CHAPTER
116
Management of Paralytic
Neuromuscular Disorders with
an Emphasis on Pelvic Obliquity
REVIEW OF BACKGROUND DATA
Paralytic deformities of the spine secondary to neuromuscular
disorders are frequently associated with pelvic obliquity. In
these patients, pelvic obliquity can be clinically defined as an
imbalance of pelvic pressures and position when sitting. Pelvic
obliquity can range from mild in a patient with good truncal
control to severe in patients with global spine deformity and
total body involvement cerebral palsy. Patients with an unbal-
anced pelvis may present with difficulty in wheelchair fitting,
pressure sores due to improper weight distribution, or loss of
functional abilities secondary to the need for truncal support
with the upper extremities (Fig. 116.1).
The driving force of pelvic obliquity can be multifactorial with
a main factor being the patients underlying neurogenic disorder.
Patients with muscular dystrophy have lost truncal and pelvic sup-
port due to their underlying myopathy. Patients with total body
involvement cerebral palsy have spastic forces, which cause under-
lying muscle imbalance with secondary obliquity, while patients
with myelodysplasia have a variable mixture of motor and sensory
loss, which contributes to the pelvic obliquity.
The goal of spinal instrumentation and arthrodesis in patients
with paralytic deformity and pelvic obliquity is an improvement
in sitting balance. Sitting balance enables the patient to interact
with the environment, assists with wheelchair functionality, has a
beneficial effect on the clearing of pulmonary secretions,
improves perineal hygiene, and prevents ischial skin break-
down.11 Instrumentation and arthrodesis to the pelvis occasion-
ally is not needed. If stopping the fusion in the lumbar spine is
complemented, careful consideration must be given to the
underlying disorder of the patient, the clinical and radiographic
parameters of the pelvic obliquity, and the likelihood of residual
spinal deformity and clinical problems1,3 (Fig. 116.2).
PATIENT EVALUATION WITH RESPECT
TO PELVIC OBLIQUITY
Pelvic obliquity can be measured both clinically and
radiographically. Classically, pelvic obliquity in neuromuscular
1252
LWBK836_Ch116_p1252-1264.indd 1252
Daniel J. Hedequist
scoliosis has been considered as mainly coronal plane tilt on
radiographs. However, pelvic obliquity should be thought of as
pelvic deformity in three planes. Surgical management of pel-
vic obliquity necessitates balancing the three-dimensional
deformity in the coronal plane, sagittal plane, and axial (rota-
tional) plane (Fig. 116.3). Clinical assessment of pelvic obliq-
uity includes not only sitting pressures but also an evaluation of
the muscle forces, or lack thereof, which controls the pelvis.
Clinically, patients with pelvic obliquity can be classified as
either neurogenic (flaccid or spastic) or myopathic. The most
common patient with pelvic obliquity seen by the spine sur-
geon is the patient with whole body involvement cerebral palsy.
Spastic muscle forces across the hips and pelvis, in concert with
scoliosis, frequently create a global spine deformity. In the past,
spastic curves have been classified based on whether there was
a fractional lumbosacral curve separate from the curve above
or whether the curve continued into the pelvis. If the pelvis was
part of the lower fractional curve then consideration was given
to fusing short of the pelvis (Fig. 116.4). Clinically, however, the
decision to fuse to the pelvis is more complex and multifacto-
rial in these patients. Truncal strength and head support need
to be clinically evaluated. Patients with poor head and truncal
control almost always have some degree of pelvic deformity,
which should be controlled with a spine fusion and instrumen-
tation to the pelvis. Spasticity around the hips with resultant
hip subluxation or dislocation also contribute to pelvic defor-
mity in patients with cerebral palsy.5 Adduction deformities
lead to pelvic obliquity and when present necessitate fusion to
the pelvis. Occasionally, hip surgery, such as adductor and/or
psoas releases, at the time of spinal surgery is indicated to con-
trol pelvic tilt and rotation. In patients with significant hip
abnormalities, fusing short of the pelvis is unlikely to control
their obliquity as they have continued abnormal hip forces,
which will drive the pelvis through the unfused lumbosacral
junction.
Classically myopathic disorders present with a collapsing
kyphoscoliosis, which continues down to include the pelvis. In
general, many of these patients (i.e., muscular dystrophy) have
located and mobile hips; however, their overall collapsing
deformity and muscle weakness frequently necessitates
8/26/11 5:45:04 PM
 Chapter 116 Management of Paralytic Neuromuscular Disorders with an Emphasis on Pelvic Obliquity 1253

