Complications after posterior spinal fusion in Duchenne's muscular dystrophy

Patients with Duchenne's muscular dystrophy often develop progressive scoliosis. Should spinal stabilization be necessary, these patients are considered at high risk for surgically related complications. This retrospective study of 30 patients with Duchenne's examined the prevalence and types of complications associated with posterior spinal fusion and determined the percentage of patients who lived > or = 2 years beyond surgery. Major complications related to cardiopulmonary compromise, infection, or hardware complications occurred in 27%, and minor complications occurred in another 16%. Seventy-seven percent of the patients lived > or = 2 years beyond their surgery. The majority of patients and their families, including half of those who had major complications, reported that surgery resulted in an improvement in their quality of life. Although complications are common, the benefits realized by the patient with Duchenne's muscular dystrophy with scoliosis reinforce the importance of surgical stabilization.

[Anesthetic management of a pediatric patient with non-Fukuyama type congenital muscular dystrophy]

Non-Fukuyama type congenital muscular dystrophy (n-FCMD), a subtype of progressive muscular dystrophy (PMD), is a very rare autosomal recessive disorder. N-FCMD is characterized by severe and progressive motor weakness and atrophies of proximal muscles during the infant period. A 9-year-old boy with n-FCMD underwent elective surgery for muscle release around the hip joints bilaterally. As many perioperative complications related with volatile anesthetics and muscle relaxants had been reported in the anesthetic management of PMD, these drugs were thought to be contraindicated in patients with n-FCMD. Because n-FCMD seemed to have very similar pathogenesis with PMD, caudal epidural block was chosen, supplemented with the administration of diazepam, pentazocine and nitrous oxide. The operation and anesthesia were conducted uneventfully. No complications occurred postoperatively.

[Oculopharyngeal myopathies: value of myotomy of the superior sphincter of the esophagus. Apropos of a case]

Since 3 years, a 74 year-old man suffered of swallowing impairment, weight loss, bilateral ptosis and proximal muscular weakness. Electron microscopy disclosed intranuclear tubular filaments and confirmed the diagnosis of oculopharyngeal muscular dystrophy. Upper oesophageal sphincter myotomy was performed with complete improvement. Four months after surgery, swallowing disorders were not recurrent and weight gain was substantial.

In situ rigidity of a new sliding rod for management of the growing spine in Duchenne muscular dystrophy

STUDY DESIGN

This biomechanical, in vitro laboratory study determined the static stiffness of a new telescoping rod and the axial motion of this implant during various loading conditions.

OBJECTIVES

To compare the stability of the new telescoping rod with the classic Luque instrumentation, and to determine whether the sliding rod elongates or contracts during spine motion.

SUMMARY OF BACKGROUND DATA

A new telescoping rod was developed to stabilize the spine in children with Duchenne muscular dystrophy and to provide capacity for spinal growth.

METHODS

The stability of 11 instrumented calf spines was determined in flexion, extension, lateral bending, and torsion to determine the stiffnesses of the spines instrumented with these two implants. The telescoping motion in the left and right rod was measured in the new rod system.

RESULTS

In flexion, the spines with the telescoping rods were stiffer than those with the Luque implant. However, no significant differences in the stiffness coefficients were found for extension, lateral bending, or torsion. The restoring force of the telescoping system was greater than that of the Luque system in all directions. All modes of loading produced an accommodating change of length in the construct.

CONCLUSIONS

The dynamic telescoping system provides stiffness comparable with that of established systems while allowing elongation during growth of the young patient.

Anatomo-experimental study for lace fixation of winged scapula in muscular dystrophy

Winging of the scapula is one of the major features of the rare facio-scapulo-humeral muscular dystrophy. Several methods of retention and fixation of the scapulae have been published, but most have technical disadvantages or complications. A modified method of operative fixation of the scapula to the chest using three polyester laces is described with the results of cadaveric studies on the stability of this system. In order to determine the optimal region for the scapula fixation using polyester laces we performed pull-out tests on twenty cadaver scapulae. Four points of insertion in the inferior part of the scapula were tested. The lateral margin showed the best results with regard to the tensile strength and the morphology of the resulting fractures. The elongation of the laces was measured as well. Compared to scapulothoracic arthrodesis interscapulo-scapulocostal scapulopexy leads to greater preserved mobility between the scapula and the chest wall and conserves vital capacity.

Thoracoscapular fusion in facioscapulohumeral dystrophy: clinical review of a new surgical method

A new method of scapulothoracic fusion is described for patients with facioscapulohumeral dystrophy. To improve upper limb function by abolishing scapula winging, bilateral procedures were performed in six patients with an average age of 30 years (range 17 to 44 years). The average follow-up was 49 months (range 1 to 7 years). A good functional and cosmetic result was obtained in all patients. An average postoperative increase in shoulder abduction of 28 degrees and flexion of 40 degrees was seen. Only a small diminution in respiratory function occurred (mean decrease in forced expiratory volume in 1 second of 14% and forced vital capacity of 21%).

