Predominantly posterior instrumentation and fusion in neuromuscular and neurogenic scoliosis in children and adolescents

Abstract

We studied the results in 46 patients with neuromuscular and neurogenic scoliosis (average age 13.5 years, range 6-19 years) who had had posterior fusion with a modified Luque technique between May 1985 and June 1992. The main criteria to recommend surgery were curve progression, loss of balance when sitting, control of the head and difficulties in wearing an external orthotic support. The mean preoperative curve was 63 degrees, the postoperative value was 24 degrees, representing a correction of about 62%. The average number of stabilized segments was 13. In 39 out of 46 patients, lumbosacral fixation was included in the construct. Failure of implants, pseudarthroses and major losses of correction in purely neuromuscular scolioses could be avoided by using rigid segmental fixation and a dorsolateral fusion with a mixture of autologous and allogenous bone. The scoliosis most difficult to influence was found to be Friedreich's ataxia. In Duchenne muscular dystrophy the best method of treatment was surgery performed as early as possible, i.e. at the time of loss of walking capacity in the case of a scoliosis exceeding 20 degrees and with two consecutive X-rays proving curve progression. Analysis of our series does not confirm the morbidity and complication rates of previous studies.

Spinal fusion in patients with Duchenne's muscular dystrophy and a low forced vital capacity

“…Historically, curves of greater than 20-35°have been considered suitable for surgery, as the progression of the curve is associated with a marked decline in respiratory function [2,3,5,7,9,13,15,17,19,21]. In addition, early spinal fusion has been suggested, as by the time the curve is greater than 35°, the FVC is almost always less than 40% PFVC [2,7,16,19,20,21].…”

“…In addition, early spinal fusion has been suggested, as by the time the curve is greater than 35°, the FVC is almost always less than 40% PFVC [2,7,16,19,20,21]. This gives the benefits of a faster procedure with less blood loss, a fuller correction of the scoliosis and a less turbulent post-operative period due to better respiratory function.…”

“…Over the last 20 years, surgical intervention has been advocated as the treatment of choice for DMD scoliosis. The aim of surgery is to maintain the seated posture and balance in these patients, and thus their quality of life [2,3,5,6,7,9,12,13,15,17,18,19,20,21,22,23]. Even though surgery removes the scoliotic contribution to deteriorating vital capacity, it improves neither pulmonary function nor life expectancy [7,10,11,15,19].…”

Can the caudal extent of fusion in the surgical treatment of scoliosis in Duchenne muscular dystrophy be stopped at lumbar 5?

“…Natural history studies on neuromuscular scoliosis demonstrated an almost invariable progression [2,18,31,33]. The progression of untreated spinal deformity in this population causes increasing pain [14,35], difficulties in sitting [2,9,22,27], decreased pulmonary function [4,27] and an increase in mortality [28]. Surgical management is the most reliable treatment for this deformity.…”

“…Several studies have reported that instrumentation and fusion to the sacrum/pelvis should be reserved for patients with large coronal curves ([40°) and severe pelvic obliquity ([10°) [27,35,37]. However, the indications for extending the instrumentation and fusion to the pelvis/sacrum have remained controversial [23,30].…”