instrumentation to the pelvis when obliquity is present. If these

Figure 116.1. Sitting anteroposterior radiograph of a patient with
severe neuromuscular scoliosis. Note the significant pelvic obliquity
and collapsing scoliosis.
patients present with lesser degrees of spinal deformity and pel-
vic obliquity, they can possibly be managed with a fusion short
of the sacrum.
Patients with myelodysplasia or complete spinal cord inju-
ries frequently have hip subluxation, dislocations, and stiffness,
which render management of their pelvic obliquity difficult
without fusion to the pelvis. In these patients, balancing the
pelvis to create equal sitting pressures on the ischia is of para-
mount importance (Fig. 116.5). Unequal sitting pressures can
cause skin breakdown due in part to the lack of protective sen-
sation, with a possible resultant full-thickness pressure ulcers,
which can be difficult to treat.3 Fusion short of the pelvis in
these patients frequently leads to pelvic imbalance and further
sitting difficulty.
Radiographically pelvic obliquity can easily be measured on
a sitting anteroposterior (AP) spine radiograph. This is quanti-
fied by an angle subtended by a line drawn across the tops of
the iliac crests and a line parallel to the horizontal. An assess-
ment of curve flexibility and pelvis balance may be done via
traction, supine or push-prone radiographic views. Failure to
obtain a balanced pelvis on a traction view can signify difficulty
in obtaining a balanced spine without fusion to the pelvis.16 An
AP view of the pelvis also can help determining the presence of
significant hip subluxation or dislocation, which if present
necessitates fusion to the pelvis.
The sagittal deformity of the pelvis plays a major role in
obtaining sitting balance. The overall pelvis position in the
sagittal plane is influenced greatly by the lumbar spine with
rotation forward in lumbar lordoscoliosis and backwards with

A B C

Figure 116.2. (A) Plain radiograph of a patient with Friedreichs ataxia demonstrating a collapsing curve
with pelvic obliquity in this patient with no truncal support. (B) Postoperative radiograph after a posterior
instrumented fusion to L5. The spinopelvic balance is excellent in the immediate postoperative period.
(C) Follow-up radiograph at 2-year follow-up. Note the development of deformity at the lumbosacral junction
and pelvis obliquity. The black lines represent the intercristal line of the pelvis.

LWBK836_Ch116_p1252-1264.indd 1253 8/26/11 5:45:05 PM

 1254 Section X Paralytic Deformity

TABLE 116.1 Patient Evaluation

Sitting balance
Hip contractures
Head control
Truncal control
Sagittal curves
Pelvic rotation

Figure 116.3. Clinical photograph demonstrating significant sag-
ittal plane deformity of the pelvis in a patient with spastic quadripa-
retic cerebral palsy.
lumbar kyphoscoliosis (Fig. 116.6). This is evident both radio-
graphically and clinically. However, pelvic rotation is difficult to
classify radiographically. Clinical evaluation of the patient
should include an assessment of the axial or rotational defor-
mity of the pelvis in these patients. Any significant rotational
deformity of the pelvis will likely make fusion to the pelvis man-
datory or decompensation may occur (see Table 116.1).
CASE EXAMPLE
The patient is a 16-year-old girl who presents with a progressive
spine deformity and hip stiffness related to a spastic dislocation
of her hip (Fig. 116.7). According to her caregivers she has had
progressive sitting difficulties related to her lumbar truncal
deformity. Her examination revealed a stiff spastic lumbar sco-
liosis as well as a dislocated hip with 20 of abduction and 30
to 90 of motion in flexionextension plane. External examina-
tion of her pelvis revealed a rotational deformity and a lordotic
posture secondary to spastic muscle forces. Radiographs
revealed a scoliosis with pelvic inequality. Hip radiographs
revealed a chronically dislocated femoral head with resultant
deformity. To improve her sitting balance as well as to arrest
her curvature, she underwent a posterior instrumented fusion
to the pelvis. Postoperatively, she has a balanced spine and pel-
vis and greatly improved sitting balance. This case highlights
the importance of fusion to the pelvis in a patient with spastic
scoliosis and a dislocated hip.

A B

Figure 116.4. (A) Radiograph demonstrating a fractional lumbosacral curve, evident by the rotation of
the spinous processes turning back as a separate curve. In a patient with reasonable truncal support and head
control, stopping short of the pelvis with a fusion is an option. The arrow points to the fractional curve.
(B) Radiograph demonstrating that the pelvis and sacrum are part of the primary curve, in this instance
fusing to the pelvis is clinically necessary.

