Original Article

Radiographic and Clinical Outcomes of Surgical Correction of Poliomyelitis-Related

Spinal Deformities: A Comparison Among Three Types of Pelvic Instrumentations
Jie Li1, Zongshan Hu2, Changchun Tseng1, Zhihui Zhao1, Yiwen Yuan3, Zezhang Zhu1, Yong Qiu1, Zhen Liu1

- BACKGROUND: We compared the clinical and radio- Oswestry Disability Index scores at the final follow-up
graphic outcomes of corrective surgery in patients with examination in the 3 groups.
poliomyelitis-related spinal deformity (PSD) using 3 types - CONCLUSIONS: The present study showed satisfactory
of pelvic fixation and investigated the incidence and risk
correction of spinopelvic deformity for 42 patients with
factors for complications.
PSD. Compared with the Galveston technique and iliac
- METHODS: We reviewed the data from 42 patients with screw fixation, the use of S2AI significantly decrease the
PSD who had undergone spinopelvic reconstruction at a operative time and estimated blood loss and obtained
single institution from 2000 to 2016. Of the 42 patients, 15 similar correction of PO. Patient age at surgery and grade
had been treated with the Galveston technique, 13 with >2 SRS-Schwab osteotomy were significant risk factors for
iliac screw fixation, and 14 with S2-alar-iliac (S2AI) screw complications.
fixation. Demographic data, radiographic parameters, and
complications were analyzed. Health-related quality of life
was determined using Scoliosis Research Society (SRS)
22-item questionnaires and the Oswestry Disability Index
INTRODUCTION

P
scores.
ostpolio syndrome is characterized by new neuromuscular
- RESULTS: After surgery, the correction rate of the main symptoms, including muscle weakness, which develops
curve was 51.7%, 57.8%, and 52.1% in the 3 groups, with years after acute paralytic poliomyelitis. Studies have
significant improvement in regional kyphosis, coronal shown that 20%e85% of affected subjects could develop postpolio
balance, and pelvic obliquity (PO) (P < 0.05). The correction syndrome.1 As a consequence of the prolonged stress on the axial
of PO was similar among the 3 types of pelvic fixation; skeleton and weakened muscles, poliomyelitis, which developed
before the growth spurt, usually causes progressive spinal
however, the patients treated with S2AI fixation required
deformity and fixed pelvic obliquity (PO).2
significantly less operative time (P < 0.05) and blood loss
Given the progressive nature of poliomyelitis-related spinal
(P < 0.006). The overall complication rate was 40.5%, with a deformities (PSDs) and the involvement of the whole spine and
major complication rate of 23.8%. Age at surgery pelvis, the surgical correction has been shown to be an ultimate
(P [ 0.006) and grade >2 SRS-Schwab osteotomy reliable treatment option. The decision to undertake surgical
(P [ 0.036) were significant risk factors for complications. treatment is generally based on curve progression, PO !15" ,
Significant improvement was found in the SRS-22 and concomitant medical comorbidities, and poor quality of life.3,4

Key words RK: Regional kyphosis

- Pelvic fixation S2AI: S2-alar-iliac
- Poliomyelitis VCR: Vertebral column resection
- Postpolio syndrome
- Spinal deformity From the 1Department of Spine Surgery, Affiliated Drum Tower Hospital of Nanjing
University Medical School, Nanjing; 2Department of Orthopaedics and Traumatology,
Abbreviations and Acronyms Chinese University of Hong Kong, Hong Kong; and 3Department of Spine Surgery, Drum
CB: Coronal balance Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
CI: Confidence interval To whom correspondence should be addressed: Zhen Liu, M.D.
EBL: Estimated blood loss [E-mail: drliuzhen@[Link]]
GMFCS: Gross motor function classification system
Citation: World Neurosurg. (2019) 122:e1111-e1119.
HRQoL: Health-related quality of life
[Link]
IOMN: Intraoperative neuromonitoring
NMS: Neuromuscular scoliosis Journal homepage: [Link]/world-neurosurgery
OR: Odds ratio Available online: [Link]
PO: Pelvic obliquity 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
PSD: Poliomyelitis-related spinal deformity

