Common Complications of Pediatric Neuromuscular Disorders

The Relationship Between Scoliosis, Spinal Bone Density, and Truncal Muscle Strength in Familial Dysautonomia Patients

This combined retrospective and prospective study aimed to investigate the relationship between scoliosis, spinal bone mineral density (BMD), and truncal muscle strength in patients with familial dysautonomia (FD). A total of 79 FD patients (40 male, 39 female) aged 5-44 years were included. The severity of scoliosis, lumbar spine BMD (Z-score), and truncal muscle strength were assessed. Correlations were analyzed using Pearson's correlation coefficient. Inverse correlations were observed between scoliosis severity and BMD (r = - 0.328, p = 0.001), as indicated by increasingly negative Z-score values with worsening osteoporosis. There were also inverse correlations between scoliosis and truncal muscle strength (r = - 0.595, p < 0.001). The correlation between scoliosis and age was notable up to 22 years (r = 0.421, p = 0.01), but not in the older age group (22-44 years). Our study identified inverse correlations between osteoporosis and scoliosis, as well as between scoliosis and truncal muscle strength, in FD patients. These findings suggest that there may be a relationship between bone density, muscle strength, and the severity of spinal curvature in this population. While our results highlight the potential importance of early diagnosis and management of osteoporosis, and possibly the benefits of physical therapy to strengthen truncal muscles, further research is needed to determine the direct impact of these interventions on preventing the progression of scoliosis and its associated complications in FD patients. A long-term longitudinal study could provide more insights into these relationships and inform treatment strategies for FD patients.

Association of Body Mass Index With Disease Progression in Children With Charcot-Marie-Tooth Disease

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the impact of body mass index (BMI) on disease progression over 2 years in children with Charcot-Marie-Tooth disease (CMT).

METHODS

BMI was classified in 242 participants aged 3-20 years with CMT enrolled in the Inherited Neuropathy Consortium, using the International Obesity Task Force (based on adult BMI values, kg/m2) criteria. Groups were categorized as severely underweight (BMI <17 kg/m2), underweight (BMI ≥17 to <18.5 kg/m2), healthy weight (BMI ≥18.5 to <25 kg/m2), overweight (BMI ≥25 to <30 kg/m2), and obese (BMI ≥30 kg/m2). Disease severity was assessed using the CMT Pediatric Scale (CMTPedS), a clinical outcome assessment of disability (0-44 points, mild to severe).

RESULTS

At baseline, compared with individuals being of a healthy weight (mean CMTPedS 15.48, SD 9.22), children who were severely underweight (mean CMTPedS difference 9.03, 95% CI 0.94-17.12; p = 0.02), underweight (mean CMTPedS difference 5.97, 95% CI 0.62-11.31; p = 0.02), or obese (mean CMTPedS difference 7.96, 95% CI 1.03-14.88; p = 0.015) exhibited greater disability. At 2 years, compared with individuals being of a healthy weight (mean CMTPedS 17.53, SD 9.41), children who were severely underweight exhibited greater disability (mean CMTPedS difference 9.27, 95% CI 0.90-17.64; p = 0.02). Over the 2-year periods, the mean CMTPedS for the whole sample deteriorated by 1.72 points (95% CI 1.09-2.38; p < 0.001), with severely underweight children progressing at the fastest rate (mean CMTPedS change of 2.3, 95% CI 1.53-6.13; p = 0.21). In children who did not have a change in BMI categories over 2 years (69% of sample), CMTPedS scores deteriorated faster in those who were severely underweight (mean CMTPedS change 6.40 points, 95% CI 2.42-10.38; p = 0.01) than those of healthy weight (mean CMTPedS change 1.79 points, 95% CI 0.93-2.69; p < 0.001). For children who changed BMI categories (31% of sample), CMTPedS scores deteriorated faster in children who became overweight/obese (mean CMTPedS change 2.76 points, 95% CI 0.11-5.41; p = 0.031).

DISCUSSION

Children with CMT who were severely underweight, underweight, or obese exhibited greater disability at baseline. Over the 2-year period in those whose BMI remained stable, severely underweight children deteriorated at the fastest rate. For children who changed BMI categories over the 2 years, CMTPedS scores deteriorated faster in children who became overweight/obese. Interventions that maintain or improve BMI toward healthy weight may reduce disability in children with CMT.