LWBK836_Ch116_p1252-1264.indd 1254 8/26/11 5:45:07 PM

 Chapter 116 Management of Paralytic Neuromuscular Disorders with an Emphasis on Pelvic Obliquity
Figure 116.5. Clinical photograph demonstrating ischial skin
breakdown in a patient with pelvic obliquity and neurogenic scoliosis.
ACCEPTED FORMS OF SURGICAL
TREATMENT
GLOBAL INSTRUMENTATION
There are multiple fixation options to the pelvis in paralytic
deformity, and in many instances the mode of fixation is sur-
geon dependent. The fixation options in the lumbar spine and
thoracic spine are varied as well and are discussed elsewhere in
this book. Segmental pedicle screw fixation optimizes the
strength of the construct and in the lumbar spine helps share
the load of the pelvic fixation construct. Sublaminar wires
remain an often used construct in the spine for neuromuscular
disease and have been shown to offer excellent stability.2,6 The
addition of pedicle screws in the lumbar spine has been shown
to improve pelvis construct stability and thus hybrid fixation in
Figure 116.6. (A) Radiograph of a patient
with a kyphotic position of the pelvis seen with
a kyphoscoliosis of the lumbar spine. The
arrow points the vertical orientation of the pel-
vis. (B) Radiograph of a patient with lordosco-
liosis of the lumbosacral spine and a horizontal
pelvis represented by the arrow. Note the
pelvic inclination, which can make fixation
A B
challenging.
LWBK836_Ch116_p1252-1264.indd 1255
1255
the form of hook-based superior anchors, sublaminar wires in
the thoracic and upper lumbar spine, and pedicle screws in the
lower lumbar spine has become commonplace (Fig. 116.8).4
Clearly, segmental pedicle screw fixation in the entire spine in
these patients would seem to be beneficial; however, to date
there have been no large studies in this patient population to
validate the difference between hybrid fixation versus all-
pedicle screw fixation.
PELVIC FIXATION
GALVESTON FIXATION
Galveston fixation relies in the strength of the iliac bone to
afford a stable base of fixation.2,6,9,15 It was originally described
with segmental Luque wiring, which provides segmental sub-
laminar fixation and remains a common method of fixation to
the pelvis. Galveston fixation requires the surgeon create a
complex three-dimensional contour of the rod to allow a
smooth transition into the pelvis from the thoracolumbar
spine. For experienced surgeons, the rod contouring is not as
challenging; however, for surgeons unfamiliar with the rod
contouring technique can be technically demanding. In this
technique, the rod is driven into the iliac crest and the thora-
columbar spine is translated to the precontoured rod by way of
sublaminar wires. The unit rod is made precontoured rod and
relies on Galveston technique into the pelvis and in the thora-
columbar spine with sublaminar wires. The advantages of this
technique are the ability to obtain balance of the global spine
by segmental sublaminar wire to translate to the precontoured
rod. The disadvantages remain the challenging two-dimen-
sional rod bend, as discussed above, and the potential for
implant loosening ilia, since the rods cross the sacroiliac
joint.
8/26/11 5:45:09 PM
 1256 Section X Paralytic Deformity

A B C

Figure 116.7. (A and B) Sitting anteroposterior and lateral radio-

graphs of a patient with cerebral palsy and progressive sitting imbalance.
(C) Radiograph of the pelvis showing a chronic fixed dislocation of the
femoral head. (D and E) Postoperative radiographs showing excellent
sitting balance and level pelvis after an instrumented fusion to the pelvis.
The patients hip dislocation was managed by a subsequent resection
D E
arthroplasty of the femoral head.

S-ROD through the sacroiliac joint and iliolumbar ligaments. Thora-

columbar spine fixation can be pedicle screws or sublaminar
The S-rod is a rod in which the caudal end of the rod is prebent
wires. McCarthy et al first described use of the S-rod in a series of
into an S configuration in the sagittal plane. The precontoured
67 patients with neuromuscular scoliosis.9 Follow-up averaged
rod is excellent at resisting kyphotic forces by lying against the
6 years with only one patient having a recurrence of pelvic obliq-
anterior portion of the sacrum. Placement of the rod requires
uity. This study documents the S-rod as a viable method of pelvic
subperiosteal exposure of the sacrum and then continuing ante-
fixation in all patients with neuromuscular scoliosis.
riorly over the sacral alae. The anterior stripping of the perios-
teum from the sacrum must be done with care given that the
lumbar plexus and great vessels lay anteriorly making dissection
PLATE FIXATION
potentially hazardous. The S-rod then hooks over the anterior
portion of the sacrum after precontouring to the desired sagittal The inherent problems of crossing the sacroiliac joint with fixa-
and coronal alignment. Placement of the rods is not technically tion to the iliac crest have led to the development of plate sys-
difficult; however, their rotational stability is not as strong as other tems, which allow for multiple screw anchors into the sacrum.
fixation methods. It is seated firmly against the ala by distraction. This form of fixation can also be helpful in patients who have a
The advantage of this form of fixation is that it avoids crossing the history of a previous pelvic surgery, such as for hip subluxation/
sacroiliac joint while at the same time allowing for pelvic fixation dislocation, where the iliac crest may not provide reasonable

