PSF to the Pelvis (Neuromuscular)

In neuromuscular conditions the muscles that normally hold the trunk upright are weak or work in an unbalanced way, so the spine tends to fall into a long, sweeping curve that continues to worsen, often even after growth is complete. As the lumbar spine curves, the pelvis is frequently dragged out of level — a problem called pelvic obliquity — so that one side of the pelvis sits higher than the other. The consequences are practical and important: difficulty sitting comfortably or safely in a wheelchair, pressure and skin breakdown over the lower side, pain, and in severe cases interference with breathing and care. The rationale for surgery is to correct the curve, level the pelvis, and produce a balanced, stable trunk that allows comfortable, upright sitting. Extending the fusion to the pelvis is generally considered when the pelvis is significantly tilted, when the trunk cannot be controlled independently, or when the lower part of the curve reaches down into the lower lumbar spine — situations where stopping short of the pelvis would leave the tilt uncorrected or allow it to recur. The underlying diagnosis also influences the decision, not the pelvic tilt alone.

This is what is generally done, although techniques vary between surgeons and centres. The operation is a posterior spinal fusion, meaning it is performed through the back. The spine is exposed along its length, and a series of anchors — most commonly pedicle screws — are placed into the vertebrae on both sides. To secure the construct to the pelvis, specialised anchors are used: common techniques include sacral-alar-iliac screws or iliac screws that pass into the strong bone of the pelvis, or an ilio-sacral screw. Two contoured metal rods are then connected to all the anchors, and the surgeon uses them to derotate and straighten the spine and to lever the pelvis back towards level. Bone graft is applied along the spine so that, over the following months, the vertebrae knit together into a single solid column — the fusion itself, which provides the lasting correction. Because these are long operations on children who are often medically fragile, they are done with careful anaesthetic and blood-management planning, and the nerves are usually monitored throughout. Some curves are very stiff and large, and additional manoeuvres may be used to gain correction.

Studies consistently show that posterior spinal fusion with pelvic fixation produces substantial correction of both the spinal curve and the pelvic obliquity, and that this translates into meaningful real-world benefits — better sitting balance, less pain, reduced pressure on the skin, and easier care. Reported correction of pelvic obliquity is typically greater when the fusion includes the pelvis than when it stops at the lower lumbar spine. Importantly, despite high complication rates inherent to this vulnerable group, parents and caregivers report high satisfaction, frequently ranking the surgery among the most beneficial interventions in the child's life. The literature also weighs the trade-offs honestly: extending to the pelvis tends to mean longer operating time, more blood loss and a somewhat higher complication rate than stopping short, and current thinking is that the decision should be guided by the underlying disease and the individual pelvis rather than by a single measurement. In muscular dystrophy specifically, correcting the deformity is associated with improved comfort and quality of life, and — alongside breathing support — has been linked with survival benefit.

Recovery is a gradual process, and families are supported through it by the whole team. After the operation the child is cared for closely, often in a high-dependency or intensive-care setting at first, because these are major operations in children with complex health needs. Pain is managed actively. Getting the child up and sitting is encouraged as soon as it is safe, because upright sitting is one of the main goals of the surgery. Many children notice they sit more evenly and comfortably, and carers often find positioning, seating and daily care easier. A hospital stay of one to two weeks is common, and full healing of the fusion takes several months, during which vigorous activity is limited while the bone knits. The spine is then followed up over the long term. It is normal for progress to feel slow at first and for confidence to build over the weeks and months that follow.

Like any major spinal operation — and particularly in medically complex children — this surgery carries real risks, which the team discusses fully beforehand. These can include bleeding, infection, problems with the anaesthetic or with breathing, and, less commonly, issues related to the implants such as loosening or the need for further surgery. The overall complication rate in neuromuscular scoliosis surgery is higher than in otherwise healthy children, which is why the decision to operate weighs the expected benefits for comfort, sitting and care against these risks for each individual child. This page is educational and does not recommend or advise for or against surgery in any particular case.

• —Current concepts in the treatment of neuromuscular scoliosis: clinical assessment, treatment options, and surgical outcomes. (PMID 35084206 / PMC9047085)
• —Clinical issues in indication, correction, and outcomes of surgery for neuromuscular scoliosis in the pedicle screw era. (PMC8987549)
• —Surgical advances in the treatment of neuromuscular scoliosis. (PMC4017305)
• —Spinal fusion with sacral-alar-iliac pelvic fixation in severe neuromuscular scoliosis. (PMC8505341)
• —Pelvic fixation for neuromuscular scoliosis deformity correction. (PMC3535148)
• —Pelvic fixation technique using the ilio-sacral screw for 173 neuromuscular scoliosis patients. (PMC10887892)
• —Pelvic vs lumbar fusion in neuromuscular scoliosis — a systematic review. (PMID 40173209 / PMC11966631)
• —The indication of fusion to the pelvis is based on the underlying disease rather than on pelvic obliquity. (PMID 37750950)
• —The variability of pelvic obliquity measurements in patients with neuromuscular scoliosis. (PMC7963507)
• —The MW construct in fusion for neuromuscular scoliosis. (PMC2200700)
• —Effect of pelvic fixation on ambulation in children with neuromuscular scoliosis. (PMID 36159626 / PMC9453276)
• —Posterior spinal fusion for neuromuscular scoliosis with Cobb angle over 100 degrees. (PMC10303956)
• —Quality of life after surgery for neuromuscular scoliosis. (PMC3662264)
• —Correlation between the degree of correction of neuromuscular scoliosis and patient quality of life. (PMC5304363)
• —Experience in perioperative management of patients undergoing posterior spine fusion for neuromuscular scoliosis. (PMC5183752)
• —Surgical management of neuromuscular scoliosis in paediatric patients: experiences from a tertiary centre multidisciplinary team. (PMC11836852)