Abstract
Purpose
Neuromuscular scoliosis associated with myelomeningocele is a difficult clinical dilemma for the treating surgeon. The traditional surgical treatment consists of a posterior spinal instrumented fusion with or without a combined anterior procedure, but this has been associated with high complication rates, mostly related to deep infection. An anterior thoracolumbar fusion is not able to address the entirety of the deformity in many cases but could potentially avoid the devastating infection risks from the posterior approach by avoiding compromised skin. This study aims to evaluate the long-term outcomes and complications associated with isolated anterior thoracolumbar fusion in this high-risk group.
Methods
This study is a retrospective analysis of patients with myelomeningocele-associated scoliosis treated with an isolated anterior spinal fusion over a 20-year time period at a single center. Surgical details, demographics, curve characteristics and complications were recorded. Comparisons were made between patients who required revision surgery and those who did not.
Results
Sixteen patients were enrolled with an average age of 12.7 years at the time of surgery and average follow-up of 5.5 years. Patients had on average 7.4 levels fused anteriorly with the most common levels being T10-L4. There were no deep wound infections associated with the anterior surgery. Overall, nine patients (56%) had to be revised posteriorly due to adding-on or junctional deformity at an average of 3.7 years after index procedure. Four patients were revised due to proximal adding-on, while 1 was extended distally. Four additional patients were extended both proximally and distally. Of the posterior revisions, 2 patients developed deep wound infections, and both of these were in patients extended distally. Preoperative lumbar lordosis was higher in patients who required distal extension (100 vs. 69 degrees; p = 0.035).
Conclusions
Patients undergoing isolated anterior fusion for scoliosis associated with myelomeningocele have low infection rates but often require posterior revision. The majority of patients can avoid the deep infection risk associated with distal posterior surgery at long-term follow-up.
Level of evidence
IV.
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All of the below authors made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. They also drafted the work or revised it critically for important intellectual content. Additionally, they gave final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. DB, MW, and JIK: data collection, writing—original draft preparation and approval of final version of manuscript, and agreed to be accountable for the work.
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Daniel Bouton is a consultant for Medtronic. This is not relevant to this manuscript. Michelle Welborn is a consultant for Dupuy Synthes, Nuvasive Spine, Stryker Spine, Zimmer spine, and Astrozenica. These are not relevant to this manuscript. J. Ivan Krajbich has no conflicts of interest to disclose.
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The study was approved by the Shriners Hospitals for Children Institutional Review Board and was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
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Bouton, D., Welborn, M. & Krajbich, J.I. Long-term outcomes and complications of isolated anterior thoracolumbar fusion for neuromuscular scoliosis associated with myelomeningocele. Spine Deform 12, 189–198 (2024). https://doi.org/10.1007/s43390-023-00747-1
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DOI: https://doi.org/10.1007/s43390-023-00747-1