Risk factors for progressive neuromuscular scoliosis requiring posterior spinal fusion after selective dorsal rhizotomy

Vijay M. Ravindra Division of Pediatric Neurosurgery, Department of Neurosurgery; and

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Michael T. Christensen Division of Pediatric Neurosurgery, Department of Neurosurgery; and

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Kaine Onwuzulike Division of Pediatric Neurosurgery, Department of Neurosurgery; and

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John T. Smith Division of Pediatric Orthopedic Surgery, Department of Orthopedic Surgery, University of Utah School of Medicine, Salt Lake City, Utah

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Kyle Halvorson Division of Pediatric Neurosurgery, Department of Neurosurgery; and

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Douglas L. Brockmeyer Division of Pediatric Neurosurgery, Department of Neurosurgery; and

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Marion L. Walker Division of Pediatric Neurosurgery, Department of Neurosurgery; and

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Robert J. Bollo Division of Pediatric Neurosurgery, Department of Neurosurgery; and

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OBJECTIVE

Selective dorsal rhizotomy (SDR) via limited laminectomy is an effective treatment of lower-extremity spasticity in the pediatric population. Children with spasticity are also at risk for neuromuscular scoliosis; however, specific risk factors for progressive spinal deformity requiring posterior spinal fusion (PSF) after SDR are unknown. The authors’ goal was to identify potential risk factors.

METHODS

The authors performed a retrospective cohort study of patients who underwent SDR via limited laminectomy between 2003 and 2014 and who had at least 1 year of follow-up. They analyzed demographic, clinical, and radiographic variables to elucidate risk factors for progressive neuromuscular scoliosis. The primary outcome was need for PSF.

RESULTS

One hundred thirty-four patients underwent SDR and had at least 12 months of follow-up (mean 65 months); 48 patients (36%) had detailed pre- and postoperative radiographic data available. The mean age at surgery was 10 years (SD 5.1 years). Eighty-four patients (63%) were ambulatory before SDR, 109 (82%) underwent a single-level laminectomy, and a mean of 53% of the dorsal rootlets from L-1 to S-1 were sectioned. Fifteen patients (11.2%) subsequently required PSF for progressive deformity. Nonambulatory status (p < 0.001) and a preoperative Cobb angle > 30° (p = 0.003) were significantly associated with PSF on univariate analysis, but no statistically significant correlation was found with any clinical or radiographic variable and PSF after SDR on multivariate regression analysis.

CONCLUSIONS

Patients with preoperative nonambulatory status and Cobb angle > 30° may be at risk for progressive spinal deformity requiring PSF after SDR. These are well-known risk factors for progressive deformity in children with spasticity in general. Although our analysis suggests SDR via limited laminectomy may not significantly accelerate the development of neuromuscular scoliosis, further case-control studies are critical to elucidate the impact of SDR on spinal deformity.

ABBREVIATIONS

GMFCS = Gross Motor Function Classification System; ITB = intrathecal baclofen; PSF = posterior spinal fusion; SDR = selective dorsal rhizotomy.
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