Sacral-Alar-Iliac (SAI) Fixation in Patients With Previous Pelvic Osteotomy

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

The purpose of this study was to investigate the technical challenges and outcomes of sacral-alar-iliac (SAI) fixation for scoliosis in patients who had previously undergone a pelvic osteotomy for hip dysplasia.

SUMMARY OF BACKGROUND DATA

Patients with neuromuscular disease are at high risk for developing hip dislocation and scoliosis. Surgical correction of one may affect the other.

METHODS

We reviewed the records of patients aged 18 years and below who underwent spinal fusion using SAI screws after having undergone a pelvic osteotomy, with ≥2-year follow-up. We recorded the SAI screw dimensions, time from osteotomy to SAI fixation, type of osteotomy, and any complications performing SAI fixation due to the pelvic osteotomy. Bivariate statistics were used to analyze the data with statistical significance defined as P -value <0.05.

RESULTS

Thirty-two patients were included. The average age was 10.3±3.2 years at pelvic osteotomy and 13.5±3.4 years at SAI fixation. Most patients had cerebral palsy (87.5%) and a unilateral Dega osteotomy (78.1%). Average screw dimensions were significantly shorter on the side of the osteotomy (66 vs. 72 mm, P <0.05). SAI screw placement was technically challenging in 8 patients (25%), due to pelvic distortion from the pelvic osteotomy. The use of a curved awl helped to find the intracortical channel. No patients had complications due to the SAI screw, and there were no significant differences in pelvic obliquity and major coronal curve correction. Two patients (6.3%) had screw lucency >2 mm around the SAI screw on the side of the pelvic osteotomy but no clinical symptoms.

CONCLUSIONS

SAI fixation in patients with previous pelvic osteotomy is technically challenging due to pelvic morphology and prior implants. Often, a shorter SAI screw is required on the side of the osteotomy. However, outcomes in this patient population are satisfactory, with no significant complications at a 2-year follow-up.

LEVEL OF EVIDENCE

Level IV.

Multimodal assessment of spasticity using a point-of-care instrumented glove to separate neural and biomechanical contributions

Accurate assessment of spasticity is crucial for physicians to select the most suitable treatment for patients. However, the current clinical practice standard is limited by imprecise assessment scales relying on perception. Here, we equipped the clinician with a portable, multimodal sensor glove to shift bedside evaluations from subjective perception to objective measurements. The measurements were correlated with biomechanical properties of muscles and revealed dynamic characteristics of spasticity, including catch symptoms and velocity-dependent resistance. Using the biomechanical data, a radar metric was developed for ranking severity in spastic knees and elbows. The continuous monitoring results during anesthesia induction enable the separation of neural and structural contributions to spasticity in 21 patients. This work delineated effects of reflex excitations from structural abnormalities, to classify underlying causes of spasticity that will inform treatment decisions for evidence-based patient care.

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Tool to shift from subjective scales to objective metrics in spasticity evaluation

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Develop a multifaceted metric to rank severity based on biomechanical properties

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Delineate effects of hyper-reflexes and structural abnormalities in spastic muscles

Pelvic Osteotomy in Patients With Previous Sacral-Alar-Iliac (SAI) Fixation

INTRODUCTION

Patients with neuromuscular disease are at high risk for developing hip dysplasia and scoliosis. The purpose of this study was to investigate the technical challenges and outcomes of pelvic osteotomy in patients with prior sacral-alar-iliac (SAI) fixation.

METHODS

We reviewed clinical and radiographic records of patients aged 18 years and below who underwent pelvic osteotomy after SAI fixation. We recorded technical challenges during the osteotomy, time from SAI fixation to osteotomy, type of osteotomy, migration index, and distance from the SAI screw to the acetabulum. A 2-sample Wilcoxon rank-sum test was used to assess the data.

