الفهرس 
Veins of the vertebral columnOnly 14 pages are availabe for public view
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Abstract
Neuromuscular disorders are a variety of lesions affecting neurological (Upper motor neuron or lower motor neuron), or muscular disorders (mypopathies). The incidence of development of scoliosis in such disorders is high with reported values of 25-100%. NMS is different from AIS in that it usually progresses even after skeletal maturity, usually have large thoracolumbar curve collapsing into kyphosis and associated with large pelvic obliquity. Management of NMS is usually complex and requires team of multiple specialties because of associated comorbidities. Conservative treatment, as bracing, can delay but not eliminate the need for corrective surgery. Bracing, wheelchair modifications, physical therapies with appropriate exercises with use of assistive devices and systemic corticosteroids in Duchenne are the commonly used conservative therapies, but with no proven effect on NMS progression. Surgical stabilization of NMS constitutes the mainstay of treatment in most cases with progressive deformity after failure of conservative methods. The operative treatment of patients with NMS is more complex than that of AIS as patients with NM disorders are commonly health-debilitated, poor nutritional status, poor bone quality, compromised respiratory function and the surgical correction is timeconsuming because of a longer construct that involves fusion and instrumentation to the pelvis with larger amount of blood loss. The main goal of surgery is to produce a stable balanced spine in sagittal and coronal planes over a stable balanced pelvis. Aim of the Work: to evaluate the results of management of NMS in pediatric and adolescent populations by both conservative and surgical methods. Patients & Methods: This study was a retrospective and prospective observational one, started from July 2016 till July 2018. Most of the cases were operated at the Pediatric orthopedic department of the medical University of Graz (Austria). The cases were divided into 2 groups; conservative & operative according to the method of management. Results: The conservative group included 27 patients in whom minimal, slowly progressive scoliotic curve, those who refused surgical intervention, or those who were not fit for surgery. Cases were managed with TLSO orthosis, seating adaptation in wheel-chair, or with both. The mean follow up period was 63.15 months. At first presentation, the mean Cobb’s angle was 59o (10-110), while at final follow-up the mean Cobb’s angle was 86.93o (20-205) with a mean curve progression of 27.89 o (0-103). The mean pelvic obliquity at final follow up was 12.52 o (0-32). About 41% of the conservative group of patients had thoracolumbar kyphosis which progressed from 25.91o (8-48) initially to 43.73 o (24-60) at the final follow up. A telephone questionnaire was made for functional assessment of daily activities and 16 patient shared (59.26%). Most of the responses were intermediate or bad activities. The operative group included 68 patients who were managed by dorsal fusion and instrumentation or combined anterior release & dorsal fusion and instrumentation. The cases included in this group were those with large, progressive scoliotic curve, those in whom cardiopulmonary functions were compromised because of scoliosis progression while they were fit for surgery. The mean follow up period was 43.28 (12-136) months. The mean postoperative ICU stay period was 5.39 (1-22) days. The mean surgery duration was 7.624 (4-10.33) hours. The mean preoperative Cobbs’ angle was 71.7o (16-137), while the mean immediate postoperative Cobbs’ angle was 29o (4-72) and the mean final postoperative Cobbs’ angle was 34.6o (6-95) with a mean Cobbs’ correction percentage of 53.25% (-18.75 to 100%). The mean preoperative pelvic obliquity was 12.37o (0-38), while the mean final postoperative pelvic obliquity was 8.25o (0-28) with a mean correction percentage of 21.7% (-460 to 100%). The mean number of fused segments was 14.87 (8-18) segments. The total number of complications were 36 and occurred in 27 patients. Major complications occurred in 10 patients (14.7%); 3 deep wound infection (4.4%) needed surgical debridement, 3 deaths (4.4%) one case died after the end of operation due to cardiopulmonary collapse and two died several years after surgery due to the main neuromuscular pathology and irrelevant to scoliosis correction surgery, two cases had hardware complications (2.94%) one distal decompensation needed distal extension of the dorsal fusion and one distal loosening of the screws needed partial removal, one case of pseudarthrosis (1.47%) and one case of crankshaft phenomenon (1.47%) and both needed complete revision of the dorsal fusion with instrumentation. All of the major complications except for death were adequately controlled with the surgical intervention and the final outcome of the patients was not adversely affected. Moderate complications occurred in 7 patients (10.29%) and included chest (6) and one visceral complication. All needed minor intervention, and all were adequately controlled without effect on the final outcome. Minor complications occurred in 10 patients with 19 complications and all were controlled adequately with conservative methods without effect on the final outcome. An evaluating questionnaire was made by telephone call with 2 parts, 1st for functional assessment like that made for the conservative group and most responses had good functional abilities. The 2nd part evaluated the patient satisfaction for surgery and most patients reported that goal of operation was fulfilled and would recommend surgery for similar patients. from the 68 patients, 52 (76.47%) shared in the questionnaire. Comparison between both groups: showed no statistical differences regarding patient age, sex, curve pattern, associated comorbidities and NM pathology, while there was statistically significant difference regarding final Cobb’s angle, final pelvic obliquity and most of the results of the functional assessment questionnaire responses.