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Instrumentation of the spine and pelvis aims to correct spinopelvic

deformity, optimize the sitting and walking posture, improve Table 1. Demographic Data and Baseline Parameters
quality of life, and rescue cardiopulmonary function. Over time, Variable Value
the measures of spinopelvic fixation have evolved from the Gal-
veston technique to iliac screw and S2-alar-iliac (S2AI) screw fix- Age (years) 38.4 # 14.2
ation.5 Additionally, with the benefits from the advancement of Sex (male/female) 19/23
surgical techniques and intraoperative neuromonitoring (IOMN),
Main Cobb angle (" ) 74.0 # 15.8
the safety and efficacy of correction surgery has substantially
improved. However, high complication rates in PSD correction Regional kyphosis (" ) 38.9 # 13.4
remained a challenge for spine surgeons.6 Coronal balance (cm) 4.7 # 1.4
Previous studies have presented the surgical outcomes of PSD
Pelvic obliquity (" ) 24.0 # 7.4
using previous instrumentation techniques.7-9 In 2014, Godzik
et al.10 investigated the outcomes and complications of spine
reconstruction for PSD. However, their study was limited by its
small sample size (22 patients) and the inclusion of 54% column resection (VCR); grade V, complete VCR plus disc resec-
revision cases. Moreover, only 5 of 22 patients had undergone tion; and grade VI, multilevel VCR). Perioperative outcomes,
spinopelvic fixation in their study.10 To date, limited modern including estimated blood loss (EBL) and operative time (mi-
reports have described the clinical outcomes for spinopelvic nutes), were collected.
reconstruction for PSD. The preoperative, 3-month postoperative, and final follow-up
We evaluated our 16-year experience with 42 consecutive pa- standing or sitting full-spine anteroposterior radiographs were
tients with PSD at a single center and explored the surgical out- analyzed using the Cobb method in the coronal and sagittal
comes of spinopelvic fixation. We sought to determine whether planes. The radiographic measurements were Cobb angles of the
modern spinopelvic fixation, including S2AI and iliac screw fixa- major curve; PO angle (angle between the line of the bilateral iliac
tion, can achieve better correction of PO than Galveston tech- anterior superior spine and a horizontal line); and regional
nique; the incidence and risk factors for complications after kyphosis (RK; angle between the superior endplate of the upper
correction surgery; and whether correction surgery for PSD will end vertebra and the inferior endplate of the lower end vertebra).
improve patients’ quality of life. Coronal balance (CB) was defined as the perpendicular distance
between the C7 plumbline and the central sacral vertical line.
METHODS The patient-reported outcomes were assessed at the follow-up
examinations using the SRS-22 and Oswestry Disability Index
Patients questionnaires. The perioperative and postoperative complications
The institutional review board of our hospital approved the pre- were recorded. Using the classification of Glassman et al.,13 the
sent study. Patients who had undergone spinal deformity correc- complications were classified as minor and major.
tion surgery for PSD from 2000 to 2016 at a single institution were
identified in the database. The inclusion criteria for the present
study were as follows: 1) a history of polio infection or postpolio
syndrome; 2) a diagnosis of spinal deformity; 3) spinal instru- Table 2. Gross Motor Function Classification System and
mentation and fusion with pelvic fixation using the Galveston Comorbidities
technique, iliac screw fixation, or S2AI fixation; and 4) a minimum
of 2 years of follow-up data available. Patients with a history of Variable Patients (n)
other types of neuromuscular scoliosis (NMS), congenital spinal
Grade
deformity, spinal trauma, tumor, and uncertain surgical data were
excluded. I 5
II 17
Clinical and Radiographic Measurements
III 13
The clinical data for the present cohort were obtained from the
medical records and the operative database of our institution. The IV 7
history of polio infection, surgical management, and patient Comorbidity
comorbidities were recorded. The patients’ functional status and
Pulmonary infection 1
gross motor development was evaluated using the gross motor
function classification system (GMFCS) proposed by Palisano Hypertension 3
et al.11 Respiratory failure 1
Surgical data, including the surgical approach (anterior vs. Deep venous thrombosis 1
posterior), staging (one-stage vs. two-staged), and levels fused,
were recorded. The use of spinal osteotomy was determined using Hip subluxation 2
the Scoliosis Research Society (SRS)-Schwab classification12 Inequality of lower limb 6
(grade I, Smith-Peterson osteotomy; grade II, Ponte osteotomy; Congenital heart disease 1
grade III, pedicle subtraction osteotomy; grade IV, vertebral