LWBK836_Ch116_p1252-1264.indd 1256 8/26/11 5:45:12 PM

 Chapter 116 Management of Paralytic Neuromuscular Disorders with an Emphasis on Pelvic Obliquity 1257

A B C

Figure 116.8. (A) Sitting radiograph of a patient with scoliosis and pelvic obliquity. (B) Traction radio-
graph showing inability to obtain a balanced pelvis with traction. (C) Postoperative radiograph demonstrating
excellent spinopelvic balance after a posterior fusion using hybrid instrumentation.

fixation. The Colorado plate system (Medtronic, Memphis, TN)
allows for screws to be placed through a plate into S1 and S2
(Fig. 116.9). The fixation points are standard S1 screws, which
should be placed, if possible, bicortically into the S1 end plate.
The S2 screws are angled laterally and cranially allowing fixation
into the sacral alae, with optimally bicortical fixation, which
improves pullout strength. The rod can subsequently be fixed to
the plate allowing for solid fixation into the sacrum. The pelvis
is balanced by either translating the spine to the precontoured
rod, which is fixed distally into the plate with any residual pelvic
imbalance corrected by distracting the rod on the side of the
elevated hemipelvis. Another method of correction is to perform
a convex cantilever method (proximal to distal) by capturing the
plate distally while correcting the lumbar curve and resultant
pelvic obliquity. Fixation strength has been shown to be improved
by 50% by adding a pair of L1 pedicle screws to the construct.4
The advantages of sacral plate fixation is the avoidance of cross-
ing the sacroiliac joint and the potential loosening seen with iliac

Figure 116.9. (A) Radiograph showing a balanced pelvis after fix-

ation using a plate device for sacral fixation. (B) Computed tomogra-
phy scan demonstrating correct placement of alar screws in a
A
bicortical fashion.

LWBK836_Ch116_p1252-1264.indd 1257 8/26/11 5:45:15 PM

 1258 Section X Paralytic Deformity

fixation methods. The disadvantages are suboptimal pullout
strength due to small or osteopenic sacrum. Significant pelvic tilt
or deformity may also make screw placement challenging and
suboptimal. Biomechanically, this construct has been shown to
be as stable as Galveston fixation.4
SACRAL SCREWS
The use of a pair of S1 screws alone as distal anchors for long
constructs in neuromuscular scoliosis is not recommended.
The biomechanical forces across the L5-S1 motion segment are
significant and will overcome a pair of S1 screws, especially in
patients with pelvic imbalance and osteopenia. The rate of
implant dislodgement, implant loosening, and pseudarthrosis
would be unacceptably high and we do not recommend ending
constructs in this patient population with unprotected S1
screws. If this form of fixation is used, it is better applied in a
larger patient with stronger bone stock (Fig. 116.10) and is best
supplemented by segmental fixation to the lumbar spine via
pedicle screws.

A B C

Figure 116.10. (A and B) Sitting anteroposterior and lateral radiographs of a patient with
neuromuscular scoliosis. (C and D) Radiographs after instrumented fusion to the pelvis. The
distal end of the construct is a pair of S1 screws, which is usually not recommended without
D
anterior column support at L5-S1.

LWBK836_Ch116_p1252-1264.indd 1258 8/26/11 5:45:18 PM

 Chapter 116 Management of Paralytic Neuromuscular Disorders with an Emphasis on Pelvic Obliquity 1259

ILIAC SCREW FIXATION
Iliac screw fixation has become a common method of fixation
to the pelvis in neuromuscular deformities. Iliac screws provide
an additional plane of fixation (inferior and lateral orienta-
tion), which protect the S1 screws from pulling out. It allows for
an easier capture of the rod into lumbar pedicle screws. Biome-
chanically, iliac screw fixation has been shown to be a consis-
tently strong method of fixation. Clinically, the rate of
pseudarthrosis and implant loosening is less for this form of
fixation than in Galveston fixation. Peele et al evaluated two
groups of pediatric neuromuscular patients treated with instru-
mentation to the pelvis with either Galveston fixation or iliac
screw fixation.9 The groups had similar preoperative radio-
graphic measures of the coronal and sagittal plane deformities
and similar postoperative correction. However, the group
treated with iliac screws had greater improvement of their pel-
vic obliquity, less implant failures, and require no revisions
when compared with the Galveston group at 3-year follow-up.
Biomechanically as well as clinically, the addition of S1 screws
significantly improves construct strength in long constructs
(Fig. 116.11). Rigid fixation to the pelvis is especially important

