[Characteristics of neuromuscular scoliosis]

[Etiology, epidemiology, prognosis and biomechanical principles of neuromuscular scoliosis]

Deformity due to neuromuscular disease is often progressive and associated with reduced vital capacity. In general, all treatment should be performed in specialized centers, since invasive measures are associated with an increased morbidity compared to adolescent scoliosis. Derived from the etiology and the resulting biomechanical basis (characteristics), important aspects and considerations arise for all healthcare institutions from the examination interval to the duration of conservative therapy and initiation of surgical therapy. Proper monitoring and assessment are key components to identify curve progression and to achieve preservation or improvement of basic functions.

[Surgical strategies in the treatment of neuromuscular scoliosis]

As part of the underlying condition, neuromuscular scoliosis occurs in early childhood. Compared to idiopathic scoliosis, neuromuscular scoliosis shows a more rapid progress of deformity, which continues even after the end of growth. This progress and the associated complications can only be prevented by surgical treatment. Depending on the patient's age and the extent of the deformity, different strategies have been established: in early childhood, so-called "growing implants" are used, while between the ages of 10 to 12, definitive treatment by reposition and fusion of the deformity is the treatment of choice. In this review, we present different surgical strategies as well as indications for surgery and discuss challenges in the treatment of these complex deformities.

[Cost coverage for complex paediatric spinal deformities with preoperative halo traction-an economic problem?]

BACKGROUND

Spinal surgery is largely reimbursed in a differentiated manner via the DRG system. For treatments of complex paediatric deformities with increased pre and postoperative effort due to special treatment approaches, it seems that the costs for the treatment are not fully covered.

MATERIALS AND METHODS

All paediatric cases with surgical treatment of the spine that were treated in a single spine centre from 2018-2020 were considered. The subgroup of patients with inpatient halo-gravity traction (halo group) before surgery was compared with all other cases treated in terms of economic and demographic factors.

RESULTS

There were 86 cases that were treated surgically without halo traction and 6 cases with halo traction. The groups did not differ significantly in age (p = 0.41) or Patient Clinical Complexity Level (PCCL, p = 0.76). The average length of hospital stay in the halo group was significantly longer than in the other cases (84.2 ± 40.1 d vs. 11.0 ± 6.4 d; p = 0.001). Due to DRG grouping and long-stay surcharges, the mean revenue per case was significantly higher in the halo group than in the other cases (€ 63,615 ± 45,138 vs. € 16,836 ± 9356) (p = 0.003). The contribution margin for the period of the long-term surcharges varied between 11,394 and 9766 €. The high additional costs due to the necessary medical devices of halo traction were not sufficiently reflected in the reimbursement.

CONCLUSION

Paediatric spine surgery can be challenging in special cases. In particular, severe deformities of the spine may require additional procedures. The subgroup of patients requiring preoperative halo traction is not adequately compensated by the DRG system.

Body Posture Defects and Body Composition in School-Age Children

The aim of the study was to assess the relationship between the shape of the anteriorposterior spinal curvature and body composition in schoolchildren. The study included 257 children, aged 11–12. Correct spinal curvature was established in 106 (41.08%) subjects. Other types included: decreased kyphosis and correct lordosis—40 participants (15.50%), correct kyphosis and decreased lordosis—24 individuals (9.30%), increased kyphosis and correct lordosis—17 subjects (6.59%), correct kyphosis and increased lordosis—22 children (8.53%), decreased kyphosis and decreased lordosis—32 people (12.40%), decreased kyphois and increased lordosis—four of the examined subjects (1.55%) increased kyphosis and lordosis—13 people (5.04%). In addition, 134 (51.94%) demonstrated scoliotic posture and eight (3.10%) scoliosis. There were significant relationships between the shape of the anteriorposterior curvatures and body composition in schoolchildren. Those with a strong body build (predominance of mesomorphs) were generally characterised by the correct formation of these curvatures. In contrast, lean subjects (with the predominance of ectomorphic factors) were more likely to experience abnormalities. No correlations with body composition were observed in the group with scoliotic posture or scoliosis. Both in the prevention and correction of postural defects, one should gradually move away from one-sided, usually one-system, therapeutic effects. An approach that takes into account both somatic and neurophysiological factors seems appropriate. With the correct body composition and structure, shaping the habit of correct posture is much easier.

Progressive Neuromuscular Scoliosis Secondary to Spinal Cord Injury in a Young Patient Treated With Nonfusion Anterior Scoliosis Correction

Ninety-eight percent of skeletally immature patients with spinal cord injury (SCI) suffer from progressive neuromuscular scoliosis (NMS). Operative treatment has typically been limited to posterior spinal fusion (PSF), but a newer technique as described may be less invasive and preserve more function. A PSF of the entire spine to the pelvis is standard of care. However, maintenance of spinal flexibility, motion, and potential growth is desirable. We present a case for proof-of-concept of utilizing a surgical motion-preserving technique to treat progressive NMS in an 11year-old girl with T10 level (AIS B) paraplegia with a progressive 60° NMS of the lumbar spine. She had anterior scoliosis correction (ASC) from T11-L5 without fusion. Over 24 months, the curve growth-modulated to a residual of 12° with continued modulation to 7° at 3-year follow-up (skeletal maturity).

Non-home discharge disposition after posterior spinal fusion in neuromuscular scoliosis-an analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database

BACKGROUND

Despite an increasing trend of corrective surgery in patients with neuromuscular scoliosis, evidence regarding risk factors associated with non-home discharge destination following surgery remains limited.

METHODS

The 2012-2016 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database was queried using Current Procedural Terminology codes for patients undergoing posterior spinal fusion (22802, 22804 and 22808) for neuromuscular scoliosis. Non-home discharge was defined as discharge to a skilled nursing facility, rehabilitation facility and/or separate acute care unit. Patients who expired during inpatient stay were excluded from the study sample. Only patients aged 2-18 years with a primary diagnosis of neuromuscular scoliosis were included in the final cohort.

RESULTS

Out of a total of 1,269 patients, 76 (6.0%) had a non-home discharge disposition. Following adjustment for baseline clinical characteristics, patients lying in the age bracket of 15-17 years {odds ratio (OR) 2.27 [95% confidence interval (CI): 1.01-5.08]; P=0.047} or >17 years [OR 2.29 (95% CI: 1.10-4.79); P=0.027], male gender [OR 1.75 (95% CI: 1.06-2.89); P=0.029], having structural pulmonary abnormality at time of surgery [OR 2.01 (95% CI: 1.17-3.43); P=0.011], a length of stay >4 days [OR 2.29 (95% CI: 1.15-4.55); P=0.018] and having a past history of childhood cancer [OR 4.50 (95% CI: 1.15-17.61); P=0.031] were significant independent predictors associated with a non-home discharge.

CONCLUSIONS

Providers can utilize these data to pre-operatively identify patients who might require continued high-level/inpatient care in a facility, and subsequently expedite discharge and reduce costs associated with a prolonged inpatient stay.