Mild Lumbar Scoliosis and Spinal Stenosis
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.
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.
Previously, the patient tried epidural steroid injections3 times over the course of 6 months and physical therapy and aquatic therapy.
Figure 1: Pre-op AP x-ray showing curve in the lumbar spine
Figure 2: Pre-op lateral x-ray
Figure 3: Pre-op T2-weighted sagittal MRIs showing compression of the spinal cord at L2-L3, L3-L4, and L4-L5.
Figure 4: Pre-op axial MRIs of L3-L4 and L4-L5. Note the spinal cord compression.
The patient was diagnosed with lumbar scoliosis at L2 to L4, sagittal imbalance, and spinal stenosis with neurogenic claudication.
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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.
Figure 5: Sagittal MRI after stage 1 of the surgery
Figure 6: Post-op stage 1 axial MRIs of L3-L4 and L4-L5. The spinal cord is now decompressed due to the indirect decompression.
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.
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.