36 Correction of Neuromuscular Pelvic Obliquity

Neuromuscular pelvic obliquity is defined as a tilt of the pelvis in the frontal plane usually as a result of severe scoliosis and/or asymmetric hip deformity, contractures, or dislocations in patients with neuromuscular disorders such as cerebral palsy or myelomeningocele (Fig. 36–1). The diagnosis is made by physical examination (waistline asymmetry, elevation of one iliac crest, scoliosis, kyphosis) and seated, upright anteroposterior (AP) and lateral radiographs of the spine and pelvis.

Indications for Surgery

1. Progressive pelvic obliquity

2. Pelvic obliquity associated with large, progressive scoliosis

3. Pelvic obliquity resulting in recurrent decubitus ulcers

Contraindications

1. Limited life expectancy

2. Unhealed decubitus ulcers and marginal soft tissue coverage (myelomeningocele patients)

3. Concurrent infection (e.g., pneumonia, urinary tract infection)

4. Limited mentation and interaction with caregivers (controversial)

Advantages

1. More powerful corrective forces

2. Ease of deformity correction

Disadvantage

Relative weak spot of the construct at the domino junctions.

Procedure

Fusion Levels

Neuromuscular deformity dictates that the fusion be long including the high thoracic spine (T1 or T2) and extending down to the sacropelvic axis. A modification of the Galveston technique into the pelvis is utilized. Anterior release and fusion may be indicated for large, rigid curves (> 70 degrees) and for myelodysplastic patients with insufficient posterior bone stock. Allograft bone is the preferred fusion material in these patients in whom preservation of the ilium for fixation is essential.

Incision

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Posterior Cervical Laminectomy and Fusion Odontoid Fixation Anterior Thoracoscopic Release for Spinal Deformity Anterior Cervical Corpectomy Anterior Lumbar Interbody Fusion Total Lumbar Disc Replacement Using the SB III Charite Prosthesis

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