Nun with Progressive Deformity: Fuse or Not Fuse?
The patient is a 24-year-old female who reports progressive deformity. She says she had a 45° right thoracic curve at age 17. She has more back pain than 5 years ago, but it is certainly not “excruciating.”
She is a nun.
Pre-treatment SRS-22 Average Broken into Domains
Figures 5A, 5B, and 5C are clinical photos showing the deformity.
Right thoracic scoliosis
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No iliac bone graft was used, and no thoracoplasties were performed.
Spinal instrumentation was used.
Figures 7A, 7B, and 7C are post-operative clinical photos.
At her 5-year follow-up visit, the patient's SCM was 12°.
Pre-operative Images Compared to Post-operative Images
Pre-operative to Post-operative SRS-22 Average Broken Into Domains
Pre-operative to Post-operative Oswestry Scores
This case presents challenges in the surgeon's decision-making about choosing to do or not do surgery. The surgery itself is relatively straight forward, but very nicely executed.
The challenge of when to operate for deformity in a young adult is substantial. Determining progression is hard as it is rare to have the x-rays from the treatment period during adolescence. Therefore, determining progression is challenging. A particularly useful strategy in older patients is to look for change in height. If it occurs, then it is probably a good indicator of progression. How much height loss is necessary? Probably, 1-2 inches. We have never determined the reliability of height measurement.
The next question is, does the patient want the deformity correction? If they do, and the curve is greater than 50-degrees, then it is probably reasonable. If this patient desires deformity correction. it is certainly reasonable.
In terms of surgery technique, this case follows the fusion selection rules for adolescent idiopathic scoliosis. She has generously-sized pedicles so segmental pedicle fixation can be achieved. This can be judged by looking at the L1 pedicles. If they are large, it will be easy; if they are small, it will be hard. Sometimes the bending films show these pedicles better than the AP.
Bone graft choices remain challenging in this scenario. This becomes a shared decision with the patient, who is provided with every choice, and the advantages and disadvantages.
In this case the operating surgeon has achieved a superb result.