Spinal Deformity in Progressive Neuromuscular Disease: Natural History and Management

Can Rapid Progression in Nonambulatory Cerebral Palsy Scoliosis Be Predicted Using Humeral Head Ossification?

BACKGROUND

Patients with cerebral palsy scoliosis (CPS) experience higher complication rates compared with idiopathic scoliosis and often present for surgery with larger curves. Prediction of an inflection point for rapid deformity progression has proven difficult. A proximal humerus-based skeletal maturity staging system (HS) has been recently validated and is commonly visible on the posteroanterior radiograph. The authors hypothesize that this system can be used to identify a period at which CPS may progress rapidly, perhaps facilitating discussion of timely surgical intervention.

METHODS

A retrospective review was conducted for nonambulatory pediatric patients with CPS who presented between 2009 and 2018 at our institution. All patients were considered for inclusion regardless of operative or nonoperative management. Patients who were skeletally mature at initial evaluation or had prior spine surgery were excluded. The authors analyzed radiographs in each HS available. Survival was calculated for cutoffs of 60 and 70 degrees (numbers found to increase intraoperative and postoperative complications for CPS).

RESULTS

Eighty-six patients with CPS were identified (54 male individuals). Major curves increased significantly between HS 1 and 2 (27.7 to 46.6 degrees, P=0.009) and HS 3 and 4 (53.1 to 67.9 degrees, P=0.023). The proportion of curves ≥70 degrees were significantly different between HS (P<0.001), with the greatest increase between HS 3 and 4 (24% to 51%; ≥70 degrees). The largest drop in the 60/70-degree survival curves was between HS 3 and 4. In a subanalysis, 69% of patients with curves ≥40 degrees but <70 degrees in stage 3 would progress ≥70 degrees by stage 4.

CONCLUSIONS

Identifying a period of rapid curve progression may guide surgical planning before CPS curves become large, stiff, and more difficult to fix. Our findings suggest that humeral skeletal maturity staging is a valuable decision-making tool in neuromuscular scoliosis, with the HS 3 to 4 transition representing the time of the greatest risk of progression. Consider a surgical discussion or shortened follow-up interval for patients with CPS with curves ≥40 degrees who are HS 3.

LEVEL OF EVIDENCE

Level II.

Prolonged Postoperative Intubation After Spinal Fusion in Cerebral Palsy: Are There Modifiable Risk Factors and Associated Consequences?

BACKGROUND

Instrumented spinal fusion is performed to correct severe spinal deformity that commonly complicates cerebral palsy (CP). Prolonged intubation (PI) is a common perioperative complication, though little is known about the risk factors and consequences of this phenomenon.

QUESTIONS/PURPOSES

The purpose of this study was to determine (1) the preoperative and intraoperative risk factors associated with PI after spine surgery for CP; (2) the perioperative and postoperative complications associated with PI; and (3) any long-term impacts of PI with respect to health-related quality of life.

PATIENTS AND METHODS

A retrospective case-control analysis of prospectively collected, multicenter data was performed on patients with Gross Motor Function Classification System (GMFCS) 4 or 5 CP who underwent instrumented spinal fusion. Patients extubated on postoperative day (POD) 0 were in the early extubation (EE) cohort and those extubated on POD 3 or later were in the PI cohort. Comparisons were made between PI and EE groups with respect to several preoperative and intraoperative variables to identify risk factors for PI. Multivariate logistic regression was performed to identify independent predictors of this outcome. The postoperative hospital course, rate of complications, and health-related quality of life at 2 years were also compared.

RESULTS

This study included 217 patients (52% male individuals; mean age, 14.0±2.8 y) who underwent spinal fusion for CP. In this cohort, 52 patients (24%) had EE and 58 patients (27%) had PI. There were several independent predictors of PI including history of pneumonia [odds ratio (OR), 6.2; 95% confidence interval (CI), 1.6-24.3; P=0.01], estimated blood loss of >3000 mL (OR, 16.5; 95% CI, 2.0-134; P=0.01), weight of <37 kg (OR, 6.4; 95% CI, 1.5-27.1), and Child Health Index of Life with Disabilities (CPCHILD) Communication and Social Interaction score of <15 (OR, 10.8; 95% CI, 1.1-107.3; P=0.04). In addition, PI was associated with a higher rate of perioperative and postoperative respiratory (P<0.001), cardiovascular (P=0.014), gastrointestinal (P<0.001), and surgical site (0.027) complications, in addition to prolonged hospitalization (P<0.001) and intensive care unit stay (P<0.001).

