The Musculoskeletal Aspects of Obesity in Neuromuscular Conditions

Team Approach: The Management of Adolescents and Adults with Scoliosis and Spina Bifida

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Globally, the prevalence of myelomeningocele, the most common subtype of spina bifida, is 0.2 to 6.5 per 1,000 live births. In the U.S., adults account for >67% of the overall population with spina bifida.

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With an estimated prevalence of up to 50%, scoliosis is one of the most common and severe orthopaedic conditions in patients with myelomeningocele.

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The variable effects that scoliosis can have on an individual, the comorbidities associated with progressive scoliosis, and the risks associated with spine surgery call for a strong partnership and care coordination between medical and surgical teams to deliver a patient-centered approach.

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A coordinated, structured, planned, and incremental team approach can help individuals achieve the overall goals of functionality and independence, as well as successful transition to adulthood.

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Teams should consider a patient's social determinants of health (e.g., poverty or language barriers) and the effect of scoliosis on quality of life before proceeding with spinal deformity correction.

Perioperative Optimization of Patients With Neuromuscular Disorders Undergoing Scoliosis Corrective Surgery: A Multidisciplinary Team Approach

STUDY DESIGN

Narrative review.

OBJECTIVE

The high rate of complications associated with the surgical management of neuromuscular spinal deformities is well documented in the literature. This is attributed to attenuated protective physiological responses in multiple organ systems.

METHODS

Review and synthesis of the literature pertaining to optimization of patients with neuromuscular scoliosis undergoing surgery. Our institutional practice in the perioperative assessment and management of neuromuscular scoliosis is also described along with a clinical vignette.

RESULTS

Respiratory complications are the most common to occur following surgery for neuromuscular disorders. Other categories include gastrointestinal, cardiac, genitourinary, blood loss, and wound complications. A multidisciplinary approach is required for perioperative optimization of these patients and numerous strategies are described, including respiratory management.

CONCLUSION

Perioperative optimization for patients with neuromuscular disorders undergoing corrective surgery for spinal deformity is multifaceted and complex. It requires a multidisciplinary evidence-based approach. Preadmission of patients in advance of surgery for assessment and optimization may be required in certain instances to identify key concerns and formulate a tailored treatment plan.

The Impact of Body Mass Index (BMI) on 30-day Outcomes Following Posterior Spinal Fusion in Neuromuscular Scoliosis

STUDY DESIGN

Retrospective.

OBJECTIVE

Assess the impact of varying severity of BMI on 30-day outcomes following posterior spinal fusions in neuromuscular scoliosis.

SUMMARY OF BACKGROUND DATA

Obesity in the pediatric population is shown to be associated with adverse outcomes across varying specialties. The weight-outcome relationship in neuromuscular scoliosis has not been thoroughly investigated.

METHODS

The 2012-2016 American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) database was queried using Current Procedural Terminology codes 22800, 22802, and 22804 to identify patients undergoing posterior spinal fusion for neuromuscular scoliosis only. BMI was classified into four groups based on the Center for Disease Control (CDC) BMI-for-age percentile chart - Normal weight (BMI ≥5th to <85th percentile), Underweight (<5th percentile), Overweight (≥85th to <95th percentile) and Obese (≥95th percentile). Multivariate regression models were built to understand the impact of varying BMI severity classes on 30-day outcomes.

RESULTS

A total of 1291 patients underwent posterior spinal fusion for neuromuscular scoliosis. A total of 695 (53.8%) were normal weight, 286 (22.2%) were underweight, 145 (11.2%) were overweight, and 165 (12.8%) were obese. Obese patients versus normal weight patients were at a significantly higher risk of surgical site infections (OR 2.15; P = 0.035), wound dehiscence (OR 1.58; P = 0.037), urinary tract infections (OR 3.41; P = 0.010), and 30-day readmissions (OR 1.94; P = 0.029). Of note, overweight versus normal weight individuals had higher odds of cardiopulmonary complications (OR 8.82; P = 0.024). No significant associations were seen for varying BMI and other 30-day outcomes.

CONCLUSIONS

Obese neuromuscular patients undergoing PSF have higher odds of experiencing adverse outcomes, particularly surgical site infections, urinary tract infections, and readmissions. Providers should promote prevention strategies, such as dietary modification and/or early physical activity in these high-risk patients to minimize the risks of experiencing complications in the acute postoperative period.

LEVEL OF EVIDENCE

3.