A B C

Figure 116.11. (A and B) Sitting anteroposterior and lateral radiographs

of a patient with scoliosis and spinal muscular atrophy. (C and D) Intraopera-
tive radiographs after an instrumented posterior fusion. Note the iliac screws
as a method of distal fixation, in this case S1 screws have been placed as well,
D
which significantly improve distal anchor construct stability.

LWBK836_Ch116_p1252-1264.indd 1259 8/26/11 5:45:20 PM

 1260 Section X Paralytic Deformity
Figure 116.12. Computed tomography scan in the immediate
postoperative period documenting the tip of an iliac screw impinging
into the hip joint.
in paralytic deformities where it is uncommon to add anterior
column support at L5-S1.
Technically, screws should be placed under direct vision of
the outer table of the pelvis. This is accomplished by exposing
the outer table of the crest and by visualizing the sciatic notch.
This permits the screw to be directed just superior to the sciatic
notch and minimizes the chance of lateral penetration of the
screw. Schwend et al studied the anatomy of the ilium with
regard to the optimum bone available for screw purchase.12
This study showed that iliac screws need to be placed in the
bony pelvic area, which consists of straight columns of bone
extending from 2 cm below the posterior iliac spine, traversing
above the sciatic notch, and ending at the anterior iliac spine.
Potential problems with iliac screws are misplacement outside
of the tables of the ilium, with resultant poor biomechanical
strength, and the potential for screws to be misguided into the
sciatic notch or the hip joint (Fig. 116.12).
Strength of fixation into the ilium may be increased by plac-
ing two screws on each side. Phillips et al in their study demon-
strated a clinically significant increase in pullout strength with
this technique.10 In their series of 50 patients comparing the
use of a single screw in each ilium to two screws in each ilium,
they reported a high complication rate in the single screw
group. As mentioned above, adding sacral and multiple lumbar
pedicle screws to an iliac screw construct acts to improve
strength of fixation. Rod capture into the screws and the
mechanics of pelvic leveling may be done by means of spine
translation to the rod, cantilever correction, or distraction
techniques.
The advantages of iliac screw fixation are the ease of inser-
tion and ease of rod capture. Variable-angle screw heads are
now available for most implant systems, which permit easier
rod capture in long constructs. Potential disadvantages are
screw prominence, screw loosening secondary to forces across
the SI joint, and screw misplacement. Screw misplacement can
be avoided by exposure, and screw prominence can be avoided
by cutting out a 1 cm 1 cm block of bone at the entry point of
the screw so that it can be countersunk deep enough to avoid
prominence. Placement of these screws also entails exposure,
LWBK836_Ch116_p1252-1264.indd 1260
which creates a potential for dead space. The routine use of
drains at the lumbosacral junction is recommended to help
avoid retained hematomas and subsequent drainage problems
due to the large dead space created during surgical dissection
(see Tables 116.2 and 116.3).
INTRAOPERATIVE METHODS
ANTERIOR RELEASE
The decision regarding whether or not to perform an anterior
release on a patient with neuromuscular scoliosis to obtain pel-
vic balance can be difficult.11,15,16 The answer to the question
revolves around whether or not a posterior-only procedure will
be able to meet the goal of obtaining a balanced spine and
horizontal pelvis. Determining flexibility in a spastic patient
can be difficult with standard flexibility films. We routinely use
a traction view of these patients to assess flexibility.16 Larger
thoracolumbar curves and large lumbar curves especially when
associated with fixed lordosis may benefit from an anterior api-
cal release with thorough discectomies. The sagittal and three-
dimensional deformity of the pelvis also may aid in this decision.
Patients with lordoscoliosis of the lumbar spine frequently have
a mixed coronal and sagittal plane deformity of the pelvis. In
these patients, the lumbar spine must be flexible enough to
correct the pelvic deformity in both planes. Frequently, more
spastic patients benefit from anterior releases whereas a patient
with a more myopathic and hypotonic curve can be managed
posteriorly. Although complete curve correction is not neces-
sary to obtain pelvic balance, fixed and rigid curves based on
clinical examination and radiographs may signify that an ante-
rior release is beneficial. In patients with deficient posterior
elements such as myelodysplasia, an anterior release and fusion
are paramount when fusing to the pelvis to obtain an adequate
arthrodesis (Fig. 116.13).
TRACTION
Traction can be used to obtain some balance through ligamen-
totaxis. This technique has been described in patients with neu-
romuscular scoliosis.7,14 Halo-femoral traction is applied with a
four- or six-pin halo and a femoral pin on the high pelvis side
and applied at the time of positioning in the operating room.
This technique will be discussed elsewhere in depth in this text-
book and is mentioned here for completeness.
HARRINGTON DISTRACTOR
The intraoperative use of a Harrington distractor can help
obtain overall spinal balance. The Harrington outrigger can be
attached to an anchor point in the upper thoracic spine and
then to a sacral screw or a large hook over the sacral alae. Grad-
ual distraction is applied to the outrigger after thorough facet-
ectomies and ligamentum flavum resection and allows significant
correction of lumbar curves. In general, the outrigger does not
negatively affect sagittal balance and can frequently help man-
age the lumbar lordoscoliosis seen in these patients with pelvic
deformity. Once the outrigger is applied and distraction
performed, a rod can be placed on the other side of the spine
to maintain correction. In theory, this is similar to intraopera-
tive halo-femoral traction. Our experience is that this is a
8/26/11 5:45:22 PM
 Chapter 116 Management of Paralytic Neuromuscular Disorders with an Emphasis on Pelvic Obliquity 1261

