Adolescent Idiopathic Scoliosis in a Young Musician
The patient is a 16-year-old female who presents with adolescent idiopathic scoliosis.
- She has a history of seizures
- Her menses have been regular for 2 years
- Review of systems is normal
- She has received no previous scoliosis treatment or bracing
- Right rib hump
- Right thoracic curve: 85-degrees
- Left lumbar curve: 50-degrees
- Rigid on forward and side bending
Neurologically, she is intact, including the abdominal reflexes.
Pre-operative Clinical Photographs
Figure 1. Posterior, standing
Figure 2. Forward bending
Figure 3. Left lateral, forward bending
Pre-operative Standing Radiographs
Figure 4. AP x-ray
Figure 5. Lateral x-ray
Figure 6. Right and left side bending x-rays
Adolescent idiopathic scoliosis
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Computerized pre-operative surgical planning in a 3D environment enabled accurate screw trajectory, rod contouring, and placement to be pre-planned.
Figure 7. AP
Figure 8. Lateral
An all posterior approach was chosen. Surgical treatment included multilevel Ponte-type and Smith-Peterson osteotomies with instrumentation and fusion from T4 to L4.
Surgeon's Treatment Rationale
The patient and her parents wanted to avoid any transthoracic approach. She is an avid musician, and they were concerned that an anterior procedure might affect her musical endeavors.
At the time of surgery, a meticulous soft-tissue release, including the rib head to transverse process articulation was undertaken. This allowed substantial mobility, more than initially anticipated, and resulted in a very gratifying overall correction.
Post-op Clinical Photos at 2-months
Figure 9. Pre-op and at 2-months post-op
Figure 10. Lateral clinical photo at 2-months post-op
The patient's surgical recovery was uneventful. She was compliant during her post-operative course of care, which included physical therapy. Today she is an active and thriving teenager, with no restrictions in her recreational or musical endeavors.
Post-op X-rays at One-year
Figure 11. AP and lateral x-rays
This is a case of a 16-year-old girl with adolescent idiopathic scoliosis (AIS). She had a clear indication for surgery given the magnitude of curvature (85-degree main thoracic scoliosis and 50-degree lumbar scoliosis). Points warranting discussion include pre-operative imaging, fusion level selection, and technique/approach for achieving correction of the deformity.
Pre-operative imaging did not include screening MRI. This was appropriate as there were no red flags or clear indications for such evaluation; such as rapid curve progression, atypical curve pattern, abnormal neurological examination (including abdominal reflexes) or radicular symptoms, or early-onset under age ten of the scoliosis. Presumably, the patient's seizure disorder was adequately evaluated and was brought under control prior to surgery.
Decision making in level selection for fusion in AIS is guided by curve classification, clinical deformity, needs of the patient, and surgeon preference. The curvature is a Lenke 1AN. That is, the major structural curvature is the main thoracic curve. Sagittal contour T5-12 is normal (Between 10- and 40-degrees).
Newton has described the "R" or "L" modifier having to do with the tilt of the lowest end vertebrae of the lumbar curvature which is, in this case, to the right. The lumbar curvature is highly flexible; however, given the "R" modifier, the thoracic curvature extends down into the lumbar spine. Dr. Lieberman chose to end the fusion construct at L4, which is a reasonable choice.
L3 could also have been considered given the highly flexible nature of the lumbar spine. This would have resulted in a slightly wedged L3-L4 disc but, in my view, an acceptable trade-off given the benefit of preserving a motion segment. The upper fusion level (UIV) chosen was T4, which resulted in a nicely leveled UIV and clinically leveled shoulders. A more distal fusion level at the upper end of the construct might have resulted in an undesirable elevation of the left shoulder given that the clavicles were level prior to correction.
Dr. Lieberman chose to perform the correction from an all posterior approach utilizing posterior column (Ponte) osteotomies of apical levels resulting in optimal radiographic correction, and a beautiful clinical outcome based on the photographic appearance of the patient following surgery. My choice would have been to address this deformity from a combined approach. The patient would be placed prone, a two-portal thoracoscopic approach through the right chest; removal of five discs would be performed with 5-10 cc of blood loss; in approximately one hour followed by a posterior approach with posterior column osteotomies added as needed.
In a retrospective matched multi-center review of cases performed with contemporary posterior technique with or without anterior release, we reported slightly improved coronal plane correction and significantly better maintenance of thoracic kyphosis with anterior release (North American Spine Society, New Orleans, 2013).