Neuromuscular Scoliosis

• Context: Neuromuscular scoliosis is a spinal deformity resulting from underlying neurological or muscular disorders that disrupt postural control and the trunk balance of forces. Unlike idiopathic scoliosis, it typically manifests earlier, progresses more rapidly, and continues to deteriorate even after skeletal maturity. The curves frequently involve extensive thoracolumbar segments and propagate to the sacropelvis, generating severe pelvic obliquity, coronal and sagittal trunk decompensation, and major difficulties with sitting balance, positioning, personal hygiene, and skin integrity. The condition is intimately linked with respiratory, nutritional, and systemic impairment, the magnitude of which varies according to the underlying disorder. Consequently, therapeutic decision-making cannot rely solely on the radiographic Cobb angle. Etiology, gross motor function, ambulatory status, pulmonary reserve, comorbidities, patient quality of life, and caregiver burden must be evaluated in an integrated fashion. The chapter emphasizes a highly individualized, multidisciplinary decision-making model.

• Chapter Objective: To present the core foundations for the clinical assessment, multidisciplinary optimization, and surgical management of neuromuscular scoliosis. The reader will learn to distinguish neuropathic from myopathic etiologies, apply structural and functional classification systems (such as GMFCS and FMS), recognize the biomechanical and functional impact of pelvic obliquity, conduct comprehensive preoperative risk assessments, understand the indications for growth-friendly versus definitive posterior fusion techniques, and anticipate major perioperative complications and realistic functional expectations.

• Clinical Application: In clinical practice, the evaluation of a patient with neuromuscular scoliosis must start with what the patient can actually do, rather than the Cobb angle alone. Sitting tolerance, transfer ability, self-feeding, hygiene, upper extremity functional use, and wheelchair positioning must be systematically documented alongside GMFCS and FMS scores. Pelvic obliquity should be examined directly in the patient's customized wheelchair and functional posture. Before indicating surgery, the multidisciplinary team must establish whether progressive deformity is actively compromising pulmonary function, sitting stability, skin integrity, comfort, or daily caregiving. The operative risk must be weighed against the natural history of unchecked deformity progression. Preoperative workup mandates nutritional optimization (often via gastrostomy), pulmonary conditioning, and cardiac evaluation (particularly in muscular dystrophies and syndromic conditions). In severe, neglected curves, preoperative halo-gravity traction can safely loosen the deformity, improve nutritional and pulmonary status, and reduce intraoperative neurological risk. In non-ambulatory patients, sacropelvic fixation (such as S2AI screws) is frequently required, whereas in ambulatory patients, preserving lumbar mobility and avoiding fusion to the pelvis protects gait mechanics. Family and caregivers must be aligned from the outset with realistic goals: surgery aims to restore sitting balance, improve head and trunk control, alleviate pain, and simplify caregiving, but cannot restore motor function lost to the underlying neuromuscular disease.