CONCLUSIONS

Surgeons should seek to optimize nutritional status and pulmonary function, and minimize blood loss in patients with CP to decrease the risk of PI after spinal fusion. Efforts should be made to extubate patients on POD 0 to decrease the risk of complications associated with PI.

The International Classification of Functioning, Disability and Health provides a Model for Adaptive Seating Interventions for Children with Cerebral Palsy

Children with severe types of cerebral palsy use adaptive seating systems to encourage function and assist in delaying the development of deformity. These systems are often assessed for and provided by occupational therapists. However, there has been no unifying policy or theoretical basis on which these systems are provided and research evidence is lacking, with studies tending to be small and non-controlled.

The International Classification of Functioning, Disability and Health (World Health Organisation 2001a,b) aims to establish a common language for clinical practice as well as research, while bringing together the opposing social and medical models of health care delivery. This paper suggests that the ICF model is an ideal theoretical basis for adaptive seating system assessment and provision, given that these systems often conflict between the medical model of reducing or delaying impairment of body functions and structures and the social model of children and families accessing life and environmental situations through mobility and seating equipment.

The paper considers all the domains of the ICF with regard to the current literature. It concludes that using the model in the context of providing adaptive seating gives occupational therapists both a powerful tool for communicating with children and families as well as managers and a basis for evaluating practice.

Pain experience, expression and coping in boys and young men with Duchenne Muscular Dystrophy - A pilot study using mixed methods

There is limited research exploring the pain experience of boys and young men with Duchenne Muscular Dystrophy.

METHODS

We conducted a mixed-methods pilot study to assess the feasibility of using particular measures of pain, pain coping and quality of life within semi-structured interviews with boys and young men with Duchenne Muscular Dystrophy and a postal survey of their parents. Non-probability, convenience sampling was used.

RESULTS

Twelve young men aged 11-21 years (median 15 years), three of whom were still ambulant, and their parents/guardians were recruited. The measures used were acceptable to the young men and demonstrated potential to provide useful data. Two-thirds of young men suffered from significant daily pain which was associated with reduced quality of life. Pain complaints were largely kept within the family. Young men's pain-coping strategies were limited by their restricted physical abilities. Statistical power based on these preliminary results suggests a study of approximately 50 boys/young men which appears feasible.

CONCLUSIONS

Further study is needed to explore acceptable and effective methods of pain management in this population and ways of enhancing pain-coping strategies. In clinical practice, assessment of pains and discomfort should form part of all routine consultations.

Correction of severe pelvic obliquity using maximum-width segmental sacropelvic screw fixation: an analysis of 20 neuromuscular scoliosis patients

STUDY DESIGN

The present study was a retrospective analysis.

OBJECTIVE

The purpose of the study was to evaluate the safety and efficacy of the maximum-width (M-W) segmental sacropelvic fixation technique, comprising iliac screws and/or iliosacral pedicle screws, to correct severe pelvic obliquity. Classic spinal fixation using the Luque-Galveston procedure for the correction of neuromuscular scoliosis may be inadequate to manage severe pelvic obliquities.

METHODS

A series of 20 consecutive patients with severe neuromuscular spinopelvic deformities was reviewed by an independent observer. Coronal and sagittal Cobb angle, frontal pelvic obliquity, and trunk shift were measured preoperatively, immediately postoperatively and at final follow-up.

RESULTS

All 20 patients underwent spinal fusion with instrumentation extending to the pelvis. Fourteen cases had primary operations, and six patients had undergone previous spinal fusion above the pelvis, requiring extension to the pelvis. The mean age of the patients at surgery was 13 years, and the mean duration of the follow-up period was 36 months. The mean preoperative Cobb angle was 84° (range 56°-135°), which was corrected to a mean of 41° (range 8°-75°) postoperatively. At the final follow-up, the mean spinal curve remained at 42° (range 10°-75°). The mean preoperative pelvic obliquity was 42° (range 15°-105°), which was corrected by 78 % to 9° (range 0°-49°) postoperatively, with a pelvic obliquity of 10° (range 2°-49°) at final follow-up. Comparing the results of the present study with results in the literature describing the Luque-Galveston or unit rod techniques, despite patients in the present study having a greater mean pelvic obliquity (42° compared with 21° in the literature), a 78 % correction was still achieved, which is similar and, in certain instances, superior to the results of other published case series (78 % compared with 53 %).

