patients with NMS showed good PO correction and low correction loss of Cobb angle and PO, but a longer duration of surgery.

Health-related quality of life after segmental pedicle screw instrumentation: a matched comparison of patients with neuromuscular and adolescent idiopathic scoliosis

Progressive neuromuscular scoliosis (NMS) often requires a long instrumented spinal fusion to improve health-related quality of life (HRQoL) and sitting balance. Segmental pedicle screw instrumentation improves HRQoL in patients with adolescent idiopathic scoliosis (AIS), but data on NMS is limited. We aimed to assess the impact of spinal fusion on HRQoL in NMS patients. We conducted a retrospective case-control study with prospective data collection of NMS patients undergoing posterior spinal fusion at a tertiary level hospital in 2009-2021. 2 controls with AIS matched for sex and age were selected for each NMS patient. The Scoliosis Research Society-24 (SRS-24) questionnaire was utilized for pre- and postoperative HRQoL assessment. Follow-up time was a minimum of 2 years. 60 NMS and 120 AIS patients were included in the analysis, and the mean age (SD) at operation was 14.6 (2.7) in NMS and 15.7 (2.5) in AIS groups. Total SRS score and all domains showed a significant improvement in NMS patients (p < 0.05). Total SRS score improved more (p < 0.001), while pain score improved less (p = 0.04) in NMS (change [95% CI], 0.31 [0.05-0.58] and 0.55 [0.27-0.81]) compared with AIS (0.01 [-0.10 to 0.12] and 0.88 [0.74-1.03]). Postoperative self-image was significantly better in NMS than in AIS at 2-year follow up (p = 0.01). Pelvic instrumentation reduced improvements in the SRS domains. HRQoL in NMS patients improved significantly after spinal fusion, and these benefits are comparable to those of AIS patients.

Utilizing two surgeons for neuromuscular scoliosis suggests improved operative efficiency.

Neuromuscular scoliosis (NMS) patients tend to have significant comorbidities with complex medical and surgical histories. When undergoing posterior spinal fusion (PSF), NMS risks can be much higher than the idiopathic population. This study aimed to identify the impact of two experienced pediatric cosurgeons (CS) compared to a single spine surgeon (SS) on the intra- and postoperative results of NMS PSF. A database of NMS patients who had undergone PSF 2016-2021 identified 53 patients, of which 32 were CS, while 21 were SS. Patients' sex, age, weight, diagnosis, curve severity, fusion performed, estimated blood loss (EBL), transfusion rates, hemoglobin, anesthesia and surgical times, length of stay, and complications were collected. Patient demographics were similar between groups. Curves were more severe in the CS group (p = 0.013). Intraoperatively, CS patients underwent larger corrections (p = 0.089) but in significantly shorter anesthetic (p = 0.0018) and operative (p = 0.0025) times. Blood loss and transfusions were similar. Postoperatively, intensive-care unit (ICU) admission and length of stay (LOS) were similar, but SS had higher rates of both unplanned ICU admissions (p = 0.36) and 30day readmissions (p = 0.053). Complications overall were similar between the groups both within 30days (p = 0.40) and in the short-term period (31-90days, p = 0.76), though the CS cohort had less Grade 2 immediate postoperative pulmonary complications (p = 0.16). Utilizing CS for NMS PSF has been found to reduce operative times. Downstream, additional potential impacts trended toward fewer unplanned ICU admissions, less-frequent postoperative pulmonary complications, and reduced 30-day readmission rates.

Perioperative Risk Factors for Bleeding in Adolescents Undergoing Pedicle Screw Instrumentation for Scoliosis.

Progressive scoliosis eventually leads to extensive spinal fusion surgery, which carries a risk for significant bleeding. Neuromuscular scoliosis (NMS) patients have an additional inherent risk of major perioperative bleeding. The purpose of our research was to investigate the risk factors for measured (intraoperative, drain output) and hidden blood loss related to pedicle screw instrumentation in adolescents, divided into adolescent idiopathic scoliosis (AIS) and NMS patient groups. A retrospective cohort study with prospectively collected data of consecutive AIS and NMS patients undergoing segmental pedicle screw instrumentation at a tertiary level hospital between 2009 and 2021 was conducted. In total, 199 AIS (mean age 15.8 years, 143 females) and 81 NMS patients (mean age 15.2 years, 37 females) were included in the analysis. In both groups, levels fused, increased operative time, and smaller or larger size of erythrocytes were associated with perioperative blood loss (p < 0.05 for all correlations). In AIS, male sex (p < 0.001) and the number of osteotomies correlated with more drain output. In NMS, levels fused correlated with drain output, p = 0.00180. In AIS, patients' lower preoperative MCV levels (p = 0.0391) and longer operation times, p = 0.0038, resulted into more hidden blood loss, but we did not find any significant risk factors for hidden blood loss in NMS patients.

