European Spine Journal

, Volume 19, Issue 3, pp 376–383 | Cite as

Scoliosis in Duchenne’s muscular dystrophy: a changing trend in surgical management

A historical surgical outcome study comparing sublaminar, hybrid and pedicle screw instrumentation systems
  • Ranganathan Arun
  • S. Srinivas
  • S. M. H. Mehdian
Original Article


A non-randomised retrospective study to compare the results of surgical correction of scoliosis in Duchenne’s muscular dystrophy (DMD) patients using three different instrumentation systems—Sublaminar instrumentation system (Group A), a hybrid of sublaminar and pedicle screw systems (Group B) and pedicle screw system alone (Group C). Between 1993 and 2003, 43 patients with DMD underwent posterior spinal fusion and instrumentation. Group A (n = 19) had sublaminar instrumentation system, Group B (n = 13) had a hybrid construct and Group C (n = 11) was treated with pedicle system. The mean blood loss in Group A was 4.1 l, 3.2 l in Group B and 2.5 l in Group C. Average operating times in Group A, B and C were 300, 274 and 234 min, respectively. Mean pre-operative, post-operative and final Cobb angle in Group A was 50.05 ± 15.46°, 15.68 ± 11.23° and 21.57 ± 11.63°, Group B was 17.76 ± 8.50°, 3.61 ± 2.53° and 6.69 ± 4.19° and Group C was 25.81 ± 9.94°, 5.45 ± 3.88°, 8.90 ± 5.82°, respectively. Flexibility index or the potential correction calculated from bending radiographs were 60 ± 6.33, 70 ± 4.65 and 67 ± 6.79% for Group A, Group B and Group C respectively. The percentage correction achieved was 72.5 ± 14.5% in Group A, 82 ± 6% in Group B and 82 ± 8% in Group C. The difference between percentage correction achieved and the flexibility index was 12.45 ± 8.22, 12.05 ± 1.3 and 15.00 ± 1.21% in Group A, B and C, respectively The percentage loss of correction in Cobb angles at final follow-up in Group A, B and C was 12.5 ± 3.5, 16.5 ± 1. and 12.5 ± 2.5%, respectively. Complications seen in Group A were three cases of wound infection and two cases of implant failure; Group B had a single case of implant failure and Group C had one patient with wound infection and one case with a partial screw pull out. Early surgery and smaller curve corrections appears to be the current trend in the management of scoliosis in DMD. This has been possible due to early curve detection and surgery thus having the advantage of less post-operative respiratory complications and stay in paediatric intensive care. Also, early surgery avoids development of pelvic deformity and extension of instrumentation to the pelvis thereby reducing blood loss. This trend reflects the advent of newer and safer instrumentation systems, advanced techniques in anaesthesia and cord monitoring. Sublaminar instrumentation system group had increased operating times and blood loss compared to both the hybrid and pedicle screw instrumentation systems due to increased bleeding from epidural vessels and pelvic instrumentation. Overall, the three instrumentation constructs appear to provide and maintain an optimal degree of correction at medium to long term follow up but the advantages of lesser blood loss and surgical time without the need for pelvic fixation seem to swing the verdict in favour of the pedicle screw system.


Duchenne’s muscular dystrophy Scoliosis Sublaminar instrumentation Hybrid instrumentation Pedicle screw system 


