Progressive Lumbar / Thoracolumbar Idiopathic Scoliosis

History

The patient is a 13+11-year-old female with progressive lumbar / thoracolumbar idiopathic scoliosis who failed bracing. She is otherwise, healthy.

Examination

The patient's lumbar Scoliometer measurement is 20-degrees. Her thoracic Scoliometer measurement is 7-degrees. Her right shoulder is slightly higher than her left. She has marked waistline asymmetry.

Images

Figure 1A. AP x-ray, standing long cassette

Figure 1B. Lateral x-ray, standing long cassette

Pre-operative clinical photos. SCM=6-degrees right thoracic, SCM=17-degrees left lumbar (Figs. 2A-2C)

Figure 2A

Figure 2B

Figure 2C

Figure 3. Pre-operative SRS-22 broken into domains.

Diagnosis

Adolescent idiopathic lumbar scoliosis greater than thoracic.

Selected Treatment

Anterior spinal fixation / anterior segmental spinal instrumentation, T11-L3

Figure 4A. 3-years postop, AP x-ray standing long cassette

Figure 4B. 3-years postop, lateral standing long cassette

Clinical photos 3-years postop. (Figures 5A-5C)

Figure 5A

Figure 5B

Figure 5C

Figure 6. SRS scores converted to 100 point scale.

Figure 7. Postoperative SRS-22 broken into domains.

Outcome

At the patient's 5-year follow-up, she is doing quite well. Currently a nursing student, she has volunteered to counsel other teens with adolescent idiopathic scoliosis about surgical treatment.

Case Discussion

This 13-and-11/12 year-old young lady is presumably approaching skeletal maturity. In summary, she has a left thoracolumbar idiopathic curvature of 64-degrees with a 42-degree compensatory right thoracic curve. There is significantly greater clinical and radiographic rotation and translation of the thoracolumbar curve compared to the thoracic curve. The sagittal plane is normal with no evidence of thoracolumbar junctional kyphosis. No flexibility data is presented, but it is likely the thoracic curve is flexible. Radiographically, the shoulders appear to be level. In my experience, a structural thoracolumbar curve with compensatory thoracic curvature is ideally approached from an anterior approach with dual rod segmental instrumentation combined with structural grafting to preserve lordosis, as was done.

The anterior approach provides a powerful correction of both the coronal and axial planes and is well-tolerated by patients. In fact, in a series of 19 patients with two-year follow-up, who underwent thoraco-abdominal approaches for thoracolumbar scoliosis, there was no significant impact on pulmonary function. (1) One could consider doing this from a posterior approach as well and ending the fusion also at L3. One common finding following anterior surgery is there is some wedging of the disc caudal to the instrumentation, but this has not been shown to have any negative clinical impact.

Untreated thoracolumbar scoliosis has been shown to result in increased lumbar degenerative disc disease and back pain compared to controls. There is potential for distal disc degeneration below this anterior fusion. If surgery were required, this could readily be addressed from a combined anterior and posterior approach or all posterior approach with interbody fusions done with posterior techniques. In a patient with significant remaining growth, leaving a residual thoracic curve confers some risk of progression and one would consider bracing the residual thoracic curve. In a nearly skeletally mature patient, there is a little concern of further progression of the thoracic curve.

This patient has clearly done very well from a selective thoracolumbar fusion and this has been my experience for this curve type in the adolescent patient.

Reference
Lonner BS, Auerbach JD, Estreicher MB, Betz RR, D'Andrea L, Crawford AH, Lenke LG, Lowe TG, Newton PO. Pulmonary function changes following various anterior approaches in the treatment of adolescent idiopathic scoliosis. J Spinal Disord Tech (In revision).