RESULTS

Nineteen patients were included. Technical challenges were defined as having greater intraoperative fluoroscopy times and noted difficult osteotomy in the operative report. The mean time from SAI fixation to pelvic osteotomy was 2.2±1.5 years. For all 12 Chiari osteotomies, the ilium could not be laterally displaced; however, medial displacement of the distal segment of the osteotomy allowed adequate coverage. All 7 Dega osteotomies were performed by cutting the cortex at the tip of the SAI screw. The screw improved proximal leverage and provided a strong buttress for bone graft. The mean migration index before pelvic osteotomy was 59±19%, and at most recent follow-up was 13±4%. Twelve patients, who had a noted complicated osteotomy, had SAI screws that were ≤1.87 cm ( P <0.01) from the acetabulum and significantly increased intraoperative fluoroscopy time (1.76 vs. 1.18 min, P <0.01).

CONCLUSIONS

The presence of SAI screws may cause iliac osteotomies to be technically challenging if the tip of the SAI screw is ≤1.87 cm to the acetabulum. When initially implanting SAI screws in neuromuscular patients, surgeons should attempt to place screw tips ∼2 cm from the acetabulum in the event these patients require subsequent pelvic osteotomy.

LEVEL OF EVIDENCE

Level IV.

Gastrostomy Placement and Management in Children: A Single-Center Experience

BACKGROUND: To prevent malnutrition and food aspiration in children with chronic neuromuscular problems, enteral nutrition provided by gastrostomy is recommended. Long-term follow-up data about surgical and medical complications of PEG are available, but few papers have addressed all of the issues in the same series. METHODS: This retrospective study enrolled patients under 18 years who had a gastrostomy tube placed at our institution between 2003 and 2017. The aim is to evaluate outcomes after gastrostomy placement, focusing both on surgical complications (early and late), and its effect on their nutritional status, on the prevention of pulmonary infections, and their parents’ opinion. RESULTS: Eighty-four gastrostomies were placed in total (35 F; 49 M). Seventy-seven patients had a severe neurocognitive impairment (GMFCS 5). The principal indication for gastrostomy was severe dysphagia (53.3%). No gastrostomy-related death was observed. Early surgical complications were observed in five of 84 (5,9%) patients; late complications were observed in 15 of 84 (17.8%) patients. Twenty-two patients were diagnosed with subsequent gastroesophageal reflux; five patients developed dumping syndrome (6%). Complete medical follow-up data were available for 45 patients. A progressive improvement of nutritional status was observed in 29 patients, and 11 maintained the same percentile; the occurrence of respiratory infections and need for hospitalization decreased. In 90% of cases, parents were fully satisfied with the g-tube. CONCLUSION: This study confirms the positive nutritional outcomes of gastrostomy-tube with an associated small risk of surgical complications and a reduction in the number of respiratory infections, with most parents scoring their experience as positive.

Complications following lengthening of spinal growing implants: is postoperative admission necessary?

OBJECTIVE The aim of this study was to evaluate the effect of postoperative admission status on 30-day perioperative complications in patients with growing spinal instrumentation undergoing surgical lengthening. METHODS This retrospective case-control study of records from the 2014-2015 National Surgical Quality Improvement Program-Pediatric database was performed to identify surgical lengthening procedures of spinal implants in patients with growing instrumentation by Current Procedural Terminology code. The 30-day postoperative complications were classified according to the Clavien-Dindo system. Patients were subdivided according to their postsurgical admission status. Admission status, American Society of Anesthesiologists (ASA) Physical Status classification, tracheostomy, neuromuscular diagnosis, ventilator dependence, and nutritional support were considered as possible risk factors in univariate and multivariate logistic regression analyses. RESULTS A total of 796 patients were identified (mean age 9.09 ± 3.44 years; 54% of patients were female), of whom 73% underwent lengthening on an inpatient basis. Patients with a tracheostomy or ventilator dependence were more likely to be admitted postoperatively. The overall rate of major complications was 3.5% and did not differ based on admission status (2.8% inpatient vs 3.8% outpatient, p = 0.517). On univariate analysis, ventilator dependence (9.5% vs 2.7%, p = 0.002), need for nutritional support (7.1% vs 2.5%, p = 0.006), and ASA class > II (4.8% vs 1.3%, p = 0.04) placed patients at a higher risk for any postoperative complications. Multivariate analysis identified only ventilator dependence as an independent risk factor for any perioperative complication. CONCLUSIONS Postoperative admission status did not affect the rate of 30-day perioperative complications, readmission, or rate of unplanned operations following lengthening of growing spinal instrumentation. Outpatient lengthening appears to be safe; however, consideration for postoperative admission should be given for those who are ventilator dependent.