Plastic multilayered closure versus orthopedic surgeon closure after spinal instrumentation in pediatric neuromuscular scoliosis

ObjectiveTo compare wound complication rates between orthopedic closure (OC) and plastic multilayered closure (PMC) in patients undergoing primary posterior spinal fusion for neuromuscular scoliosis (NMS). We hypothesize that multilayered closure...

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.

A Nationwide Study Characterizing the Risk and Outcome Profiles of Multilevel Fusion Procedures in Neuromuscular Scoliosis Patients with Neurofibromatosis Type 1

Spine abnormalities are a common manifestation of Neurofibromatosis Type 1 (NF1); however, the outcomes of surgical treatment for NF1-associated spinal deformity are not well explored. The purpose of this study was to investigate the outcome and risk profiles of multilevel fusion surgery for NF1 patients. The National Inpatient Sample was queried for NF1 and non-NF1 patient populations with neuromuscular scoliosis who underwent multilevel fusion surgery involving eight or more vertebral levels between 2004 and 2017. Multivariate regression modeling was used to explore the relationship between perioperative variables and pertinent outcomes. Of the 55,485 patients with scoliosis, 533 patients (0.96%) had NF1. Patients with NF1 were more likely to have comorbid solid tumors (P < 0.0001), clinical depression (P < 0.0001), peripheral vascular disease (P < 0.0001), and hypertension (P < 0.001). Following surgery, NF1 patients had a higher incidence of hydrocephalus (0.6% vs. 1.9% P= 0.002), seizures (4.9% vs. 5.7% P= 0.006), and accidental vessel laceration (0.3% vs.1.9% P= 0.011). Although there were no differences in overall complication rates or in-hospital mortality, multivariate regression revealed NF1 patients had an increased probability of pulmonary (OR 0.5, 95%CI 0.3-0.8, P= 0.004) complications. There were no significant differences in utilization, including nonhome discharge or extended hospitalization; however, patients with NF1 had higher total hospital charges (mean -$18739, SE 3384, P < 0.0001). These findings indicate that NF1 is associated with certain complications following multilevel fusion surgery but does not appear to be associated with differences in quality or cost outcomes. These results provide some guidance to surgeons and other healthcare professionals in their perioperative decision making by raising awareness about risk factors for NF1 patients undergoing multilevel fusion surgery. We intend for this study to set the national baseline for complications after multilevel fusion in the NF1 population.

Avoiding PICU admission following PSF for neuromuscular scoliosis in non-ambulatory cerebral palsy managed with ERAS protocol.

Children with neuromuscular scoliosis (NMS) undergoing posterior spinal fusion (PSF) have historically been managed post-operatively in the pediatric intensive care unit (PICU) due to institutional tendencies. This study sought to define risk factors for PICU admission when using an enhanced recovery after surgery (ERAS) pathway. A retrospective review of children with non-ambulatory (GMFCS 4 or 5) cerebral palsy undergoing PSF for NMS performed at two institutions by 5 surgeons. Both institutions have a pre-existing ERAS pathway for NMS patients consisting of post-surgical transfer to the hospital floor with early reinstitution of feeding and mobilization. PICU admission is used at the discretion of the surgeon and anesthesiologist rather than by institutional decree. Patient and surgical factors were assessed for risk factors of PICU admission. A total of 103 children were included (84% GMFCS 5, mean 14.52years (± 3.4years)). Forty children (38.8%) required postoperative PICU admission. PICU admission was associated with seizure disorder (P = 0.09), pre-existing feeding tube (P = 0.003), tracheostomy (P = 0.03), and modified GMFCS-5 subclassification (P = 0.003). Independent predictors of PICU admission include pre-existing feeding (Odd's ratio = 2.9, P = 0.02) and length of surgery (Odd's ratio = 2.6, P < 0.001), with surgery lasting ≥ 5.0h having an 82.5% sensitivity and 63.5% specificity (AUC 0.8, P < 0.001) for post-operative PICU admission. The majority of children with non-ambulatory cerebral palsy can be successfully managed on the hospital floor following PSF. The extent of central neuromotor impairment is significantly associated with PICU admission along with surgery lasting longer than 5h.

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

BackgroundProgressive 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. MethodsA 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. ResultsNeuromuscular 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). ConclusionsHidden 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.

Paraspinal muscle approach for neuromuscular scoliosis: A comparative study evaluating deformity correction and perioperative morbidity in 91 patients with minimum 2-year follow-up.

