10-10-2024
As discussed in previous posts, the indications and issues for surgical treatment of scoliosis in neuromuscular patients (such as cerebral palsy, spina bifida, spinal muscle atrophy, etc.…) can be much different than for other types of scoliosis.
The ambulatory ability of neuromuscular patients can be highly variable. It is important to have a good understanding about the amount of ambulation (distance and frequency), the assistance needed to ambulate, and recent changes to ambulation.
This post is focused on neuromuscular patients who cannot ambulate, but may use a standing frame, and have scoliosis.
These neuromuscular patients have a more “C-shaped” scoliosis, one which is long sweeping. As opposed to idiopathic scoliosis in below picture.
Neuromuscular scoliosis also causes the pelvis or hips to tip, sometime a lot, which can cause significant difficulty sitting since they are putting pressure under one hip and not both and can cause pain.
To help with sitting position the wheelchair can undergo modifications (sitting cushions, side supports, etc.…). Bracing is only an option if the patient has normal or low tone. Patients with high muscle tone do not benefit from bracing.
The failure of nonsurgical management to help the sitting imbalance and pain is when surgery is considered.
Correcting the scoliosis deformity is obviously an important goal of surgery. In neuromuscular patients (such as below) a goal which is just as important is to improve the sitting posture, so correcting the hip position by leveling them, is important.
In a patient who is near or at skeletal maturity or has finished growth, a posterior spinal fusion is typically the recommended procedure.
But what about the young patient (7 years old)? Performing a posterior spinal fusion in this age patient will permanently shorten their trunk (neck to pelvis) distance and can cause long-term breathing problems. So, we would like to correct and control the scoliosis but also allow the spine to grow.
One technique is to use growing rods which can be lengthened in the outpatient clinic. This is done by creating foundation at the top and bottom of the scoliotic spine.
After the surgery the growing rods are painlessly lengthened about every 3 months. Ideally this is continued until the growing rods are maximally lengthened (see below).
At maximal lengthening new rods can be inserted or the surgery can be converted to a definitive posterior spinal fusion. The decision on which surgery to do depends on many factors.