Don’t You Wish You Had Fused to the Pelvis the First Time

Nielsen, Ena; Andras, Lindsay M.; Bellaire, Laura; Fletcher, Nicholas D.; Minkara, Anas; Vitale, Michael G.; Troy, Michael; Glotzbecker, Michael P.; Skaggs, David L.

doi:10.1097/brs.0000000000002888

Cited by 14 publications

(11 citation statements)

References 20 publications

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“…As such, these authors suggest including the pelvis at the index posterior spinal fusion in this patient population. 8 Although the DSA patients in our study had better scores in several EOSQ-24 domains compared with the DPA patients at their most recent follow-up, it is difficult to know how to interpret these data, as we had incomplete preindex EOSQ-24 scores in the database. Nearly 50% of the complications in the DPA group were medical compared with one third of the complications in the DSA group.…”

Section: Discussionmentioning

confidence: 76%

“…Although we did not find a difference in the complication rate between patients with distal spine or DPAs, increased rates of skin breakdown and infection, implant failure, intraoperative blood loss, longer operative times, and limited mobility have been reported with pelvic instrumentation. 1,7,8,15 Thus, it seems pertinent to determine whether exclusion of the pelvis in spinal deformity procedures is warranted in certain subsets of pediatric NMS patients. Takaso et al 10 retrospectively evaluated patients with flaccid NMS who underwent posterior spinal fusion to L5 using segmental pedicle screw instrumentation.…”

Section: Discussionmentioning

confidence: 99%

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Comparison of Distal Spine Anchors and Distal Pelvic Anchors in Children With Hypotonic Neuromuscular Scoliosis Treated With Growth-friendly Instrumentation

Ahmady

Rosenthal

Abraham

et al. 2023

Journal of Pediatric Orthopaedics

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Background: Lower preoperative pelvic obliquity (PO) and L5 tilt have been associated with good radiographic outcomes when the fusion ended short of the pelvis in children with neuromuscular scoliosis (NMS). Our purpose was to identify indications to exclude the pelvis in children with hypotonic NMS treated with growth-friendly instrumentation. Methods: This was a multicenter retrospective review. Children with spinal muscular atrophy and muscular dystrophy treated with dual traditional growing rod, magnetically controlled growing rod, or vertical expandable prosthetic titanium rib with minimum 2-year follow-up after the index surgery were identified. Results: A total of 125 patients met the inclusion criteria. Thirty-eight patients had distal spine anchors (DSAs) and 87 patients had distal pelvic anchors (DPAs) placed at the index surgery. Demographics and length of follow-up were similar between the groups but there was a greater percentage of DPA patients who were nonambulatory [79 patients (91%) vs. 18 patients (47%), P<0.0001]. Preindex radiographic measures were similar except the DSA patients had a lower PO (11 vs. 19 degrees, P=0.0001) and L5 tilt (8 vs. 12 degrees, P=0.001). Postindex and most recent radiographic data were comparable between the groups. There was no difference in the complication and unplanned returns to the operating room rates. Subanalysis of the DSA group based on ambulatory status showed similar radiographic measures except the ambulatory patients had a lower PO at all time points (preindex: 5 vs. 16 degrees, P=0.011; postindex: 6 vs. 10 degrees, P=0.045; most recent follow-up: 5 vs. 14 degrees, P=0.028). Only 1 ambulatory DSA patient had a PO ≥10 degrees at most recent follow-up compared with 6 nonambulatory DSA patients. Three (8%) DSA patients, all nonambulatory, underwent extension of their instrumentation to the pelvis. Conclusions: Pelvic fixation should be strongly considered in nonambulatory children with hypotonic NMS treated with growth-friendly instrumentation. At intermediate-term follow-up, revision surgery to include the pelvis was rare but DSAs do not seem effective at maintaining control of PO in nonambulatory patients. DSA and DPA were equally effective at maintaining major curve control, and complication and unplanned returns to the operating room rates were similar. Level of Evidence: Level III—therapeutic.

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Section: Discussionmentioning

confidence: 76%

Section: Discussionmentioning

confidence: 99%

Comparison of Distal Spine Anchors and Distal Pelvic Anchors in Children With Hypotonic Neuromuscular Scoliosis Treated With Growth-friendly Instrumentation

Ahmady

Rosenthal

Abraham

et al. 2023

Journal of Pediatric Orthopaedics

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“…It is important to note that revision procedures to extend fusion to the pelvis, when unsatisfactory correction occurs, are often difficult and may be associated with greater morbidity. Nielsen et al 18 demonstrated that extension of fusion to the pelvis in neuromuscular scoliosis was associated with double the reoperation rate (excluding the revision itself) and increased the risk of implant failure, pseudarthrosis, and pain compared with fusion to the pelvis initially.…”

Section: Discussionmentioning

confidence: 99%

When to Perform Fusion Short of the Pelvis in Patients with Cerebral Palsy?

