title: Posterior spinal fusion to sacrum in non-ambulatory hypotonic neuromuscular patients: sacral rod/bone graft onlay method.
abstract: OBJECTIVE
  A retrospective study involving 65 non-ambulatory patients with hypotonic neuromuscular scoliosis has assessed the effectiveness of a sacral rod/bone onlay technique for extending spinal fusion to the sacrum.
  
  
  METHODS
  To extend posterior spinal fusion to the sacrum, we used either 1 Harrington rod and 1 Luque L rod with sublaminar wires in 14 patients (Group 1) or two rods with sublaminar wires in 51 patients (Group 2) along with abundant autograft and allograft bone covering the ends of the rods.
  
  
  RESULTS
  Diagnoses were Duchenne muscular dystrophy 53, spinal muscular atrophy 4, myopathy 3, limb girdle muscular dystrophy 2, infantile FSH muscular dystrophy 1, cerebral palsy 1, and Friedreich ataxia 1. Mean age at surgery was 14.3 years (±2.2, range 10.9-25.2). Radiographic follow-up (2 years post-surgery or greater) was 6.4 years (±4.4, range 2-25.3). Using the onlay technique, all patients fused with no rod breakage or pseudarthrosis. For the entire series, the mean pre-operative scoliosis was 54.7° (±31.1, range 0°-120°) with post-operative correction to 21.8° (±21.7, range 0°-91°) and long-term follow-up 24° (±22.9, range 0°-94°). For pelvic obliquity, pre-operative deformity was 17.3° (±11.3, range 0°-51°) with post-operative correction to 8.9° (±7.8, range 0°-35°) and long-term follow-up 10.1° (±8.1, range 0°-27°). Five required revision at a mean of 3.3 years post-original surgery involving rod shortening at the distal end. One of these had associated infection.
  
  
  CONCLUSIONS
  Lumbosacral stability and long-term sitting comfort have been achieved in all patients. Problems can be minimized by positioning the rods firmly against the sacrum at the time of surgery with a relatively short extension beyond the L5-S1 junction. The procedure is valuable in hypotonic non-ambulatory neuromuscular patients whose immobility enhances the success rate for fusion due to diminished stress at the lumbosacral junction. It is particularly warranted for those with osteoporosis and a small, deformed pelvis. Considerable weight loss and lengthy rods not closely apposed to the sacrum at the time of surgery played a major role in patients needing revision.
authors.affiliation: Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
authors.forename: Theresa
authors.initials: T
authors.lastname: Bui
authors.forename: Frederic
authors.initials: F
authors.lastname: Shapiro
references.citation: Childs Nerv Syst. 2010 Jan;26(1):81-6
references.pmid: 19629492
references.citation: Spine (Phila Pa 1976). 2005 Sep 15;30(18):2056-60
references.pmid: 16166895
references.citation: Eur Spine J. 2010 Mar;19(3):384-93
references.pmid: 19885687
references.citation: Spine (Phila Pa 1976). 1984 May-Jun;9(4):388-94
references.pmid: 6474253
references.citation: Infect Control Hosp Epidemiol. 2009 Feb;30(2):109-16
references.pmid: 19125680
references.citation: Eur Spine J. 2010 May;19(5):787-96
references.pmid: 20213296
references.citation: J Pediatr Orthop. 2009 Sep;29(6):594-601
references.pmid: 19700989
references.citation: Eur Spine J. 2010 Mar;19(3):376-83
references.pmid: 19760271
references.citation: J Child Orthop. 2011 Feb;5(1):41-8
references.pmid: 22295048
references.citation: Spine (Phila Pa 1976). 1997 Aug 1;22(15):1722-9
references.pmid: 9259782
references.citation: J Pediatr Orthop. 1993 Nov-Dec;13(6):752-7
references.pmid: 8245201
references.citation: J Bone Joint Surg Br. 2004 May;86(4):550-5
references.pmid: 15174552
references.citation: J Bone Joint Surg Am. 1949 Apr;31A(2):400-5
references.pmid: 18116573
references.citation: J Bone Joint Surg Br. 1999 Sep;81(5):821-4
references.pmid: 10530843
references.citation: Clin Orthop Relat Res. 1986 Feb;(203):141-50
references.pmid: 2937592
references.citation: Spine (Phila Pa 1976). 2002 Sep 15;27(18):2072-9
references.pmid: 12634572
references.citation: Spine (Phila Pa 1976). 2001 Sep 15;26(18):1984-9
references.pmid: 11547196
references.citation: J Bone Joint Surg Am. 2013 Jun 19;95(12):1057-61
references.pmid: 23783200
references.citation: Spine (Phila Pa 1976). 1992 Aug;17(8 Suppl):S235-43
references.pmid: 1523506
references.citation: J Bone Joint Surg Br. 2001 Jan;83(1):22-8
references.pmid: 11245532
references.citation: Eur Spine J. 2008 Feb;17(2):255-61
references.pmid: 18057966
references.citation: Childs Nerv Syst. 2011 Nov;27(11):1931-5
references.pmid: 21360168
references.citation: Spine (Phila Pa 1976). 2005 Jun 15;30(12):1396-401
references.pmid: 15959368
references.citation: Spine (Phila Pa 1976). 1989 Mar;14(3):281-3
references.pmid: 2711243
references.citation: Dev Med Child Neurol. 1992 Sep;34(9):775-86
references.pmid: 1526348
references.citation: J Pediatr Orthop. 1997 Jan-Feb;17(1):109-14
references.pmid: 8989712
references.citation: J Bone Joint Surg Am. 2005;87 Suppl 2:89-106
references.pmid: 16326728
references.citation: Spine (Phila Pa 1976). 2010 Dec 1;35(25):2245-51
references.pmid: 21102300
references.citation: Spine (Phila Pa 1976). 2012 Apr 1;37(7):583-91
references.pmid: 21673625
references.citation: Spine (Phila Pa 1976). 2006 Sep 15;31(20):2392-8; discussion 2399
references.pmid: 16985470
references.citation: Muscle Nerve. 1992 May;15(5):604-14
references.pmid: 1584253
references.citation: Spine (Phila Pa 1976). 2009 Mar 1;34(5):436-40
references.pmid: 19247163
references.citation: J Pediatr Orthop. 1992 Jul-Aug;12(4):465-9
references.pmid: 1613088
references.citation: Spine (Phila Pa 1976). 2006 Feb 1;31(3):303-8
references.pmid: 16449903