TABLE 116.2 Pelvic Fixation Options Factors Influencing Fixation

TABLE 116.3
Galveston fixation
Choice
S-rod fixation Previous bony pelvic surgery
Plate fixation Patient size
Sacral screws Bone quality
Iliac screws Sagittal profile
Surgeon experience

powerful technique given the direct attachment to the spine
(Fig. 116.14).
STRENGTHS AND WEAKNESSES
POSTOPERATIVE MANAGEMENT
Postoperative management in these patients in the immediate
perioperative period revolves around nutritional support and
pulmonary and wound care.8 The surgical wounds in these
patients are large, and the dead space can be significant at the
lumbosacral junction allowing for hematoma formation and
subsequent drainage.13 Wound drainage in these patients is
problematic and the best defense against this is the intraopera-
tive placement of a subfascial drain. Our practice is to keep the
drain in the first two postoperative days with removal on the
third day. We prophylactically place these patients on intrave-
nous antibiotics until the drain is removed given the intimate
relationship to the implants. Soiling of the distal end of the
wound is a potential source of wound contamination and sub-
sequent infection. The distal end of the wound must be dressed
with an occlusive, adhesive dressing and frequent inspection by
the nursing staff to prevent urine or fecal contamination. If

Patient with neuromuscular

scoliosis requiring
instrumented fusion for
sitting balance, interaction,
and personal care

Is clinically
Does the patient have
evident pelvic
head control and some NO
obliquity
truncal control?
present?

YES NO YES

Are there hip

Consider fusion short contractures or
of pelvis dislocations controlling
pelvic
rotation/obliquity?

NO YES

Does a traction film reveal reasonable

Consider surgical
flexibility of curve, which may be
NO release of hip
managed by a posterior-only
contractures
operation?

YES

Consider anterior spinal

Figure 116.13. Flow diagram which release before posterior
Posterior spinal fusion with
serves as a basic algorithm for the surgical instrumentation to pelvis
procedure
management of neuromuscular patients.

