SpineUniverse Case Study Library

Progressive Lumbar / Thoracolumbar Idiopathic Scoliosis

Patient History

The patient is a 13+11-year-old female with progressive lumbar / thoracolumbar idiopathic scoliosis who failed bracing. She is otherwise, healthy.

Examination

The patient's lumbar Scoliometer measurement is 20-degrees. Her thoracic Scoliometer measurement is 7-degrees. Her right shoulder is slightly higher than her left. She has marked waistline asymmetry.

Images

anterior posterior x-ray, standing long cassette
Figure 1A. AP x-ray, standing long cassette

lateral x-ray, standing long cassette
Figure 1B. Lateral x-ray, standing long cassette

Pre-operative clinical photos. SCM=6-degrees right thoracic, SCM=17-degrees left lumbar (Figs. 2A-2C)

clinical photo, posterior standing
Figure 2A

clinical photo, lateral standing
Figure 2B

clinical photo, standing bent forward at waist
Figure 2C

Pre-operative SRS-22 broken into domains
Figure 3. Pre-operative SRS-22 broken into domains.

Diagnosis

Adolescent idiopathic lumbar scoliosis greater than thoracic.

Suggest Treatment

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Selected Treatment

Anterior spinal fixation / anterior segmental spinal instrumentation, T11-L3

3-years postoperative, anterior posterior x-ray, standing long cassette
Figure 4A. 3-years postop, AP x-ray standing long cassette

3-years postoperative, lateral x-ray, standing long cassette
Figure 4B. 3-years postop, lateral standing long cassette

Clinical photos 3-years postop. (Figures 5A-5C)

3-years postoperative, clinical photo, posterior standing
Figure 5A

3-years postoperative, clinical photo, lateral standing
Figure 5B

3-years postoperative, clinical photo, lateral standing
Figure 5C

SRS score converted to 100 point scale
Figure 6. SRS scores converted to 100 point scale.

Postoperative SRS-22 broken into domains
Figure 7. Postoperative SRS-22 broken into domains.

Outcome

At the patient's 5-year follow-up, she is doing quite well. Currently a nursing student, she has volunteered to counsel other teens with adolescent idiopathic scoliosis about surgical treatment.

Case Discussion

This 13-and-11/12 year-old young lady is presumably approaching skeletal maturity. In summary, she has a left thoracolumbar idiopathic curvature of 64-degrees with a 42-degree compensatory right thoracic curve. There is significantly greater clinical and radiographic rotation and translation of the thoracolumbar curve compared to the thoracic curve. The sagittal plane is normal with no evidence of thoracolumbar junctional kyphosis. No flexibility data is presented, but it is likely the thoracic curve is flexible. Radiographically, the shoulders appear to be level. In my experience, a structural thoracolumbar curve with compensatory thoracic curvature is ideally approached from an anterior approach with dual rod segmental instrumentation combined with structural grafting to preserve lordosis, as was done.

The anterior approach provides a powerful correction of both the coronal and axial planes and is well-tolerated by patients. In fact, in a series of 19 patients with two-year follow-up, who underwent thoraco-abdominal approaches for thoracolumbar scoliosis, there was no significant impact on pulmonary function. (1) One could consider doing this from a posterior approach as well and ending the fusion also at L3. One common finding following anterior surgery is there is some wedging of the disc caudal to the instrumentation, but this has not been shown to have any negative clinical impact.

Untreated thoracolumbar scoliosis has been shown to result in increased lumbar degenerative disc disease and back pain compared to controls. There is potential for distal disc degeneration below this anterior fusion. If surgery were required, this could readily be addressed from a combined anterior and posterior approach or all posterior approach with interbody fusions done with posterior techniques. In a patient with significant remaining growth, leaving a residual thoracic curve confers some risk of progression and one would consider bracing the residual thoracic curve. In a nearly skeletally mature patient, there is a little concern of further progression of the thoracic curve.

This patient has clearly done very well from a selective thoracolumbar fusion and this has been my experience for this curve type in the adolescent patient.

Reference
Lonner BS, Auerbach JD, Estreicher MB, Betz RR, D'Andrea L, Crawford AH, Lenke LG, Lowe TG, Newton PO. Pulmonary function changes following various anterior approaches in the treatment of adolescent idiopathic scoliosis. J Spinal Disord Tech (In revision).

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