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Table 3. Comparison of Radiographic Outcomes Among 3 Types of Pelvic Instrumentation

Variable Galveston Iliac Screw S2AI P Value

Main Cobb angle (" ) 74.2 # 15.7 72.1 # 15.9 75.8 # 15.7 0.895
Postoperative 34.9 # 12.7 30.4 # 9.1 36.3 # 7.2 0.315
Final follow-up 36.8 # 12.3 32.0 # 8.7 37.6 # 7.3 0.302
Regional kyphosis (" ) 40.4 # 15.6 42.6 # 11.9 34.2 # 10.7 0.142
Postoperative 14.5 # 10.4 14.6 # 5.6 16.4 # 5.8 0.802
Final follow-up 15.1 # 10.8 15.9 # 5.8 17.8 # 5.5 0.854
Coronal balance (" ) 4.7#1.7 4.9 # 1.2 4.4 # 1.3 0.465
Postoperative 1.4 # 0.8 1.6 # 0.8 1.9 # 1.1 0.308
Final follow-up 1.5 # 0.9 1.7 # 0.8 2.0 # 1.0 0.255
Pelvic obliquity ( )
"
23.5 # 7.9 23.5 # 7.7 25.2 # 6.8 0.862
Postoperative 11.1 # 6.2 9.5 # 4.9 11.6 # 5.6 0.550
Final follow-up 12.1 # 6.5 10.5 # 5.1 12.9 # 5.6 0.488

Data presented as mean # standard deviation.

S2AI, S2-alar-iliac.

Statistical Analysis risk factors for complications. A P value <0.05 was considered
Statistical analyses were performed using the SPSS statistical statistically significant.
package, version 19.0 (IBM Corp., Armonk, New York, USA).
Continuous variables are presented as the mean # standard de- RESULTS
viation. The comparisons of preoperative and postoperative
radiographic parameters were performed using the paired t test. Demographic and Surgical Data
One-way analysis of variance was used to determine any differ- A total of 49 patients were identified in the database. Of these 49
ences among the 3 groups. The Bonferroni correction was used as patients, 3 with a contradiction for surgery (type II respiration
post hoc analysis. The Fisher exact test was used to determine the failure, blood gas analysis showing intractable hypoxemia with a

Table 4. Complications After Correction Surgery

Complication Patients (n) Treatment and Prognosis Details

Pulmonary infection 2 Antibiotics, recovered at discharge*

Infection 2 1, Surgical site infection, wound debridement, and drainage, with recovery at 3 months postoperatively;
1, allograft rejection, with revision surgery*
Instrument related
Rod breakage 4 Revision surgery, reinstrumentation*
Screw misplacement 2 Asymptomatic, routine follow-up
Neurological
Nerve root injury 1 Left nerve root injury at L1, front thigh numbness, conservative treatment*
IOMN events and incomplete 2 1, 85% decrease in SEP, loss of TceMEP of left lower limb, and decreased myodynia of left quadriceps
paraplegia femoris*; 1, loss of SEP, loss of TceMEP of right lower limb, persistent sphincter dysfunction*
Other
Dual tear 1 Intraoperative dual repair
Massive hemorrhage 3 RBC transfusion

IOMN, intraoperative neuromonitoring; SEP, sensory evoked potentials; TceMEP, transcranial electrical motor evoked potentials.
*Major complication.

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Figure 1. Views of a 43-year-old female patient with poliomyelitis-related connectors of the iliac screw on the left side. (E and F) Radiographs 1 year
spinal deformity. (A and B) Preoperative radiographs showing main curve of after revision surgery showing reinforcement of multiple rod constructs at
89" , pelvic obliquity (PO) of 20" , and regional kyphosis of 39" . (C and D) the lumbar sacral junction with S2-alar-iliac screw fixation. (G) Preoperative
Radiographs at 2 years postoperatively showing rod breakage at the and (H) postoperative photographs showing improved PO.