et al. 2023

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Background:Patients with scoliosis secondary to cerebral palsy (CP) are often treated with posterior spinal fusion (PSF) with or without pelvic fixation. We sought to establish criteria to guide the decision of whether or not to perform fusion “short of the pelvis” in this population, and to assess differences in outcomes.Methods:Using 2 prospective databases, we analyzed 87 pediatric patients who underwent PSF short of the pelvis from 2008 to 2015 to treat CP-related scoliosis and who had ≥2 years of follow-up. Preoperative radiographic and clinical variables were analyzed for associations with unsatisfactory correction (defined as pelvic obliquity of ≥10°, distal implant dislodgement, and/or reoperation for increasing deformity at 2- or 5-year follow-up). Continuous variables were dichotomized using the Youden index, and a multivariable model of predictors of unsatisfactory correction was created using backward stepwise selection. Finally, radiographic, health-related quality-of-life, and clinical outcomes of patients with fusion short of the pelvis who had neither of the 2 factors associated with unsatisfactory outcomes were compared with those of 2 matched-control groups.Results:Deformity correction was unsatisfactory in 29 of 87 patients with fusion short of the pelvis. The final model included preoperative pelvic obliquity of ≥17° (odds ratio [OR], 6.8; 95% confidence interval [CI], 2.3 to 19.7; p < 0.01) and dependent sitting status (OR, 3.2; 95% CI, 1.1 to 9.9; p = 0.04) as predictors of unsatisfactory correction. The predicted probability of unsatisfactory correction increased from 10% when neither of these factors was present to a predicated probability of 27% to 44% when 1 was present and to 72% when both were present. Among matched patients with these factors who had fusion to the pelvis, there was no association with unsatisfactory correction. Patients with independent sitting status and pelvic obliquity of <17° who had fusion short of the pelvis had significantly lower blood loss and hospital length of stay, and better 2-year health-related quality-of-life scores compared with matched controls with fusion to the pelvis.Conclusions:In patients with scoliosis secondary to CP, pelvic obliquity of <17° and independent sitting status are associated with a low risk of unsatisfactory correction and better 2-year outcomes when fusion short of the pelvis is performed. These may be used as preoperative criteria to guide the decision of whether to perform fusion short of the pelvis in patients with CP.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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“…15,17 Further, when revising patients fused to L5 initially with extensions to the pelvis, there is a higher overall complication rate, risk of implant failure, pseudarthrosis, and revision surgery compared with patients in whom the pelvis was included in the initial operation. 7 In a multicenter retrospective review, Nielsen demonstrated that compared with those with initial pelvic instrumentation, those that were revised to include the pelvis had decreased PO correction (18 vs. 22 degrees). 7 Significantly fewer patients underwent reoperation if treated with fusion to the pelvis at the index procedure (23% vs. 50%), and the revision group had significantly higher rates of implant failure (43% vs. 7%).…”

Section: Consmentioning

confidence: 99%

“…1,2,4,5 Surgical intervention aims to reconstruct a well-aligned, compensated spine over a balanced pelvis while minimizing complications. 2,6,7 Pelvic obliquity (PO) is frequently seen in children with NMS, 8 which may be managed with the extension of the fusion to include the pelvis. Techniques for pelvic instrumentation commonly used at present are iliac and sacral-alar-iliac screws.…”

mentioning

confidence: 99%

When Should Instrumentation to the Pelvis be Considered in Minimally Ambulatory Adolescents With Neuromuscular Scoliosis?

Douleh¹,

Greig²,

Thompson³

et al. 2021

Journal of Pediatric Orthopaedics

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Introduction:The goal of neuromuscular scoliosis (NMS) surgery is to improve sitting balance, facilitate daily care, and alleviate pain. In nonambulatory patients, where sitting balance is key, fusion to the pelvis is usually required. However, in minimally ambulatory patients, fusion to the pelvis remains controversial, and there is considerable practice variability in this patient population. The purpose of this study is to evaluate and summarize the available evidence regarding fusion constructs in minimally ambulatory patients with NMS and to provide expert opinion regarding when fusion to the pelvis should be considered. Methods: A search of the English literature was performed using PubMed to identify papers pertaining to patients with NMS treated with instrumented posterior spinal fusion. Papers published before 2000, case reports, and level V evidence were excluded. Results: The authors identified 8 studies for review. The majority included both nonambulatory and minimally ambulatory patients. Structured review of the literature demonstrated fusion to the pelvis may allow for greater curve and pelvic obliquity correction, but it is also associated with increased blood loss and operative time. There is no evidence that fusing to the pelvis decreases ambulatory status in minimally ambulatory patients. Conclusions: In minimally ambulatory patients with NMS, fusion short of the pelvis may be considered in patients with adequate head control without the presence of hip subluxation or dislocation and when pelvic obliquity is <15 degrees. Fusion to the pelvis is recommended in patients who do not meet these criteria.

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Don’t You Wish You Had Fused to the Pelvis the First Time

Cited by 14 publications

References 20 publications

Comparison of Distal Spine Anchors and Distal Pelvic Anchors in Children With Hypotonic Neuromuscular Scoliosis Treated With Growth-friendly Instrumentation

Comparison of Distal Spine Anchors and Distal Pelvic Anchors in Children With Hypotonic Neuromuscular Scoliosis Treated With Growth-friendly Instrumentation

When to Perform Fusion Short of the Pelvis in Patients with Cerebral Palsy?

When Should Instrumentation to the Pelvis be Considered in Minimally Ambulatory Adolescents With Neuromuscular Scoliosis?

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