CONCLUSIONS

Maximum-width (M-W) segmental sacropelvic fixation, comprising iliosacral screws and/or iliac screws, enables a superior correction of severe pelvic obliquity in patients with neuromuscular scoliosis.

Treatment of spine deformity in neuromuscular diseases

Surgical management of spinal deformity in neuromuscular diseases (NMDs) often requires a multidisciplinary approach beginning in the preoperative surgical planning period, owing to concomitant restrictive lung disease and cardiomyopathy in selected NMD conditions. The need for thorough and thoughtful discussions must occur with the family and other caregivers before any scheduled surgery. The decision to proceed with spinal instrumentation may alter functional abilities in weak and marginally ambulatory NMD patients. With care and treatment involving a multidisciplinary team, proper planning, and support, patients will likely experience rewarding outcomes and improved quality of life.

Consensus treatment recommendations for late-onset Pompe disease

INTRODUCTION

Pompe disease is a rare, autosomal recessive disorder caused by deficiency of the glycogen-degrading lysosomal enzyme acid alpha-glucosidase. Late-onset Pompe disease is a multisystem condition, with a heterogeneous clinical presentation that mimics other neuromuscular disorders.

METHODS

Objective is to propose consensus-based treatment and management recommendations for late-onset Pompe disease.

METHODS

A systematic review of the literature by a panel of specialists with expertise in Pompe disease was undertaken.

CONCLUSIONS

A multidisciplinary team should be involved to properly treat the pulmonary, neuromuscular, orthopedic, and gastrointestinal elements of late-onset Pompe disease. Presymptomatic patients with subtle objective signs of Pompe disease (and patients symptomatic at diagnosis) should begin treatment with enzyme replacement therapy (ERT) immediately; presymptomatic patients without symptoms or signs should be observed without use of ERT. After 1 year of ERT, patients' condition should be reevaluated to determine whether ERT should be continued.

Aging with muscular dystrophy: pathophysiology and clinical management

Major advances in the fields of medical science and physiology, molecular genetics, biomedical engineering, and computer science have provided individuals with muscular dystrophy (MD) with more functional equipment, allowing better strategies for improvement of quality of life. These advances have also allowed a significant number of these patients to live much longer. As progress continues to change management, it also changes patients' expectations. A comprehensive medical and rehabilitative approach to management of aging MD patients can often fulfill expectations and help them enjoy an enhanced quality of life.

Pediatric rehabilitation: 4. Prescribing assistive technology to promote community integration

OBJECTIVE

This self-directed learning module highlights the equipment and assistive technology needs of children and youth with disabilities. This article specifically focuses on preparing families and patients for equipment transitions that occur over the course of childhood and adolescence including progressing from stroller to wheelchair to powerchair, as well as job training and use of augmentative communication. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to modify the learner's current practice techniques to ensure that assistive technology is used to promote community integration from early childhood through transition and into adulthood.

Clinical etiological classification of scoliosis: report of 1289 cases

OBJECTIVE

With the development of diagnostic techniques and in-depth understanding of lateral curvature of the spine (scoliosis), it is possible to differentiate idiopathic scoliosis from other forms with various known etiologies. The present study was to analyze data collected at the authors' center according to the current etiological spectrum and classification of scoliosis.

METHODS

One thousand, two hundred and eighty-nine consecutive patients with different forms of structural scoliosis were reviewed. The average age at first visit was 18 years, ranging from 4 months to 79 years. Corrective surgery was performed on patients aged from 9 to 28 years; their clinical data were retrieved for independent statistical analyses, and further compared with those obtained from the whole group.

RESULTS

The prevalence of non-idiopathic scoliosis was 25.3% in the whole series, but it increased to 34% in the surgical group aged from 9 to 28 years. Thirty-nine percent of patients with congenital scoliosis presented at least one developmental spinal cord malformation.

CONCLUSION

The current study has shown that the etiological distribution of scoliosis has changed a lot from what was true decades ago. Developmental malformation related to scoliosis is one of the risk factors for neurological complications during corrective surgery, so it is important to make an accurate diagnosis and take appropriate prophylactic measures to avoid relative neurological complications.

Neuromuscular scoliosis treated by segmental third-generation instrumented spinal fusion

We aimed to investigate whether the outcome and complications of surgical treatment of neuromuscular curves with segmental third-generation instrumentation could compare with those reported with standard second-generation instrumentation. The clinical and radiologic data of a single surgeon's consecutive series of patients with neuromuscular scoliosis treated with two types of newer-generation instrumentation and posterior or anteroposterior approaches were retrospectively and independently reviewed. The results of this study support the concept that third-generation instrumentation is able to provide at least as good results as second-generation instrumentation in the treatment of neuromuscular scoliosis patients, at the expense of a lower complication rate.