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Table 5. Comparison of Preoperative and Postoperative Health-Related Quality of Life Scores

Variable Preoperative Postoperative P Value

Pain 4.0 # 0.2 4.1 # 0.2 0.319

Self-image 3.2 # 0.3 3.6 # 0.2 <0.001
Function 3.2 # 0.3 3.5 # 0.2 0.001
Mental heath 3.3 # 0.2 3.6 # 0.2 <0.001
Satisfaction NA 3.9 # 0.5 NA
ODI (%) 45.7 # 10.6 25.7#6.8 <0.001

NA, not applicable; ODI, Oswestry Disability Index.

maximum partial pressure of oxygen $50 mm Hg), 2 who had Complications

previously undergone surgery and declined the proposed revision The overall complication rate was 40.5% (17 of 42), with a 23.8%
surgery, and 2 who had undergone Galveston fixation but had (10 of 42) incidence of major complications. The details of the
uncertain surgical data were excluded. Thus, 42 patients with PSD complications are presented in Table 4. Instrument-related com-
were ultimately included. Their mean age was 38.4 # 14.2 years plications were the most common complications (16.7%), with 4
(range, 15e63). The mean follow-up time was 38.9 # 8.8 months patients experiencing instrumentation failure and revision surgery
for Galveston group, 37.5 # 9.8 months for the iliac screw group, performed with a multiple-rod construct (Figure 1). Two patients
and 34.3 # 5.4 months for the S2AI group (P ¼ 0.792). The pre- experienced IOMN events during surgery and developed a
operative radiographic parameters are listed in Table 1. The neurological deficit after surgery. Patient age at surgery (age,
GMFCS grade was grade I in 5 cases, grade II in 17, grade III in 45.4 # 11.3 years vs. 33.6 # 14.1 years; P ¼ 0.006) and grade >2
13, and grade IV in 7 cases. The comorbidities, including SRS-Schwab osteotomy (odds ratio [OR], 6.27; 95% confidence
pulmonary infection, hypertension, and respiratory failure, are interval [CI], 1.09e36.3; P ¼ 0.036) were associated with
presented in Table 2. complications. Major complications were associated with
The type of pelvic fixation included the Galveston technique for grade >2 SRS-Schwab osteotomy (OR, 9.7; 95% CI, 1.7e53.9;
15 patients, iliac screw fixation for 13 patients, and S2AI fixation P ¼ 0.012). The preoperative GMFCS grade (F ¼ 3.863;
for 14 patients. The mean number of levels fused was 12.2 # 2.0 P ¼ 0.0s.316), patient sex (OR, 0.804; 95% CI, 0.23e2.85;
for all 42 patients. Anterior release surgery was performed in 5 P ¼ 0.757), and the use of different types of pelvic fixation
patients, including the lumbar sacral region in 4 patients (fixed (F ¼ 3.294; P ¼ 0.221) were not associated with the rate of com-
with Galveston technique) and the thoracolumbar region in 1 plications. In addition, the use of anterior release (OR, 0.443; 95%
patient. The SRS-Schwab classification grade, which determined CI, 0.085e2.300; P ¼ 0.413), operative time (276 # 53 minutes vs.
the use of osteotomy, was as follows: grade I in 14 patients, grade 260 # 64 minutes; P ¼ 0.379), number of levels fused (12.6 # 1.9
III in 4, grade IV in 3, and grade VI in 1 patient. vs. 12.0 # 2.0; P ¼ 0.316) and the main Cobb angle (71.3" # 16.4"
When stratified by the type of pelvic fixation, the mean EBL in vs. 64.2" # 16.7" ; P ¼ 0.575) were not associated with
the S2AI group (1613 # 413 mL) was lower than that in the Gal- complications.
veston group (2493 # 503 mL; P < 0.001) and iliac screw group
(2197 # 436 mL; P ¼ 0.006). In addition, the mean surgical time Patient-Reported Outcomes
for the S2AI group (222 # 38 minutes) was shorter than that for The preoperative and postoperative health-related quality of life
the Galveston group (306 # 44 minutes; P < 0.001) and iliac screw (HRQoL) scores are presented in Table 5. A significant
group (268 # 64 minutes; P ¼ 0.046). improvement in HRQoL scores was identified in SRS function
(P ¼ 0.001), self-image, and mental health (P < 0.001) and the
total Oswestry Disability Index scores (P < 0.001).
Radiographic Outcomes
The preoperative, postoperative, and final follow-up radiographic
data are presented in Table 3. The preoperative radiographic DISCUSSION
parameters were comparable among the 3 groups. For all 3 Although progress has been made on poliomyelitis eradication,
groups, significant improvement was found in the main Cobb 10e20 million people worldwide experience the sequelae of
angle, RK, CB, and PO after surgery (P < 0.001). At the final poliomyelitis.1 In patients with PSD, fixed PO with an unbalanced
follow-up visit, a significant loss of correction was found in the spine deformity adversely affects sitting and walking balance,
main Cobb angle, RK, PO (P $ 0.001), and CB (P ¼ 0.018). cardiopulmonary function, and quality of life.2,3,14,15 Correction
However, correction of the main Cobb angle, RK, CB, and PO of the fixed PO has been considered a challenging procedure.
showed no statistically significant differences postoperatively and Despite previous studies investigating the clinical outcomes and
at the final follow-up examination among the 3 groups of spino- complications of PSD,10,16,17 a paucity of clinical research has
pelvic fixation (P > 0.05). specifically focused on the different types of spinopelvic fixation in