  1. 1.
    Kinali M, Messina S, Mercuri E et al (2006) Management of scoliosis in Duchenne muscular dystrophy: a large 10-year retrospective study. Dev Med Child Neurol 48(6):513–518CrossRefPubMedGoogle Scholar
  2. 2.
    Chataigner H, Grelet V, Onimus M (1998) Surgery of the spine in Duchenne’s muscular dystrophy. Rev Chir Orthop Reparatrice Appar Mot 84(3):224–230PubMedGoogle Scholar
  3. 3.
    Cervellati S, Bettini N, Moscato M, Gusella A, Dema E, Maresi R (2004) Surgical treatment of spinal deformities in Duchenne muscular dystrophy: a long term follow-up study. Eur Spine J 13(5):441–448CrossRefPubMedGoogle Scholar
  4. 4.
    Gayet LE, Duport G, Pries P (1999) Flexible and semi-early vertebral instrumentation in surgical treatment of Duchenne muscular dystrophy scoliosis. Eur J Orthop Surg Traumatol 9(4):223–231CrossRefGoogle Scholar
  5. 5.
    Mehta KS, Gibson MJ (2003) The treatment of neuromuscular scoliosis. Curr Orthop 17(4):313–321CrossRefGoogle Scholar
  6. 6.
    Rideau Y, Glorion B, Delaubier A, Tarlé O, Bach J (1984) The treatment of scoliosis in Duchenne muscular dystrophy. Muscle Nerve 7(4):281–286CrossRefPubMedGoogle Scholar
  7. 7.
    Sussman MD (1984) Advantage of early spinal stabilization and fusion in patients with Duchenne muscular dystrophy. J Pediatr Orthop 4:532–537PubMedGoogle Scholar
  8. 8.
    Forst R, Forst J, Heller KD, Hengstler K (1997) Characteristics in the treatment of scoliosis in muscular diseases. Z Orthop Ihre Grenzgeb 135(2):95–105CrossRefPubMedGoogle Scholar
  9. 9.
    Hopf C, Forst R, Forst J, Eysel P, Reitter B (1994) Multi-segmental fusion of scoliosis in Duchenne’s muscular dystrophy. Z Orthop Ihre Grenzgeb 132(5):377–382CrossRefPubMedGoogle Scholar
  10. 10.
    Bonnett C, Brown JC, Perry J et al (1975) Evolution of treatment of paralytic scoliosis in Rancho Los Amigos hospital. J Bone Joint Surg Am 57:206–215PubMedGoogle Scholar
  11. 11.
    Harrington PR (1962) Treatment of scoliosis correction and internal fixation by spine instrumentation. J Bone Joint Surg Am 44:591–634PubMedGoogle Scholar
  12. 12.
    Luque ER (1982) Segmental spinal instrumentation. Clin Orthop Relat Res 163:192–198PubMedGoogle Scholar
  13. 13.
    Mehdian H, Eisenstein S (1989) Segmental spinal instrumentation using short closed wire loops. Clin Orthop Relat Res 247:90–96PubMedGoogle Scholar
  14. 14.
    Mehdian H, Shimizu N, Draycott V (1989) Spinal stabilization for scoliosis in Duchenne muscular dystrophy: experience with various sublaminar instrumentation system. Neuro-Orthopedics 7:74–82Google Scholar
  15. 15.
    Mubarak SJ, Morin WD, Leach J (1993) Spinal fusion in Duchenne muscular dystrophy: fixation and fusion to the sacropelvis? J Pediatr Orthop 13:752–757PubMedGoogle Scholar
  16. 16.
    Alman BA, Kim HK (1999) Pelvic obliquity after fusion of the spine in Duchenne muscular dystrophy. J Bone Joint Surg Br 81:821–824CrossRefPubMedGoogle Scholar
  17. 17.
    Sengupta DK, Mehdian SH, McConnell JR, Eisenstein SM, Webb JK (2002) Pelvic or lumbar fixation for the surgical management of scoliosis in Duchenne muscular dystrophy. Spine 27(18):2072–2079CrossRefPubMedGoogle Scholar
  18. 18.
    Galasko CS, Delaney C, Morris P (1992) Spinal stabilisation in Duchenne muscular dystrophy. J Bone Joint Surg Br 74-B:210–214Google Scholar
  19. 19.
    Galasko CS, Williamson JB, Delaney CM (1995) Lung function in Duchenne muscular dystrophy. Eur Spine J 4(5):263–267CrossRefPubMedGoogle Scholar
  20. 20.
    Kennedy JD, Staples AJ, Brook PD et al (1995) Effect of spinal surgery on lung function in Duchenne muscular dystrophy. Thorax 50(11):1173–1178CrossRefPubMedGoogle Scholar
  21. 21.
    Herndon WA, Sullivan JA, Yngve DA, Gross RH, Dreher G (1987) Segmental spinal instrumentation with sublaminar wires. A critical appraisal. J Bone Joint Surg Am 69:851–859PubMedGoogle Scholar
  22. 22.
    Gurr KR, McAfee PC (1988) Cotrel-Dubousset instrumentation in adults. A preliminary report. Spine 13(5):510–520CrossRefPubMedGoogle Scholar
  23. 23.
    Hitchon PW, Brenton MD, Black AG et al (2003) In vitro biomechanical comparison of pedicle screws, sublaminar hooks, and sublaminar cables. J Neurosurg 99(1 Suppl):104–109PubMedGoogle Scholar
  24. 24.
    Rosner MK, Polly DW, Kuklo TR, Ondra SL (2003) Thoracic pedicle screw fixation for spinal deformity. Neurosurg Focus 14(1):e7CrossRefPubMedGoogle Scholar
  25. 25.
    Kim YJ, Lenke LG, Kim J et al (2006) Comparative analysis of pedicle screw versus hybrid instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis. Spine 31(3):291–298CrossRefPubMedGoogle Scholar
  26. 26.
    Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER (2001) Thoracic pedicle screw fixation in spinal deformities: are they really safe? Spine 26(18):2049–2057CrossRefPubMedGoogle Scholar
  27. 27.
    Suk SI, Kim WJ (2004) Biomechanics in posterior spinal instrumentation in biomechanics and biomaterials, Chapter 43. In: Poitout DG (ed) Orthopaedics. Springer, Berlin, pp 462–491Google Scholar
  28. 28.
    Edler A, Murray DJ, Forbes RB (2003) Blood loss during posterior spinal fusion surgery in patients with neuromuscular disease: is there an increased risk? Paediatr Anesth 13(9):818CrossRefGoogle Scholar
  29. 29.
    Bentley G, Haddad F, Bull TM, Seingry D (2001) The treatment of scoliosis in muscular dystrophy using modified Luque and Harrington-Luque instrumentation. J Bone Joint Surg Br 83-B:22–28CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Ranganathan Arun
    • 1
    • 3
  • S. Srinivas
    • 2
  • S. M. H. Mehdian
    • 2
  1. 1.Trauma and OrthopaedicsNorthern DeaneryNewcastle-Upon-TyneUK
  2. 2.Centre for Spinal Studies and SurgeryNottingham University HospitalNottinghamUK
  3. 3.MiddlesbroughUK

Personalised recommendations