Adult Idiopathic Thoracolumbar Kyphoscoliosis
MIS or Open?
A 66-year-old female presented with a history of chronic low back pain, left thigh pain, and a progressive left-sided lumbar hump. She was "hunched over" forward and to the right.
The physical exam revealed that the patient was pitched forward 20 cm and to the right 13 cm. She had a 47º left apex thoracolumbar curve, as well as 75º kyphosis.
Previously, the patient had had a pain pump placed by a pain anesthesiologist.
Figure 1: Clinical pictures showing left curve.
Figure 2: Clinical pictures demonstrating 75º kyphosis. The patient is hunched forward and leans to the right.
Figure 3: Note the left-sided lumbar lump.
Figure 4: X-ray showing 47º thoracolumbar curve.
Figure 5: Lateral x-ray showing 75º kyphosis.
The patient was diagnosed with adult idiopathic thoracolumbar kyphoscoliosis.
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The patient underwent a two-stage surgery.
The first stage was L1-L5 XLIF.
Two days later, the patient had T10-S1 percutaneous instrumented spinal fusion with an L5-S1 TLIF and facet fusions at T10-L1.
Post-stage 1 Image
Figure 6: Standing x-ray after Stage 1.
Figure 7: Standing lateral x-ray after Stage 1.
Stage 2 Intraoperative Images
Figure 8: Rod insertion
Figure 9: MIS incisions
Figure 10: Pre-operative x-ray (left) compared to post-operative x-ray (right) showing reduction of thoracolumbar curve to 6º.
Figure 11: Pre-operative lateral x-ray (left) compared to post-operative lateral x-ray (right). Note the decrease in kyphosis-from 75º to 20º.
Figure 12: Pre-operative clinical picture (left) compared to post-operative clinical picture (right). Note the decreased hump.
The patient's thoracolumbar curve was reduced from 47 ºto 6º. The kyphosis was reduced from 75º to 20º.
This is a complex deformity that requires correction of both the sagittal and coronal planes. The XLIF procedure corrected both of these deformities quite well.
Without MRI, my concern is that restoration of the coronoal and sagittal deformity only will in part address the stenosis. Part of her sagittal plane imbalance may in fact be stenosis-related.
The jury is still out on the amount of distal fixation required for these minimally invasive deformity constructs. It has become the standard of care with open degenerative deformity to add iliac fixation, which is not present in this case. In addition, there appears there was no attempt at a posterior fusion through the entire construct.
It has been our experience that the most difficult area to obtain arthrodesis is at the thoracolumbar junction, and without an interbody arthrodesis, this will be the likely region of potential pseudoarthrosis. Psuedoarthrosis can lead to implant failure at the thoracolumbar region and will likely lead to recurrence of sagittal plane imbalance. It also appears that the immediate post-operative lateral full length spine did not completely address the sagittal plane imbalance.