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Figure 2. Views of a 27-year-old female patient with 3 months showing main curve of 50" , PO of 16" , and regional kyphosis
poliomyelitis-related spinal deformity. (A and B) Preoperative of 15" . (E and F) Radiographs at 2 years postoperatively showed no
radiographs showing main thoracic curve of 84" , pelvic obliquity (PO) of significant correction loss. (G) Preoperative and (H) postoperative
25" , and regional kyphosis of 30" (C and D) Postoperative radiographs at photographs showing improved PO.

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Figure 3. Views of a 21-year-old female patients with poliomyelitis-related scan showing thickening of the pulmonary vessels. (D and E) Radiographs
spinal deformity and chronic respiratory failure. (A and B) Preoperative at 3 months postoperatively showing main curve of 120" , PO of 13" , and
radiographs showing main thoracic curve of 165" , pelvic obliquity (PO) of regional kyphosis of 64" . (F and G) Follow-up radiographs at 6 years
37" , and regional kyphosis of 89" . (C) Preoperative computed tomography postoperatively showing no significant correction loss.

these patients. To the best of our knowledge, the present study is segmental pedicle screw fixation. In the present study, we
the largest modern reported cases series on the clinical outcomes achieved an average 51.7%e57.8% correction of the major curve
of deformity correction surgery for PSD using 3 types of postoperatively. We speculated that the comparatively low
instrumentation. correction rates in the study by Godzik et al.10 could have
In 1981, Mayer et al.18 investigated the surgical outcomes of 118 resulted from the 54% rate of revision surgery. In addition, the
patients with PSD using earlier instrumentation types. They RK and CB improved postoperatively, although without
achieved an average 49% correction of scoliosis using the achieving the normal range (CB <2 cm).
anterior Dwyer device and 61.1% correction using posterior Fixed PO is commonly seen in patients with PSD and consists of
Harrington instrumentation.18 Recently, Godzik et al.10 reported soft tissue contractures and skeletal deformities above and below
33% correction of scoliosis in 22 patients with PSD using the pelvis.14 Previous studies reported that the correction of PO