Spinal fusion in Duchenne's muscular dystrophy

The Women's and Children's Hospital experience with Luque spinal fusion in Duchenne's muscular dystrophy was reviewed from its commencement in 1983 to the present with a view to assessing the clinical and radiologic outcome and safety of the procedure. Seventeen boys have undergone spinal fusion. L-rod instrumentation was used in 10, six of whom had significant problems with sitting imbalance or progression of the scoliosis or both. In seven cases, distal instrumentation was taken to the pelvis with a Galveston construct and rigid crosslinking. Apart from some progression and sitting imbalance in the L-rod group, there were few complications. In the Galveston group, pelvic obliquity was corrected by a mean of 63%, and there was better maintenance of correction. There were no pseudoarthroses or instrument failures in the Galveston group. Of the total group, four patients had forced vital capacity (FVC) values < 25% predicted, and two required ventilation postoperative (< 48 h). There were no other respiratory complications. The effect of surgery on respiratory function remains uncertain. Spinal fusion with the Luque rod construct and pelvic fixation is a safe procedure. It provided a mean correction of 60% and control of pelvic obliquity without significant postoperative deterioration. In our experience, surgery can be safely performed with FVC value down to 20% predicted. On the basis of these data, one current practice is to instrument to the pelvis with a Galveston construct and Texas Scottish Rite Hospital cross-linking.

[Preoperative risk assessment of children with Duchenne muscular dystrophy and relevance for anesthesia and intra- and postoperative course]

BACKGROUND

Patients suffering from muscle disorders have an elevated anesthetic risk, i.e. to develop malignant hyperthermia or rhabdomyolysis. In addition serious cardial and pulmonal complications are imminent during anesthesia for surgery.

PATIENTS AND METHODS

We investigated retrospectively the preoperative risk factors of 81 Duchenne patients undergoing 101 anesthesia (79 for muscle releasement operations and 23 for spine surgery) and the relation to possible complications due to the anesthesia and the intra- and postoperative course.

RESULTS AND DISCUSSION

83% of the patients showed pathologic ECG, 26% cardiac insufficiency in echocardiography, 31% pathologic X-rays of the thorax and 73% serious pulmonary restriction. Consequently avoiding of anesthetic agents with a high trigger potential for developing malignant hyperthermia (i.e. halothane or muscle relaxants type succinylcholine) prevented severest complications as malignant hyperthermia, rhabdomyolysis or cardiac arrest. Nevertheless other complications (i.e. arrhythmia, cardiac insufficiency) occurred due to the cardiac and pulmonary limitations more pronounced in the older patients of the spine surgery group.

Long-term results of spine surgery in Duchenne muscular dystrophy

We report the long-term orthopaedic and functional results of segmental spinal instrumentation and fusion in 30 Duchenne patients. Twenty-nine had a mean 59% correction of scoliosis with post-operative immobilization in a brace of only three months on average and with a very limited loss of correction over time. One died after cardiac arrest. The mean vital capacity preoperatively was 57 +/- 17% with a decrease to 34 +/- 13% at 3.9 +/- 2 yr after surgery. The sitting position, aesthetic improvement and the quality of life after spinal fusion have been positively evaluated by the large majority of the patients and their parents. Head control was lost in the 14 patients who developed a more severe extension contracture of the neck measured as a significantly longer chin-sternum distance. More than 90% would have the operation or would give their consent again for their son having the operation.

Effect of spinal surgery on lung function in Duchenne muscular dystrophy

BACKGROUND

The effect on subsequent respiratory function of spinal stabilisation for scoliosis in Duchenne muscular dystrophy is unclear. In order to clarify this clinical problem, changes in the forced vital capacity of a group of children with Duchenne muscular dystrophy who had undergone spinal surgery were measured and compared with a group of children with Duchenne muscular dystrophy who had not had surgery.

METHODS

In this retrospective study 17 boys with Duchenne muscular dystrophy who underwent spinal stabilisation at a mean age of 14.9 years (surgical group) were compared with 21 boys with Duchenne muscular dystrophy who had not had surgery (non-surgical group). The mean (SD) Cobb angle of the surgical group at 14.9 years was 57 (16.4) degrees, and of the non-surgical group at 15 years was 45 (29.9) degrees. Forced vital capacity expressed as percentage predicted (% FVC) was measured in total over a seven year period in the surgical group and over 6.5 years in the non-surgical group, and regression equations were calculated. Survival curves for both groups were also constructed.

RESULTS

No difference was found between spinal stabilisation (surgical group) and the non-surgical group in the rate of deterioration of % FVC which was 3-5% per year. There was no difference in survival in either group.

CONCLUSIONS

Spinal stabilisation in Duchenne muscular dystrophy does not alter the decline in pulmonary function, nor does it improve survival.

