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Adult Scoliosis: Progressive Lower Extremity Radicular Pain

Patient History

The patient is a 44-year-old female who underwent scoliosis surgery (T3-L4) at age 14. She presents with low back pain for 6-years and progressive lower extremity radicular pain for 1-year.

Examination

Her neurological exam revealed 4/5 weakness for left extensor hallicus longus and decreased sensation at L5, left greater than right.

Images

AP x-ray, 47-degree curvature
Figure 1. AP x-ray shows a 47-degree curvature

Lateral x-ray, 4.2 cm PSB
Figure 2. Lateral x-ray shows 4.2 cm PSB

Axial CT scan, L3
Figure 3A. Axial CT scan, L3

Axial CT scan, L4
Figure 3B. Axial CT scan, L4

Axial CT scan, L4-L5
Figure 3C. Axial CT scan, L4-L5

Axial CT scan, L5-S1
Figure 3D. Axial CT scan, L5-S1

 CT myelography shows sagittal reconstruction
Figure 4. CT myelogram showing sagittal reconstruction

Diagnosis

The patient was diagnosed with adjacent segment degeneration after prior Harrington rod treatment.

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Selected Treatment

Nonoperative treatment was not successful; increasing neurologic deficit. The patient underwent an ALIF at L4-L5, L5-S1 with T12-iliac fusion attached to the previous Harrington rod.

AP x-ray, 1-year postoperative
Figure 5A. AP x-ray, postoperative 1-year

Lateral x-ray, 1-year postoperative
Figure 5B. Lateral x-ray, postoperative 1-year

AP CT scan, lumbar spine
Figure 6A

Sagittal CT scan, lumbar spine
Figure 6B

Outcome

The patient is symptom free 1-year after surgery.

Case Discussion

The patient has a neurologic deficit due to the L5 nerve root. The previous fusion goes to L4. The patient has high-grade stenosis at L5-S1 and lateral recess stenosis at L4-L5. She also has a relatively flat back across the instrumented fusion levels, with the only remaining motion from L4 to the sacrum, which is deformed. There is now disc space collapse at L4-L5 and L5-S1 and stenosis. She failed nonoperative care.

The best option to me is a laminectomy to decompress the roots and interbody and posterior fusions. I would include both levels in the fusion because of potential breakdown of whatever level was not included. The interbody options include: a) two-level ALIFs, which would give the best opportunities for distraction and realignment of the endplates, b) XLIF at L4-L5 and TLIF at L5-S1, or c) two-level TLIFs.

A final consideration would be bilateral posterolateral 2-level posterolateral fusions, but I do not feel that would align the space as well. My choice would be to start posteriorly, removing the lower half of the Harrington rods, perform L4 and L5 laminectomies, and osteotomies at L4-L5 and L5-S1. Under that anesthesia, I would insert screws from approximately L2 to the sacrum. I would then return 4-days later for anterior L4-L5 and L5-S1 interbody fusions with the wedges placed appropriately to correct the scoliosis and create lordosis. Under the same anesthetic, I would turn the patient prone and complete the instrumentation with compression posteriorly and fusion.

If there was adequate graft obtained from the laminectomy and the proximal fusion mass, and iliac crest graft was not needed, and the distal fixation was of concern, iliac bolts could be added. However, iliac crest autograft may be needed for the posterior lateral fusion. This could be a consideration in the iliac bolt placement.

The other alternatives listed (L4-L5 XLIF, or more so, TLIFs) would be less likely to achieve the degree of lordosis that a staged procedure could provide with posterior Osteotomies, generous anterior releases, and placement of large wedges.

In the case presented, it appears the surgeon chose anterior L4-L5 and L5-S1 interbody fusions, followed by posterolateral fusion. I would not have connected the new rods to the old rods, as that adds bulk and can create a palpable, painful ridge prominence in some people, particularly at the deformity level (which this is). The surgeons did correct the lordosis, as well as the lumbosacral scoliosis, in an excellent fashion. It is not stated whether posterior osteotomies were performed.

Author's Response

A number of different approaches could have been performed to correct the spinal stenosis, scoliosis, and loss of lordosis. In my hands, I can maximize lordosis more effectively with an ALIF compared with an XLIF or TLIF procedure. Posterior decompression and chevron osteotomies where performed to provide neural decompression and enhance the correction of the spinal deformity. The side-to-side connectors used to attach to the Harrington rods were low profile and no instrumentation prominence has resulted, although this can be a concern (particularly in thin patients).

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