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ranged from 50.3% to 82.0%.19,20 In the present study, the rates, regardless of the extent of deformity correction.25 In the
correction of PO was similar in patients with 3 types of pelvic present study, 25 patients completed the HRQoL
fixation, with a PO correction rate (52.8%e59.6%) comparable to questionnaires, and significant improvement was found
that in the reported data. However, compared with the Galveston regarding self-image, function, and mental health. However,
technique, the use of S2AI screw fixation could reduce the EBL Jones et al.26 found no significant improvement in physical
and operative time (Figure 2). In consistent with the results from function, school absence, comorbidities, or parental health
previous studies,5,21 our findings have confirmed the fundamental after surgery in patients with cerebral palsy. The difference
advantage of S2AI in pelvic fixation. It could be explained by the could be because the HRQoL of patients with preexisting
massive soft tissue damage during exposure and the use of dysfunction and high GMFCS grades would be unlikely to
anterior release when applying the Galveston technique and iliac be improved to the normal range.
screw fixation.22 Additionally, the use of S2AI fixation allows for a The strengths of the present study were that we presented the
direct connection between spinal instrumentation and pelvic surgical outcomes of spinopelvic fixation using 3 types of instru-
anchors, which successfully reduced the rate of mechanical mentation in patients with PSD at a minimum of 2 years of
failure at the lumbosacral junction. In the present study, 2 follow-up and reported the incidence of, and risk factors for,
patients experienced rod breakage at the connectors between the complications. A recently reported study showed that neurosur-
rod and iliac anchors and required revision surgery (Figure 1). geons are displaying an increasing interest in pediatric spinal
The prevalence of complications in NMS has ranged from 18% deformity.27 Given the extensive experience in managing the
to 75% in the reported data.6 Turturro et al.6 found that patients spinal cord, neurosurgeons engaging in spinal deformity
with poliomyelitis have the greatest complication rate at 50% treatment can be expected to produce satisfactory clinical
compared with other types of NMS in a large case series. In the results, especially in deformities with a neurological etiology.
present study, the overall complication rate was 40.5%, with a Therefore, we believe that the present study has
23.8% rate of major complications. The rate of neurological provided valuable information for both spine surgeons and
complications was 7.1%, lower than that in previous studies.10 neurosurgeons. However, several limitations should be
Owen et al.10 suggested that preexisting neurological conditions acknowledged. First, the EBL and operative time both decreased
in NMS could affect IOMN and cause false-negative findings. In with greater surgical experience, consistent with previous
the present study, IOMN events predicted for neurological deficits studies investigating the learning curve for spine surgeons.27,28
postoperatively, with 2 patients with IOMN events experiencing a Second, the HRQoL outcomes were only evaluated for 25
poor prognosis postoperatively. patients, because the Chinese version of the SRS-22 questionnaire
Previous studies have shown that older age at surgery, non- was not available until 2009.
ambulatory status, and preoperative curve magnitude are risk
factors for complications after spinal reconstruction for NMS.23
Godzik et al.10 reported that revision surgery and the use of CONCLUSION
spinal osteotomy was associated with complications in patients The results of the present study have demonstrated satisfactory
with PSD. Similarly, we found that patient age at surgery was a surgical outcomes of spinopelvic fixation in 42 patients with PSD.
risk factor for complications. Additionally, the use of grade >2 The use of S2AI fixation can obtain similar correction of PO, with a
SRS-Schwab osteotomy was related to a greater complication decreased operative time and EBL. The overall complication rate
rate and major complications in the present study. Intra- was 40.5%, and the incidence of instrument-related complications
operatively, we observed 1 patient with severe incomplete para- was greatest. Neurological complications occurred in 3 patients,
plegia during the vertebral column resection procedure. with 2 cases predicted by IOMN events. Patient age at surgery and
Understanding the potential risks with aggressive osteotomy, we grade >2 SRS-Schwab osteotomy were identified as significant
prefer unilateral fusion in the apex region for patients with severe risk factors for the development of complications. From our
spinal deformity, severe comorbidities, and a poor general 16-year experience in treating this particular subset of patients, an
condition (Figure 3). Similarly, Cawley et al.24 reported satisfactory important lesson is that even with a 23.8% rate of the major
surgical outcomes with unilateral fusion for NMS. complication, spinopelvic reconstruction surgery can achieve
Despite the high complication rates, investigations of the substantial deformity correction and definitive improvement in
HRQoL of patients with PSD have shown high satisfaction patients’ HRQoL.

4. Broom MJ, Banta JV, Renshaw TS. Spinal fusion surgery in a 30-years consecutive series. Eur Spine
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and management. J Bone Joint Surg Br. 1997;79: mity. Spine J. 2018;18:648-654. the Jiangsu Health and Family Planning Commission (grant
190-196. Q201510) and Natural Science Foundation of Jiangsu
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