Significant Back and Leg Pain in a 70-Year-old Female

History

The patient's previous medical history is significant for poliomyelitis and generalized left leg weakness. She experiences increasing inability to stand, walk, or perform activities of daily living, such as cooking secondary to severe back pain and right leg pain. She stated she "can't live like this". She has a several year history of poor bladder function and leg length discrepancy/problems. Included is a past surgical history significant for previous "decompression" or laminectomy.

Examination

Overall, fair sagittal balance, but she is unable to maintain posture. Her trunk shifts to the right. The neurologic examination is significant for right quadriceps weakness (4/5) with positive femoral stretch test.

Images

Left and right standing, as well as posterior photos demonstrate mild sagittal imbalance and right trunk shift. Note: She needs to "balance" herself with her hand on wall in Figure 1C.

Figure 1A

Figure 1B

Figure 1C

The patient's AP and lateral standing 36-inch radiographs demonstrate right trunk shift and coronal imbalance. There is mild rotatory subluxation at L4-L5.

Figure 2A

Figure 2B

Sagittal T2 weighted MRI demonstrates multi-level degenerative changes, most severe at L2-L3. Note Figure 3B with "clumping" of nerve roots.

Figure 3A

Figure 3B

Diagnosis

The patient was diagnosed with adult degenerative scoliosis.

Selected Treatment

The patient underwent a posterior spinal fusion from T11-S1/ilium.

Early 6-week follow-up radiographs are seen in Figures 4A and 4B.

Figure 4A

Figure 4B

Outcome

At 1-year following surgery, the patient's Oswestry Disability Index score decreased from 49 to 22.

Case Discussion

The decision to proceed with spinal stabilization and decompression for degenerative scoliosis has a great deal to do with the level of disability and pain a patient is experiencing. This patient clearly stated she "can't live like this", and has also reported an increasing deficit. A full work up includes an MRI or CT myelogram to evaluate central and foraminal stenosis. A long standing A/P and lateral Radiograph is essential in the pre-operative evaluation.

Each of the selected treatments has merit in the appropriate patient, however, only a decompression/fusion that includes the thoracolumbar and lumbosacral junctions will address all this patient's symptoms, including progressive trunk imbalance and increasing motor weakness. Recent studies also indicate that posterior stand-alone constructs demonstrate the same level of scoliosis correction as anterior/posterior procedures at a lower rate, if complication.

Studies of scoliosis patients, in age groups greater than 65-years, show postoperative complication rates as high as 25%. Patient expectation and education relating to surgery, recovery, and long term outcomes are vital in achieving the long term goals of increased function and decreased pain.

Surgery for adult degenerative scoliosis has evolved due to advances in instrumentation, technique, and anesthesia, and can now reliably improve the quality of life for a wide range of patients.