SpineUniverse Case Study Library

Mild Lumbar Scoliosis and Spinal Stenosis

History

The patient is a retired female in her 60s with longstanding history of back and bilateral extremity pain that both improve with sitting and lying down. Her symptoms have been going on for more than 3 years, and her leg pain is consistent with neurogenic claudication.

Examination

On examination, the patient is standing with an obvious sagittal imbalance that worsens with ambulation despite using knee flexed posture and pelvic retroversion.

Her back and bilateral extremity pain are significant.

She has normal motor function/strength throughout, but she is hypo-reflexive.

Prior Treatment

Previously, the patient tried epidural steroid injections3 times over the course of 6 months and physical therapy and aquatic therapy.

 

Pre-treatment Images

Fig 1 Koski Lumbar Scoliosis and Spinal Stenosis Pre-op AP X-rayFigure 1: Pre-op AP x-ray showing curve in the lumbar spine

 

Fig 2 Koski Lumbar Scoliosis and Spinal Stenosis Pre-op Lateral X-rayFigure 2: Pre-op lateral x-ray

 

Fig 3 Koski Lumbar Scoliosis and Spinal Stenosis Pre-op T2-weighted Sagittal MRIsFigure 3: Pre-op T2-weighted sagittal MRIs showing compression of the spinal cord at L2-L3, L3-L4, and L4-L5.

 

Fig 4 Koski Lumbar Scoliosis and Spinal Stenosis Pre-op Axial MRIsFigure 4: Pre-op axial MRIs of L3-L4 and L4-L5. Note the spinal cord compression.

Diagnosis

The patient was diagnosed with lumbar scoliosis at L2 to L4, sagittal imbalance, and spinal stenosis with neurogenic claudication.

Suggest Treatment

Indicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.

Selected Treatment

Anterior-posterior fusion L2-S1 without the ilium was performed. The surgery was done in 2 stages. The patient had a minimally invasive ALIF, DLIF, and an anterior-posterior fusion without laminectomy.

The first stage was mini-open ALIF at L4-L5 and L5-S1 and a DLIF at L2-L3 and L3-L4. This provided realignment and indirect decompression at L3-L4, L4-L5, and L5-S1.

The second stage of the surgery was done 3 days later. This stage included percutaneous pedicle screw fixation from L2-S1 with facet arthrodesis.

Post-treatment Images

Fig 5 Koski Lumbar Scoliosis and Spinal Stenosis Sagittal MRI after Stage 1 of SurgeryFigure 5: Sagittal MRI after stage 1 of the surgery

 

Fig 6 Koski Lumbar Scoliosis and Spinal Stenosis Post-op Stage 1 Axial MRIsFigure 6: Post-op stage 1 axial MRIs of L3-L4 and L4-L5. The spinal cord is now decompressed due to the indirect decompression.

Outcome

The patient had complete resolution of bilateral leg pain. Her back pain is mild and does not require regular analgesics. She went on to successful fusion, which is evident on her MRI. She has returned to all her normal activities, including bowling.

Case Discussion

I would do a similar procedure in 2 stages. However, I would do an open procedure.

For the first stage, I would do an anterior approach first and then a lateral approach, either a DLIF or an XLIF. Then, I would do a TLIF at L5-S1. For the second stage, I would do posterior spinal fusion with instrumentation (rods and screws) from L2 to the ilium along with an interbody fusion at L4-L5 and L5-S1 because it’s important to go to the pelvic bones. I would also do a lumbar laminectomy at L3-L5.

Community Case Discussion (7 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.


The cord ends at L1. Pictures are miscaptioned. The axials are unimpressive and the sagittals do show canal stenosis. Where is the instability requiring a 360? Simple decompression appears more reasonable and allows faster recovery. Should she then become unstable in rhe future, adding hardware is then reasonable.

This case represents spinal canal stenosis at L3/4 and L4/5 with "cord" compression. First of all, the MRI scan does not demonstrate significant stenosis on the axial views and the spinal cord ends at the L1/2 level. The axial views not demonstrating significant stenosis is the reason 25% of the respondents elected the other choice which is to decide against surgery as there was no selection for none of the above.

Although there are many ways to operate this particular situation but I would select other option, I don't see flexion/extension view for know how much instability is there but howsoever my option would be XLIF at L3-4, L4-5 and AxiaLIF for L5-S1 with posterior pedicle screws ( if there is instability ).

This case shows excellent surgical decision making. This patient's clinical outcome is superior to prolonging non-operative management. Her pain and disability were high before surgery and were much improved at one year post-operatively. How can anyone question the indication for surgery? With all due respect, there already is significant coronal plane imbalance and instability pre-operatively. Decompressive surgery without fusion would be negligent. This case illustrates the standard of care for degenerative scoliosis with lateral recess stenosis.

i´M AGREE WITH THE TREATMENT BUT I WOULD DO A POSTERIOR DESCOMPRESSION WITHOUT ILEUM FIXATION AND I WOULD DO ALIF TO L4-5 AND L5-S1 AND TLIF FOR THE OTHER LEVELS THANKS

The patient has worsening standing and walking tolerance with stenosis but also with significant sagittal imbalance despite compensation as shown by the increased pelvic tilt and the hip flexion. The stenosis is not the only cause for symptoms. The patient has a high pelvic incidence but has very little residual lumbar lordosis indicating that she needs restoration of lordosis to restore sagittal balance. Decompression alone will not work in this situation and will likely lead to a rapid deterioration. Posterior only fusion would not restore lordosis and without going to the ilium will lead to L5/S1 pseudarthrosis.

I agree with the decision to perform front and back surgery with extension to the pelvis. I would have used an open but otherwise identical technique. A nice result has been achieved.

This case vividly highlights the role of MISS techniques (and the lateral approach in particular) in the treatment of multilevel degenerative lumbar spine disease. Specifically, this example demonstrates the feasibility of providing 1) disc height restoration, 2) indirect decompression (as the post-op MRI confirms), 3) lordosis and 4) posterior stabilization all via MISS approaches. Most importantly, the patient enjoyed a good outcome.

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