We present the paraspinal approach use for neuromuscular scoliosis with focus on deformity correction, perioperative (≤30 days) morbidity and outcome at a minimal follow-up length of 2 years. We prospectively collected data of 61 neuromuscular scoliosis patients operated using a paraspinal (Wiltse) approach between 2013 and 2019. We additionally collected data of 104 control cases, operated using a midline approach between 2005 and 2016. Fifteen Wiltse, respectively 37 control patients were excluded due to a short follow-up (<2 years), and 22 controls were excluded secondary to lacking follow-up data. Hence, 46 Wiltse and 45 control patients were compared. Wiltse and control patients had comparable follow-up lengths, demographics, deformity corrections, complication rates, number of levels fused, and intensive care unit and hospital lengths of stay. Wiltse cases had a lower estimated blood loss (535 vs 1187 mL; p-value < 0.001), allogenic transfusion rate (48% vs 96%; p-value < 0.001), and operating time (ORT) (337 vs 428 min; p-value < 0.001) than controls. This was also the case when selecting for patients without pelvic fixation (p-values < 0.001). When selecting the cases with pelvic fixation (20 among 91 cases), only the number of levels fused and the ORT differed significantly according to the approach (p-value <0.015 and <0.041). The paraspinal approach for neuromuscular scoliosis is safe, associated with significant deformity correction, reduced estimated blood loss, and allogenic transfusion rate. These potential benefits still need to be evaluated, especially for cases with pelvic fixation, with further follow-up of larger cohorts. level III.

Neuromuscular Scoliosis: A Dual-Surgeon Approach

Neuromuscular Scoliosis (NMS) causes severe deformity and operative correction for these patients carries high complication rates. We present a retrospective study comparing a series of consecutive patients who underwent posterior fusion via a single-surgeon (SS) approach with a consecutive series of patients treated via a dual-surgeon (DS) approach. Patients with NMS who underwent posterior fusion via a SS approach from 2019 to 2022 were analyzed and compared to a series of patients with NMS who underwent posterior fusion via a DS approach. In the SS group, the average estimated blood loss (EBL) was 675 mL, average length of stay (LOS) was 6.3 days, average operative time (OT) was 6.5 hours, average packed red blood cell transfusion was 1.5 units, with a complication rate of 30%. The DS group had an average EBL of 400 mL, a LOS of 4.8 days, an OT of 4.75 hours, an average packed red blood cell transfusion of 0.8 units, with a complication rate of 20%. The DS approach was significant for a lower EBL, OT (P < 0.001), and LOS (P < 0.03). This study suggests that for patients with NMS the DS approach decreases OT, EBL, complication rates, and LOS. This further supports that this approach may benefit outcomes in NMS patients.

The Early and Late Postoperative Complications of Pediatric Neuromuscular Scoliosis at King Abdulaziz Medical City, Riyadh, Saudi Arabia: A Case Series

Background Neuromuscular Scoliosis (NMS) is defined as “a coronal plane spinal curvature of 10 degrees or more, measured by the Cobb method, in the setting of muscle imbalance secondary to an underlying neuropathic or myopathic disease”. Patients who have the disease usually manifest with diminished balance, asymmetrical seating, abnormal gait, and decreased pulmonary function, which are related to the change in spine posture. Surgery benefits patients with NMS in terms of stopping disease advancement and improving quality of life, but is known to be associated with certain complications in this population. The aim of this study is to identify the most common complication in NMS patients after surgical correction.MethodsThis study is a chart review-based retrospective case series that has covered patients’ data going from 2015 to 2019. The study focused on patients who underwent scoliosis correction surgery of both genders and mainly of a single ethnicity, with the inclusion of patients aged 9 to 18 years old. Under consecutive sampling, the study has met a sample size of 14 patients. ResultsMost of the study subjects nine (64%) were female. The age median was 13 years (2.25). The highest documented intraoperative complication was blood loss in 11 (79%) patients. The most prevalent early postoperative complication was urinary tract infection in two (14%) patients. No late postoperative complications were documented in the study.Conclusion The study concluded that blood loss was the most common intraoperative complication. Pulmonary problems were one of the least reported complications. Possible reasons for these findings and prevention methods should be the focus of future studies.

Effect of pelvic fixation on ambulation in children with neuromuscular scoliosis.

BACKGROUNDThe effect of posterior spinal fusion (PSF) incorporating the pelvis on an ambulatory patient’s ability to mobilize after the fusion is not well understood. AIMTo see whether a posterior spinal fusion with pelvic fixation using iliac or sacral alar iliac screws in ambulatory neuromuscular scoliosis (NMS) patients influences postoperative ambulatory ability.METHODSA retrospective review of all patients with NMS that underwent PSF with fixation incorporating the pelvis between January 1, 2012 and February 29, 2019. A total of 118 patients were eligible, including 11 ambulatory patients. The primary outcome was the maintenance of ambulatory status postoperatively. Secondary outcomes included postoperative curve magnitude, pelvic obliquity, and complications, comprising infections, instrumentation failure, and any unplanned returns to the operative room.RESULTSThe ambulatory function was maintained in all 11 ambulatory NMS patients. One patient had an improvement in functional status with equipment-free ambulation postoperatively. An average postoperative follow-up was 19 mo. The overall complication rate was 19.4% (n = 23) with no significant differences between the groups in infection (P = 0.365), hardware failure (P = 0.505), and reoperation rate (P = 1.0). Ambulatory status did not affect complication rate (P = 0.967).CONCLUSIONSpinal fusion to the pelvis in ambulatory patients with NMS provides effective deformity correction without the reduction in ambulatory capabilities.