Physical complaints in ageing persons with spinal muscular atrophy

OBJECTIVE

While life expectancy is improving for persons with spinal muscular atrophy, new physical complaints may arise. To investigate this, we studied persons with a long duration and severe course (high functional limitations) of the disease.

DESIGN

Cross-sectional descriptive study.

SUBJECTS/PATIENTS

Persons with spinal muscular atrophy.

METHODS

Questionnaires and structured interviews on prevalence of physical complaints and their duration. Of 190 questionnaires 99 were returned; of 23 persons (with the longest disease duration and high functional limitation level) selected for structured medical interviews 9 participated.

RESULTS

Patterns common within and different between the different types of spinal muscular atrophy were identified. Of the 10 most common complaints, types 1-2 had a significantly higher prevalence of kyphoscoliosis, difficulty in coughing, joint contractures and voice/speech problems, while type 3 had a significantly higher prevalence of fatigue. No statistically significant correlation was found between the appearance of physical complaints and disease duration. However, sleeping and swallowing problems were in the 5 most common complaints with the shortest mean time of appearance. The structured interview revealed hypermobility in the hand, suffusion of the eyes, and itching as new complaints with high prevalence.

CONCLUSION

There are indications that the frequency of less well-known physical complaints increases with ageing.

Practical problems and management of seating through the clinical stages of Duchenne's muscular dystrophy

OBJECTIVE

To describe seating problems in patients with Duchenne's muscular dystrophy (DMD), for the purpose of identifying management solutions that are practicable for both patient and caregiver.

DESIGN

Case series.

SETTING

A Japanese long-term care facility.

PARTICIPANTS

Ninety-five patients with DMD (mean age, 15.9+/-4.4y; Swinyard stages: stage 5, n=17; stage 6, n=24; stage 7, n=33; stage 8, n=21).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Spinal deformity types, frequency and sites of pain, wheelchair propulsive ability, activities of daily living, and caregiving-related problems.

RESULTS

Thirty-three percent of the patients belonged to the early straight group, 21% to the scoliotic group, 20% to the kyphoscoliotic group, 2% to the kyphotic group, and 24% to the extended spine group. The percentage needing support for sitting was higher in patients with spinal deformities (76% vs 0%, P<.05). Forty-one percent had pressure problems, and the percentage increased with advancing stages, with pain sites related to spinal deformity types. Self-feeding was difficult in 10 patients having spinal deformities. Four patterns of manual wheelchair propulsion were observed: upper extremity, anteroposterior trunk flexion, lateral trunk flexion, and wrist-hand patterns; and propulsion became increasingly less practical in this order. For toileting, more patients were cared for on wheelchairs with backrests reclined with stage progression. Of 60 caregivers, 58% experienced trauma related to seating systems.

CONCLUSION

The seating problems that were identified enabled specific, practical suggestions to be made for better management.

Scoliosis and severe pelvic obliquity in a patient with cerebral palsy: surgical treatment utilizing halo-femoral traction

STUDY DESIGN

Case report of severe scoliosis and associated pelvic obliquity in a 14-year-old patient with cerebral palsy.

OBJECTIVES

To report the presentation of the case, the operative considerations, and the management of this spinal deformity.

SUMMARY OF BACKGROUND DATA

Spinal deformity in cerebral palsy may include scoliosis, kyphosis, and hyperlordosis. Pelvic obliquity is a frequent feature associated with neuromuscular scoliosis. The severity of the pelvic obliquity deformity presented here is unusual, and this case study delineates an effective surgical treatment plan for these patients using intraoperative halo-femoral traction.

METHODS

A same-day, two-stage surgical reconstruction was performed to effectively correct this spinal deformity. The patient underwent an anterior spinal fusion from T10 to S1 and a posterior spinal fusion from T2 to the pelvis; the posterior procedure was performed with the patient in intraoperative halo-femoral traction. Sacral fixation was obtained using the Galveston technique bilaterally.

RESULTS

The patient responded well to surgical intervention, had no complications, and continues to have stable correction of his pelvic obliquity deformity 2 years after surgery.

CONCLUSION

It is concluded that scoliosis with associated severe pelvic obliquity deformities can be treated with anterior and posterior spinal fusion and instrumentation with intraoperative halo-femoral traction in the properly selected and prepared patient with cerebral palsy.