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There are not, as yet, clear indications for the surgical management of scoliosis in Duchenne muscular dystrophy (DMD), taking into account the varying severity of the clinical course. Monitoring the vital capacity can be most important for the indication and timing of surgery. In some cases, delaying surgical intervention with conservative management using spinal braces and wheelchair inserts can permit the restrictive lung syndrome to advance to the point that surgery will be contraindicated. Ten such patients conservatively treated for an average of 5 years exhibited perhaps a slower progression but ultimately an advanced deformity. From a second group of five carefully selected and surgically treated patients, indications for spinal surgery were reviewed. Surgical intervention should be prophylactically undertaken when there is high risk of a rapidly evolving curve with a severe restrictive lung syndrome.

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Duchenne muscular dystrophy (DMD), which presents with progressive muscle weakness and associated complications, can be characterized by two principal phases of evolution (Fig. 1). Children with DMD often experience difficulties attaining all motor milestones and oniy achieve independent ambulation at a mean age of eighteen months.' The first, or ambulatory, phase of DMD extends to about 10 years of age. The ability to run is alwavs severelv attenuated or is never attained. Muscle , strength initially increases, plateaus, and then begins to diminish rapidly by five or six years of age.24 At the outset of the ambulatory stage the child can raise himself from the floor to standing position only by using objects near him to assist his efforts or by manually supporting his hip and knee extensors in the manner described by Gowers (Gowers' sign)." The time required for a child to come to stand using this maneuver (Gowers' maneuver time [GMT]) initially decreases, then plateaus, and ultimately increases until coming to stand is no longer possible, usually at 7 to 8 years of age. The child functions more or less normallv. however. onlv until around this , , , , time,' then the ability to get up from the floor is lost and the ability to walk begins to rapidly deteriorate (period of decreasing ambulation). The child, who has always been subject to falls, falls more frequently. This creates anxiety in the parents and in the child, who incurs considerable risk of injury. Subsequently, the ability to climb stairs, to get up from a chair, and finally, to walk unassisted is lost.3 The second, or wheelchair, phase of DMD, when -walkingis impossible, is discussed elsewhere in this i s s~e .~"During the period of decreasing ambulation, standing balance is increasingly impaired by lower extremity musculotendinous contractures-most notably, hip and knee flexion contractures and equinus ankle deformities."" During this period, the con;entional management strategy has centered around physical therapy and bracing.'' When ambulation is lost or has become too precarious to continue safely, lower extremity subcutaneous musculotendinous releases and muscle transfers have been used to correct deformities and prolong ambulation with orthotic aids."-l3 With this approach, however, physical therapy, often intensively administered, extensive lower extremity bracing, and the use of upper extremity orthotic aids are frequently p r~p o s e d . '~ These add to constraints already imposed on the patient and his family by the disease. In addition, ambulation managed in this way can remain dysfunctional and precarious. 15 We initially tried a late management approach using intensive surgical intervention, which we labeled "surgeryrehabilitation,"15 in order to eliminate the need for bracing. However, we found that it was often difficult for the child to regain lost locomotor abilities or to prolong ambulation in all cases without long le bracin . F5. gAs a result of this experience, a d~stinctly alternative, much simpler, early intervention approach w...