LWBK836_Ch116_p1252-1264.indd 1261 8/26/11 5:45:22 PM

 1262 Section X Paralytic Deformity
Figure 116.14. Photograph of a Harrington outrigger, which may
be used as an intraoperative means of obtaining curve correction via
distraction.
contamination occurs, a dressing change must be performed
with a Betadine scrub gently to the area of contamination.
In the first 3 months after surgery protection of the instru-
mentation is paramount and is done by first insisting that trans-
fers be done by two or more people to prevent implant dis-
lodgement during transfers of the patients unsupported lower
extremity and pelvis. Patients with significant global body
involvement should be prevented from leaning forward and
placing a kyphotic stress onto the instrumentation. We also
advocate that physical therapy should be judicious in the
amount of postoperative therapy that is done for the hip flex-
ors, hip adductors, and hamstrings. These muscle groups con-
trol the pelvis and any indiscriminate therapy should be avoided
in these patients given their osteopenia and potential for
implant dislodgement.
DISCUSSION OF COMPLICATIONS
HOW TO MANAGE
CASE PRESENTATION
The patient is a 15-year-old boy with spastic quadriparesis sec-
ondary to neonatal hypoxia (Fig. 116.15). He presents to ortho-
pedic clinic with a progressive spine deformity that has affected
his ability to sit in his wheelchair. His parents report that his
progressive deformity is making it difficult to function in his
environment at school and daily interactions; they also voice
concern regarding the potential for continuing curvature. His
spinal-based examination revealed poor head control and trun-
cal shift not controlled with side bolsters in his wheelchair.
Pelvic examination revealed uneven sitting pressures with bilat-
eral hip flexion deformities of 20 and abduction of each hip
of approximately 40. Given his spinal deformity, total body
involvement, and abnormal muscle forces across the pelvis he
underwent an instrumented fusion to his pelvis. Intraopera-
tively the patient developed a coagulopathy and thus had dom-
inos placed to more rapidly finish the case. His postoperative
radiographs demonstrated appropriate coronal and sagittal
balance. At 6 months postoperatively, he developed significant
radiographic lucencies (windshield wipering) around the
iliac screws. The lucencies progressed at the 1-year follow-up.
LWBK836_Ch116_p1252-1264.indd 1262
Clinically the patient was doing well without problems and was
scheduled for follow-up at 2 years postoperatively. He presented
back to clinic at 18 months postoperatively with fevers and an
elevated serum C-reactive protein levels. The lucencies around
the iliac screws had increased further. He was taken to the oper-
ating room after ultrasound showed a fluid collection around
the rods. All the spine implants were removed at the time of
irrigation and debridement with subsequent healing of the
infection. He currently has a balanced spine with no clinical
evidence of continuing problems.
This case highlights the need for not only iliac screws but
also distal lumbar and sacral screws. It is unclear whether or not
his lucency at the beginning was related to biomechanical fac-
tors or infection. Likely, in this patient he had progressive loos-
ening related to a poor biomechanical construct, which became
a focus for hematologic seeding. This patient underwent com-
plete removal of implants, which is paramount in the presence
of a delayed, deep wound infection. Clinically he has done well
after implant removal.
Complications in this patient population are frequent.
Stopping the fusion short of the pelvis can be complicated by
adding on to the deformity of the caudal unfused spine and
pelvis and further pelvic sitting inequality. This can be poten-
tially avoided by proper preoperative planning. If there is any
doubt about including the pelvis in the fusion then fusing long,
with pelvic fixation, is usually the best operation and can pre-
vent the adding on phenomena postoperatively.
The risk of infection in patients with paralytic deformity is
increased due to these patients poor nutritional status.
Preoperative assessment of serum total protein and lymphocyte
counts and nutritional consults is recommended if concerns
are present. Standard antibiotic prophylaxis is done with a first-
generation cephalosporin antibiotic given prior to skin incision
and then dosing 24 hours postoperatively; if a drain is used, we
will continue antibiotic coverage until the drain is taken out.
Instrumentation and fusion to the sacrum or pelvis creates lon-
ger operating room times and bigger surgical dissections. The
use of postoperative drains may help minimize the dead spacing
due to surgical dissection and secondary hematoma formation.
Early postoperative infections are ideally managed by aggressive
surgical debridement and intravenous antibiotics. Unfortunately,
delayed infections are best managed by deep wound irrigation
and debridement with complete implant removal.
Implant prominence, especially iliac screws, can be a prob-
lematic complication in these patients. This can best be man-
aged by taking a square of bone away from the iliac crest start-
ing point for iliac screws. In addition, the use of sacral
screwplate systems can minimize implant bulk in those patients
who are instrumented to the sacrum.
Windshield wipering of Galveston rods or iliac screws can be
seen in neuromuscular patients managed with instrumentation
and arthrodesis to the pelvis. This can be seen, even in the face
of a fusion to the sacrum as the sacroiliac joint remains unfused.
However, progressive radiolucency around screw can be a har-
binger of pseudarthrosis or deep infection and should be cor-
related with the patients clinical course. The addition of S1
screws and L5 screws to constructs involving iliac screws greatly
enhances stability and should be done to avoid loosening of the
iliac screws.
Implant failure can be seen as either fatigue fractures or dis-
lodgement. Fatigue fractures are usually related to pseudart-
hrosis. Fatigue fractures may need to be treated with revision if
8/26/11 5:45:22 PM
 Chapter 116 Management of Paralytic Neuromuscular Disorders with an Emphasis on Pelvic Obliquity 1263

A B C

D E F

Figure 116.15. (A and B) Sitting radiographs of a patient with progressive neuromuscular scoliosis.
(C and D) Postoperative radiographs after an instrumented posterior fusion. (E) Radiograph at postoperative
follow-up showing clear radiolucency represented by the arrow and halo signs around both iliac screws.
(F) Sitting radiograph obtained 1 year after instrumentation removal for infection.

