Neuromuscular Scoliosis

Brian Snyder

Operative Indications

Expected benefit outweighs negative consequences of natural history and surgical risks
Curve >50° with progression
Difficulty with seating, failed bracing
Age >10 versus <10 years → fusion versus growth sparing instrumentation
Adequate hip range of motion for sitting
Stable medical status (nutrition, pulmonary, neurologic)

Preoperative Workup

Pulmonary—restrictive lung disease
- FVC < 25%—higher risk of complications
- Upper airway obstruction—tonsillectomy/adenoidectomy
- Need for BiPAP, CPAP, cough assist
Seizure medications (valproic acid increases bleeding)
Gastrointestinal disorders—reflux, constipation
Nutrition—poor nitrogen balance = poor wound healing
- ANC > 1200, albumin > 3
- G-tube
Cardiomyopathy—left ventricular (LV) ejection fraction < 50% contraindication
Osteopenia—poor purchase of bone anchors
- Vitamin D supplement, bisphosphonates if previous fragility fractures

High-Risk Spine Protocol

Screen for methicillin-resistant Staphylococcus aureus (MRSA; swab nares, axilla, groin/anus)
Chlorhexidine shower night before
Alcohol + ChloraPrep skin prep
Antibiotics within 1 hour of incision, 24 hours postop
Cephalexin + aminoglycoside to lessen risk surgical site infection; plus vancomycin if there is methicillin resistant staph aureus (MRSA)
Tranexamic acid (TXA) to decrease blood loss
Titanium instrumentation
Prior to wound closure:
- Dilute povidone lavage (3 minutes); debride necrotic tissue
- Sprinkle 1 g of vancomycin powder into wound
- Soak allograft in gentamycin irrigation solution × 2 hours
- Drains deep to muscle closure—prevent hematoma

Positioning

Standard spine table
Headrest with pressure off eyes (Figure 6.1)
- Halo ring for significant kyphosis, expected prolonged operative time, traction cases
Muscular releases may be needed prior to spine surgery in order to position patient. This may include pectoralis release, biceps and wrist flexor release, hip releases, and hamstring releases (Figure 6.2)
Halo-femoral traction
- Halo ring with single or bilateral femoral traction pins
  - Single pin in ipsilateral femur of high pelvis side
  - Levels pelvis and improves flexibility of lumbar curve