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Severe Progressive Adult Idiopathic Scoliosis

Patient History

The patient is a 54-year-old female diagnosed with idiopathic scoliosis as an adolescent. Twenty years earlier, despite the presence of a significant progressive spinal deformity, she was told that she was not a surgical candidate because of her age. She has experienced pain in the thoracic spine particularly over the convexity of the curvature and in the lumbosacral region in the midline. She has also noted a worsening of her truncal deformity and loss of height over the years.

The patient is a school teacher and notes increasing fatigue at the end of the day.

She was first evaluated by me two years earlier and was prescribed core-strengthening exercise as well as physical therapy. She was placed on bisphosphonate therapy (alendronate), calcium and Vitamin D for osteopenia. Despite this regimen, pain persisted and progression of the deformity occurred.

Examination Results

The patient is healthy in appearance. She is well-balanced in the coronal and sagittal planes despite the presence of severe right thoracic scoliosis and a smaller left lumbar scoliosis. Gait and neurological status are normal. Leg lengths are equal and hips are painless with full range of motion. There is a right thoracic rib prominence of 25-degrees as measured with an inclinometer.

Pulmonary function testing reveals normal forced vital capacity and forced expiratory volume in one second (FVC and FEV1).

Her DEXA scan reveals normal bone density both age-matched and compared to young standards (T-score).

Pre-treatment Images

Full-length anteroposterior (AP) and lateral radiographs of the spine reveal a right thoracic curvature that is 87-degrees; one year earlier, the curve was 80-degrees. Thoracic kyphosis measures 63-degrees.

Magnetic resonance imaging (MRI) reveals marked disc degeneration throughout the lumbar spine, particularly in the caudal lumbar segments. No significant neural element compression is noted.

Bending x-rays reveal a rigid thoracic curvature with correction to only 64-degrees.

adult idiopathic scoliosisFigure 1A. AP                        Figure 1B. Lateral

Left (Fig. 2A) and right (Fig. 2B) bending x-rays

adult idiopathic scoliosis, bending x-raysFigure 2A                                 Figure 2B

MRI studies reveal disc degeneration and facet arthrosis including L4-L5 and L5-S1.

Diagnosis

Severe, progressive adult idiopathic scoliosis

Suggest Treatment

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Treatment

The nature of the surgery with fusion to the sacrum through a combined anterior and posterior approach performed in a staged fashion separated by one week was discussed with the patient. Post-operative care was explained including the need for in-patient rehabilitation following surgery.

  • Thoracoscopic anterior spinal release including osteotomies and fusion
  • Anterior lumbar interbody fusion at L4-L5 and L5-S1 with structural allograft
  • One week later; posterior instrumented fusion to the sacrum with unilateral iliac fixation.

Graft: Local bone from the laminae spinous processes, rib from thoracoscopic portal, crushed cancellous allograft, and bone marrow from the vertebra through the pedicles at multiple levels.

TPN was not used. Nutritional status was normal pre-operatively. The patient was tolerating enteral nutrition by three days post-operatively and was placed on oral high calorie/protein supplementation.

Outcome

One month post-op
One month post-op AP (Fig. 3A) and lateral (Fig. 3B) x-rays.

one month post-op surgery; adult idiopathic scoliosisFigure 3A                       Figure 3B

2 years, 8 months post-op
The patient returned to work as a schoolteacher after three months. Her pain was negligible at latest follow-up. She was highly satisfied by her surgical outcome.

She was well-balanced in both the coronal and sagittal planes. There is a 4-degree residual rib prominence compared to 25-degrees prior to surgery. Neurological status is intact.

FVC and FEV are 89% and 93% of the predicted values, respectively for her age and height of 62.75 inches.

Full-length AP and lateral radiographs of the spine reveal maintenance of alignment and correction with the implants in good position. The thoracic curvature is stable at 37-degrees down from 87-degrees prior to surgery.

Two years and 8 months after surgery; AP (Fig. 4A) and lateral (Fig. 4B) x-rays.

