Treatment and complications in flaccid neuromuscular scoliosis (Duchenne muscular dystrophy and spinal muscular atrophy) with posterior-only pedicle screw instrumentation

Abstract

Literature has described treatment of flaccid neuromuscular scoliosis using different instrumentation; however, only one article has been published using posterior-only pedicle screw fixation. Complications using pedicle screws in paralytic neuromuscular scoliosis has not been described before. To present results and complications with posterior-only pedicle screws, a retrospective study was carried out in 27 consecutive patients with flaccid neuromuscular scoliosis (Duchenne muscular dystrophy and spinal muscular atrophy), who were operated between 2002 and 2006 using posterior-only pedicle screw instrumentation. Immediate postoperative and final followup results were compared using t test for Cobb angle, pelvic obliquity, thoracic kyphosis and lumbar lordosis. Perioperative and postoperative complications were noted from the hospital records of each patient. Complications, not described in literature, were discussed in detail. Average follow-up was 32.2 months. Preoperative, immediate postoperative and final follow-up Cobb angle were 79.8°, 30.2°(63.3% correction, p \ 0.0001) and 31.9°, respectively; and pelvic obliquity was 18.3°, 8.9°(52% correction, p \ 0.0001) and 8.9°. Postoperative thoracic kyphosis remained unchanged from 27.6°to 19.9°(p = 0.376); while lumbar lordosis improved significantly from ?15.6°t o -22.4°lordosis (p = 0.0002). Most patients had major to moderate improvement in postoperative functional and ambulatory status compared to the preoperative status. Thirteen (48.1%) perioperative complications were noted with five major complications (four respiratory in the form of hemothorax or respiratory failure that required ventilator support and one death) and eight minor complications (three UTI, two atelectasis, two neurological and one ileus). Postoperatively, we noted complications, such as coccygodynia with subluxation in 7, back sore on the convex side in 4 and dislodging of rod distally in 1 patient making a total of 12 (44.4%) postoperative complications. Of 12 postoperative complications, 6 (50%) required secondary procedure. We conclude that although flaccid neuromuscular scoliosis can be well corrected with posterior-only pedicle screw, there is a high rate of associated complications.

Duchenne muscular dystrophy: the management of scoliosis

“…During the early stages of pedicle screw use, there was evidence that their technical difficulty to insert, especially into osteopenic bone, led to higher rates of complications compared to a sublaminar alone system (60).…”

“…This led to the development of the hybrid method using both techniques which showed improved outcomes (60,61).…”

Hemothorax caused by the trocar tip of the rod inserter after minimally invasive transforaminal lumbar interbody fusion: case report

“…They concluded that the cause of the hemothorax was breaching of the lateral wall of the pedicle or the anterior vertebral body cortex during pedicle screw probing or insertion. 10 Pang et al reported a hemothorax caused by a Gelpi retractor during posterior surgery for adolescent idiopathic scoliosis. 14 In the present case, a postoperative CT scan confirmed a hematoma of the left paravertebral muscle at the T-11 level, which is the skin entry point of the trocar tip.…”

Pelvic fixation for neuromuscular scoliosis deformity correction

“…Together with the recent trend to treat neuromuscular scoliosis patients with pedicle screws instrumentation through a posterior-only approach, the use of screws instead of smooth rods to anchor the ilium is increasingly documented in the literature [32,33,67,68]. It offers the theoretical advantage of diminishing implant pullout or cutout associated with a smooth rods inserted in the iliac wings.…”

“…Most authors report this technique for the treatment of neuromuscular scoliosis in pediatric patients without additional sacral fixation. Proximal spinal anchorage is done with sublaminar wires [67,71] or with pedicle screws from the L5 level [32,33,72].…”