Less Invasive Spinal Deformity Correction
A 72-year-old female presented with progressive symptoms of severe back and right sided leg pain for three years. The pain worsened with standing and ambulating, and improved with sitting and lying down.
The patient rated her leg pain at 5 out of 10, and back pain at 8 out of 10 on the Numeric Pain Score (NPS). She had a distance limited gait of 100 feet. Her Oswestry Disability Index (ODI) was 42. Her SF-36 Physical Component Summary (PCS) sub-score was 39 and the Mental Component Summary (MCS) sub-score was 43.
She had no history of previous spinal surgery, scoliosis, infection, or neoplasia. She was otherwise healthy and a non-smoker.
On examination the patient had no focal areas of tenderness to palpation and there were no signs of sacroiliac or hip joint pain on provocative maneuvers. The motor examination was intact, but there was some loss of sensation in her hands. There was a positive Hoffman's reflex bilaterally and 3 out of 4 reflexes in the knees.
The patient had no previous history of spinal surgery. She had tried physical therapy, chiropractic management, anti-inflammatory medications, and a total of six epidural steroid injections.
Previous treatment with lumbar epidural injections and physical therapy had initially been helpful, but for the past year was ineffective. The patient had also, more recently, developed hand numbness and loss of dexterity in her fine hand motions.
This patient presented with symptoms typical for advanced adult degenerative scoliosis with loss of lumbar lordosis. Her sagittal balance was aligned, but only due to pelvic retroversion (Figures 1 & 2). Her symptoms of back and leg pain were due to severe facet joint and disc arthropathy, as well as neural entrapment. In addition, she had the signs and symptoms of cervical stenosis, a diagnosis that was confirmed with a subsequent cervical spine MRI examination.
Figure 1. Pre-operative AP 36" standing X-Ray demonstrating lumbar degenerative scoliosis.
Figure 2. Pre-operative lateral 36" standing X-Ray demonstrating loss of lumbar lordosis.
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Author's Treatment Commentary
For the patient's cervical myelopathy several treatment options exist. The first would be expectant non-surgical management. Surgical options include multi-level ACDF, laminectomy with instrumented fusion, and cervical laminoplasty.
For her thoracolumbar degenerative scoliosis several options also exist. If the patient was frail and with a limited life expectancy, a limited decompression targeted at the level of her radiculopathy may yield sufficient benefit with minimal surgical and anesthetic risk.
For definitive treatment of the kyphoscoliosis several options also exist. A long segment posterior instrumented fusion with facet joint osteotomies would allow for at least partial scoliosis correction, and would yield some improvement in lordosis. A combined approach, with anterior interbody fusion first, followed by posterior instrumented fusion would allow for more corrective power, particularly at the L5-S1 disc space. This would also directly address the patient's fractional curve and enhance the likelihood of successful arthrodesis at the lumbosacral junction. A combined anterior-posterior approach could also be undertaken with a less invasive lateral technique supplemented with percutaneous screws. However, such an approach would essentially require three distinct surgical elements: L5-S1 mini-open anterior interbody fusion, MIS lateral interbody fusion at L2-L5, and percutaneous pedicle screws. Furthermore, the ability of the lateral MIS approach to effectively add lumbar lordosis remains debatable and is technically challenging. Most deformity surgeons would approach the patient with an open posterior surgery with a pedicle subtraction osteotomy (PSO).
The patient underwent two operations. The first was a C4-C5, C5-C6, and C6-C7 ACDF to treat her cervical stenosis and myelopathy. Under the same hospitalization, and four days later, she had a minimally invasive T10-S1 instrumented fusion. This included a mini-open PSO at L2 and L4-L5, and L5-S1 MIS TLIF.
The surgery was accomplished by first performing the two-level MIS TLIF on the right side. The entire operation was performed with a midline skin incision to avoid the untoward cosmesis and troublesome bleeding associated with multiple stab incisions of a surgery this extensive. A bilateral subperiosteal dissection was then made at the L2 level to expose laterally to the L2 transverse processes. The PSO was accomplished with a standard decancellation technique and was performed using a mini-open method to allow protection of the neural elements and to manage bone bleeding (Figures 3 & 4).
The pedicles were then cannulated using a percutaneous technique through the muscle fascia at T10-T12 and L3-S1. Passage of four properly bent sub-fascial rods then allowed control of both the rostral and caudal spinal segments above and below the destabilizing PSO site at L2. Connection of the rods with dual rod connectors secured and maintained correction of lordosis. Surgical treatment involved 550 cc of blood loss and 290 minutes of surgical time.
The patient tolerated both procedures well and was discharged home five days following her second stage operation. She had an uneventful recovery.
At one year after surgery, the patients leg NPS improved from 5 to 1 and her back NPS improved from 8 to 2. Her ODI improved from 42 to 14. The SF-36 PCS sub-score changed from 39 to 51, and the MCS sub-score improved from 43 to 47. Her gait limitation improved to over two miles.
Imaging studies demonstrated improvement in lumbar lordosis (Figures 5 & 6) and CT scanning revealed bony bridging demonstrating arthrodesis at all the treated levels.
Figure 5. Post-operative AP 36" standing X-Ray demonstrating lumbar degenerative scoliosis.
Figure 6. Post-operative lateral 36" standing X-Ray demonstrating loss of lumbar lordosis.
Ali A. Baaj, MD
Assistant Professor of Neurological Surgery
Weill Cornell Medical College, Cornell University
Vernard S. Fennel, MD
Division of Neurosurgery, University of Arizona
This patient presents with cervical stenosis and degenerative lumbar scoliosis. The chosen surgical treatment of the former is standard, but that of the latter warrants discussion.
Adult degenerative scoliosis (ADS) of the lumbar spine is increasingly common in the active and aging population. Symptoms can include radiculopathy, neurogenic claudication, and mechanical back pain. The surgical goals are to decompress the neural elements, re-establish focal and global alignment, and stabilize the spinal column. The key radiographic parameters that must be considered in the surgical planning, at minimum, should include: Sagittal and coronal balance, lumbar lordosis, and sacropelvic morphology.
In this case, Dr. Wang executed a highly-technical procedure and has achieved excellent radiographic and clinical results at 1-year follow-up. The key considerations (decompression, re-alignment, stabilization) were addressed in an elegant, minimally invasive fashion.
In treating ADS, we know what works, but we continue to search for what works "better." Traditional open thoraco-pelvic corrective procedures work, but this comes at a high cost in terms of peri-operative morbidity. Minimally invasive spine (MIS) techniques are associated with less morbidity, but arguably at the expense of definitive deformity correction and increased radiation.
The surgical procedure must ultimately be tailored to each specific case and to the surgeon's preference to ensure safety and success. However, efforts to advance our techniques, to decrease morbidity, and to continue the quest for finding "better" options need to continue.