2 years, 8 months post-op; adult idiopathic scoliosisFigure 4A                              Figure 4B

Case Discussion

The operative indications for this 54-year-old female with long-standing idiopathic scoliosis are strong with documented curve progression and increasing clinical symptomatology in this otherwise healthy female. In any patient over age 50, where a significant spinal reconstruction is planned, I always obtain a T-score to assess bone density and Vitamin D levels, as well as medical and cardiac clearance. In this case, it is obvious the thoracic spine needs to be instrumented and fused. The MRI results indicate the entire lumbar spine needs to be included.

I congratulate Dr. Lonner on an excellent radiographic and clinical outcome on this challenging adult deformity. The patient is extremely well-balanced, especially in the sagittal plane, which we know is probably the most important radiographic parameter leading to good clinical outcomes in adult scoliosis treatment. Also, the patient went through this extensive surgery without any complications and seemingly has recovered very nicely at most recent follow-up.

However, I would have approached this patient's deformity (as I have done on all adult scoliosis patients since 2000) with a single-stage all posterior procedure from T2-T3 to the sacrum and ilium with segmental pedicle screw fixation at all levels, thoracic apical multi-level posterior Ponte-type ligament/facet excisions, and TLIF's at L4-L5 and L5-S1. Bone graft would include a combination of local autogenous bone, fresh-frozen morselized allograft bone, and BMP-2 (off-label use for the posterior fusion).

In my practice, use of various posterior osteotomies and secure segmental pedicle screw fixation has enabled us to avoid any anterior releases for any size and/or stiffness of thoracic or lumbar deformity. In this case, convex rod compression and cantilever would have been performed as the initial deformity maneuver to simultaneously correct the thoracic scoliosis/kyphosis. The all posterior approach would be effective since the main operative goals are to obtain balanced correction, optimal balance, solid fusion, and avoid complications.

A final point is adult deformity patients really need to be followed for at least 5-10 years to make sure they have solid multi-level arthrodesis. The results of a large group study of adult primary deformities revealed that many patients were found to have pseudarthrosis with implant failure 5 years post-op.1

Reference
1. Pichelmann MA, Lenke LG, et al. Revision Rates Following Primary Adult Spinal Deformity Surgery: Six Hundred Forty-Three Consecutive Patients Followed-up to Twenty-Two Years Postoperative. Spine. 2010. Jan 15; Vol. 35, Issue 2, pp 219-226.

Community Case Discussion (2 comments)

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this is an excellent, really demanding case of adult idiopathic scoliosis with superimposed degenerative arthrosis changes both in thoracic but mainly in lumbar and lumbosacral region. There should be no doubt that in this double major, SRS-Lowe type 3 curve both main thoracic e secondary lumbar curve should be included in the artrodesis so as to achieve a well ballanced final correction, both in coronal but mainly in sagittal plain (preoperative thoracic kyphosis > 60 deg).Unfortunately no MRI immages have been provided so as to assess whether L5-S1 disc was healthy enough to be saved in such young adult female. Lateral bending flexibility dimonstrate a relatively stiff, but not highly rigid deformity. The use of large (6.5/7.0) and long (possibly bicortical) multiaxial pedicle screws, new generation rigid and semirigid rod materials (titanium/cromocobalt), the use of TLIF for sagittal/coronal restoration of lower instrumented vertebras and a 360 deg artrodesis, and the recently widespread use of posterior based release/osteotomies, i.e Ponte-like multiple osteotomies,permit a single stage posterior only approach with excellent mid-long term results in overall correction and pseudoartrhosis rates. Posterior only recostructive spinal deformity surgery has been the solution provided since 1995 at the Rizzoli Spine Deformity Department, and the one being applied for the last 2 years at our current Institution. Nevertheless the outstanding results shown by Dr. Lonner point out the importance of excellence and self confidence with a given surgical technique a surgeon should reach,whether anterior/posterior or posterior only, so as to safely and effectively treat such demanding major spinal deformity. As suggested by Dr. Lenke a minimum 5 to 10 years of follow-up should be guaranteed.

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