Clinical results of early orthopaedic management in Duchenne muscular dystrophy

Although the primary defect of Duchenne muscular dystrophy has been found, there is no causal treatment to alter the natural course of this disease. Based on the recommendations by Glorion and Rideau with early treatment of contractures of the hips and the lower limbs we performed a modified release of the spina muscles, resection of tensor fasciae latae muscle and a lengthening of the tendo calcaneus in 32 patients. The mean age of DMD patients at time of operation was 6.1 years. The mean follow-up was 3.4 years. All children underwent mobilisation the day after surgery. Complete correction of all contractures was immediately achieved after operation and kept in all but two cases up to the follow-up examination after 3.4 years. No loss of ambulation was observed. Our results demonstrate that early selective surgery in DMD patients just at or better before the onset of contractures without performing an additional aponeurectomy of the iliotibial band and percutaneous tenotomy of the hamstrings according to the original Glorion-Rideau technique safely prevents severe contractures and thereby delays the progression of scoliosis.

[Treatment results of modified Glorion-Rideau release in Duchenne muscular dystrophy]

Although the cause of Duchenne muscular dystrophy has been recently found, there is no causal treatment to alter the natural course of this disease. Based on the recommendations by Glorion and Rideau with early treatment of contractures of the hips and the lower limbs we performed a modified release of the spina muscles, resection of tensor fasciae latae and a lengthening of the tendo calcaneus in 32 patients. The mean ae of DMD patients at time of operation was 6.1 yrs. The mean follow-up was 3.4 yrs. All children underwent mobilization the day after surgery. Complete correction of all contractures was immediately achieved after operation and kept in all but two cases up to the follow-up examination. No loss of ambulation was observed. Our results demonstrate that early selective surgery in DMD patients before or just at the onset of contractures without performing an additional aponeurectomy of the iliotibial band and percutaneous tenotomy of the hamstrings according to the original Glorion-Rideau-technique safely prevents severe contractures and should prolong ambulation.

[Spinal anesthesia for patients with progressive muscular dystrophy]

Spinal anesthesia was applied on 8 occasions to 7 patients with progressive muscular dystrophy (PMD) undergoing orthopedic lower limb surgery. No postoperative complication occurred in all patients. During the operations, however, two patients were subjected to high spinal anesthesia, which caused ventilatory suppression in one patient and bronchial asthma attack in another. Both respiratory complications were easily managed by ventilatory assistance with endotracheal intubation or by administration of bronchodilator, respectively. High spinal anesthesia should be avoided in applying spinal anesthesia to patients with PMD.

Importance of lower limb surgery in Duchenne muscular dystrophy

A total of 123 patients with Duchenne muscular dystrophy (DMD) was surgically treated during two different periods of their course by hip and knee release, aponeurectomy of the iliotibial band and z-shaped Achilles' tendon lengthening. In 57 patients (group I) this was carried out prophylactically as retractions of the lower limb joints were just beginning at the age of 6.4 +/- 1.43 years and in 66 patients (group II) as mild contractures of the joints at the end of walking ability were already manifest with an average age of 9.27 +/- 1.86 years. The average follow-up was 3.7 +/- 1.2 years in both groups. To be able to assess the interindividual course of both groups, we defined "joint and motor quotients", which allowed a complex assessment of joint function and motoric capacity. In addition, both groups were compared with a control group (natural history) consisting of 100 non-operated DMD patients. In both groups a significant release of the contractures could be obtained primarily. Patients in group I showed a much better long-term effect than those in group II. The motor quotient in group I was significantly better over the whole follow-up period (P < 0.001) than in group II or the control group. The prolongation of walking ability by about 2 years compared with the natural history is in our opinion not the central goal of this surgical treatment concept of lower limbs in DMD, but rather the additionally achieved prolongation of an assisted standing ability with the lower limbs free from contractures and deformities.(ABSTRACT TRUNCATED AT 250 WORDS)

[Presentation of a treatment concept of Duchenne muscular dystrophy with the aim at improvement and restoration of walking and standing ability]

A concept for treating progressive muscular dystrophy type Duchenne is presented. It aims at the improvement of quality of life by surgery of the lower extremities. 60 Duchenne patients were treated by a standard operating regime. The different stages of the disease required different postoperative rehabilitation measures.

[Sevoflurane anesthesia for a patient with facioscapulohumeral muscle dystrophy]

We gave anesthesia to a patient with facioscapulohumeral muscle distrophy (FSHMD). Patient was an 18 year old male, having no peculiar complaint and without family history nor past history relating to FSHMD. The restriction of right arm lifting was pointed out in medical examination. Diagnosis of FSHMD was made by muscle biopsy. The thoraco-scapula fixation was scheduled. Four hours prior to the induction, dantrolene 50 mg was administered per os. Before the induction, to estimate the effect of neuromuscular blockade, we applied Datex Relaxograph to the upper and lower extremities. Anesthesia was induced with thiamylal 200 mg and vecuronium 4 mg, and maintained with sevoflurane and nitrous oxide monitoring ETCO2. The time for the onset of muscular relaxation after the administration of vecuronium was quite different between upper and lower extremities (200 sec. and 407 sec.). Neostigmine and atropine for the reversal of neuromuscular blockade was administered evaluating the extent of neuromuscular relaxation obtained from Datex Relaxograph. We concluded that Relaxograph is essential as a monitor of muscular relaxation, especially in the case of neuromuscular disease.