symptoms develop or curve progression/further obliquity SUMMARY

develops. Implant dislodgement can be due to improper place-
ment, osteopenia, or tremendous forces on implants in the face
of pseudarthrosis. If clinically significant, implant dislodge-
ment can be problematic and need to be managed with revi-
sion of instrumentation. However, if nonproblematic and no
symptoms are present, there may be no need for surgical inter-
vention (see Table 116.4).
Patients who present with scoliosis and pelvic obliquity secondary
to neurologic causes present a challenge to the treating physi-
cian. The goal of surgery for these patients is to obtain a balanced
spine over a level pelvis. These goals may be met using a variety of
implants, each with inherent advantages and disadvantages. The

LWBK836_Ch116_p1252-1264.indd 1263 8/26/11 5:45:23 PM

 1264 Section X Paralytic Deformity

4. Early S, Mahar A, Oka R, Newton P. Biomechanical comparison of lumbosacral fixation

Pelvic Fixation using Luque-Galveston and Colorado II sacropelvic fixation: advantage of using locked
TABLE 116.4 proximal fixation. Spine 2005;30(12):13961401.
Complications
5. Flynn JM, Miller F. Management of hip disorders in patients with cerebral palsy. J Am Acad
Orthop Surg 2002;10(3):198209.
Implant pullout
6. Gau YL, Lonstein JE, Winter RB, Koop S, Denis, F. Luque-Galveston procedure for correc-
Implant loosening tion and stabilization of neuromuscular scoliosis and pelvic obliquity: a review of
Implant prominence/skin breakdown 68 patients. J Spinal Disord 1991;4(4):399410.
Infection 7. Huang MJ, Lenke LG. Scoliosis and severe pelvic obliquity in a patient with cerebral palsy:
surgical treatment utilizing halo-femoral traction. Spine 2001;26(19):21682170.
8. Jevsevar DS, Karlin LI. The relationship between preoperative nutritional status and com-
plications after an operation for scoliosis in patients who have cerebral palsy. J Bone Joint
Surg Am 1993;75(6):880884.
end result of surgery should be overall balanced sitting, balanced
9. Peelle MW, Lenke LG, Bridwell KH, Sides B. Comparison of pelvic fixation techniques in
pressure on the ischia, and improvement in custodial care. While neuromuscular spinal deformity correction: Galveston rod versus iliac and lumbosacral
complications are frequent in this patient population, implant screws. Spine 1976; 31(20):23922398.
10. Phillips JH, Gutheil JP, Knapp DR Jr. Iliac screw fixation in neuromuscular scoliosis. Spine
complications can be minimized with good surgical technique 2007;32(14):15661570.
and solid fixation at the pelvic base. 11. Sarwark J, Sarwahi V. New strategies and decision making in the management of neuro-
muscular scoliosis. Orthop Clin North Am 2007;38(4):485496, v.
12. Schwend RM, Sluyters R, Najdzionek J. The pylon concept of pelvic anchorage for spinal
instrumentation in the human cadaver. Spine 2003;28(6):542547.
REFERENCES 13. Sponseller PD, LaPorte DM, Hungerford MW, Eck K, Bridwell KH, Lenke LG. Deep wound
infections after neuromuscular scoliosis surgery: a multicenter study of risk factors and
1. Alman BA, Kim HK. Pelvic obliquity after fusion of the spine in Duchenne muscular dys- treatment outcomes. Spine 2000;25(19):24612466.
trophy. J Bone Joint Surg Br 1999;81(5):821824. 14. Vialle R, Delecourt C, Morin C. Surgical treatment of scoliosis with pelvic obliquity
2. Cotton LA. Unit rod segmental spinal instrumentation for the treatment of neuromuscular in cerebral palsy: the influence of intraoperative traction. Spine 2006;31(13):
scoliosis. Orthop Nurs 1991;10(5):1723. 14611466.
3. Drummond D, Breed AL, Narechania R. Relationship of spine deformity and pelvic obliq- 15. Westerlund LE, Gill SS, Jarosz TS, Abel MF, Blanco JS. Posterior-only unit rod instrumenta-
uity on sitting pressure distributions and decubitus ulceration. J Pediatr Orthop tion and fusion for neuromuscular scoliosis. Spine 2001;26(18):19841989.
1985;5(4):396402. 16. Winter RB, Pinto WC. Pelvic obliquity. Its causes and its treatment. Spine 1986;11(3):
225234.

LWBK836_Ch116_p1252-1264.indd 1264 8/26/11 5:45:25 PM