Posterior spinal fusion to sacrum in non-ambulatory hypotonic neuromuscular patients: Sacral rod/bone graft onlay method

Abstract

PurposeA retrospective study involving 65 non-ambulatory patients with hypotonic neuromuscular scoliosis has assessed the effectiveness of a sacral rod/bone onlay technique for extending spinal fusion to the sacrum.MethodsTo extend posterior spinal fusion to the sacrum, we used either 1 Harrington rod and 1 Luque L rod with sublaminar wires in 14 patients (Group 1) or two rods with sublaminar wires in 51 patients (Group 2) along with abundant autograft and allograft bone covering the ends of the rods.ResultsDiagnoses were Duchenne muscular dystrophy 53, spinal muscular atrophy 4, myopathy 3, limb girdle muscular dystrophy 2, infantile FSH muscular dystrophy 1, cerebral palsy 1, and Friedreich ataxia 1. Mean age at surgery was 14.3 years (±2.2, range 10.9–25.2). Radiographic follow-up (2 years post-surgery or greater) was 6.4 years (±4.4, range 2–25.3). Using the onlay technique, all patients fused with no rod breakage or pseudarthrosis. For the entire series, the mean pre-operative scoliosis was 54.7° (±31.1, range 0°–120°) with post-operative correction to 21.8° (±21.7, range 0°–91°) and long-term follow-up 24° (±22.9, range 0°–94°). For pelvic obliquity, pre-operative deformity was 17.3° (±11.3, range 0°–51°) with post-operative correction to 8.9° (±7.8, range 0°–35°) and long-term follow-up 10.1° (±8.1, range 0°–27°). Five required revision at a mean of 3.3 years post-original surgery involving rod shortening at the distal end. One of these had associated infection.ConclusionLumbosacral stability and long-term sitting comfort have been achieved in all patients. Problems can be minimized by positioning the rods firmly against the sacrum at the time of surgery with a relatively short extension beyond the L5–S1 junction. The procedure is valuable in hypotonic non-ambulatory neuromuscular patients whose immobility enhances the success rate for fusion due to diminished stress at the lumbosacral junction. It is particularly warranted for those with osteoporosis and a small, deformed pelvis. Considerable weight loss and lengthy rods not closely apposed to the sacrum at the time of surgery played a major role in patients needing revision.

Simultaneous progression patterns of scoliosis, pelvic obliquity, and hip subluxation/dislocation in non-ambulatory neuromuscular patients: An approach to deformity documentation

“…Pelvic flexibility decreasing obliquity can be seen on a sitting antero-posterior spinal radiograph in brace, compared with a sitting radiograph out of brace, and it is also visible at times on supine radiographs qualitatively compared to the upright sitting views. While pelvic obliquity and early flexibility are recognized in the scoliosis literature, the obliquity frequently becomes rigid and its correction is one of the main reasons why spinal fusions are extended to the pelvis [ 1 , 7 , 8 , 16 , 25 ]. Documentation of pelvic flexibility, however, unlike with spine and hip, is not standardized and generally is not done.…”

Early limited instrumentation of scoliosis in Duchenne muscular dystrophy: is a single-rod construct sufficient?

“…operative Cobb angle of 24°, indicates that the decision to operate was taken at a time 4 earlier than other series [6,7,12]. An overall correction to mean of 15.6° signifies that 5 stabilization takes precedence over deformity correction.…”