Iatrogenic Scoliosis in a Former Rock Guitarist
History
A 68-year-old female ex-rock guitarist presented with a 5-year history of excruciating back pain that got worse with any activity. Her pain was constant—24 hours a day.
She had no secondary gain issues.
Examination
On examination, the patient was neurologically intact. She had neurogenic claudicatory leg pain in both legs, and a claudication distance of 1 block.
Prior Treatment
Previously, the patient had had 3 surgeries. She had 2 decompressions at L4-L5 and at one at L5-S1 with laminectomy from L3-S1.
The patient had failed all conservative measures.
Pre-treatment Images
Figure 1: Pre-op x-rays
Figure 2: Pre-op MRIs showing severe degeneration at L4. Note how L3 has collapsed onto L4, especially on the left side. Note, too, the facet joint that's in the canal at L4-L5. There is stenosis at L3-L4 and L4-L5.
Figures 3-6: Pre-op CT scans showing the facet of L4 that's collapsed into L5. There is a lytic fracture at L3. The facet subluxation is creating severe spinal stenosis with a 4 mm spinal canal.
Figure 3
Figure 4
Figure 5
Figure 6
Diagnosis
The patient was diagnosed with iatrogenic scoliosis and spinal stenosis.
Suggest Treatment
Indicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.Selected Treatment
The patient had a two-stage MIS surgery. Stage 1 was a lateral lumbar interbody fusion (specifically, a DLIF). Two days later, the patient underwent an AxiaLIF at L5-S1 and multi-level percutaneous pedicle screws instrumentation and fusion. BMP was used.
The DLIF provided indirect decompression of the spinal canal, which helped realign the facet joint at L3-L4.
Also, the patient had had 3 prior surgeries with laminectomy with considerable scarring, making the DLIF and AxiaLIF attractive minimally invasive options for correcting the deformity.
Post-treatment Images
Figure 7: Pre-op (left) to post-stage 1 DLIF CT scans. In the CT scan following the DLIF, note the realigned facet at L3-L4.
Figure 8: Pre-op (left) to post-stage 1 DLIF sagittal CT scans
Figure 9: CT scans from 2 years after surgery. There is evidence of full fusion.
Figure 10: Pre-op (left) to 3 years post-op PA x-rays showing deformity correction
Figure 11: Pre-op (left) to 3 years post-op sagittal x-rays showing deformity correction, especially in the lumbar spine
Outcome
The patient is asymptomatic, and she isn’t taking any pain medications. She has gone back playing guitar and is even teaching guitar lessons.
Case Discussion
This patient obviously displays some iatrogenic instability with scoliosis with multi-level listhesis. We do not have pre-operative 36-inch films to access overall spinal alignment.
Her surgical plan consisted of a combined minimally invasive approach over 2 stages to address her instability alignment and stenosis. Her outcome has been quite good to this point considering she is off all pain medications and has resumed her normal activities, and her x-rays show excellent realignment in the coronal plane.
Our evaluation of her sagittal alignment is somewhat limited due to our inability to see her femoral heads, but she does appear to be slightly malaligned. The included plumbline does not appear to drop from the C7 level. Also, I'm concerned that she appears to have some junctional kyphosis at this stage, although it still seems to be asymptomatic at the 3-year point.
This case clearly points out the power of minimally invasive scoliosis surgery to correct a coronal deformity, but the ability to sagittally realign patients has not yet been clearly demonstrated. The outcome of this patient has been quite good, and hopefully she continues to have long-term success.
An all posterior T10-S1 single-stage operation would likely have accomplished
similar outcomes with the advantage of improved sagittal plane realignment,
but with the drawback of more blood loss and the potential for more peri-operative
complications.
Community Case Discussion (6 comments)
Remarkable case (I got it right!). Almost hurt to see that spine. She must be very grateful.
Best Regards
Jerry Hesch
Sagittal balance has not been restored. The C7 plumb line on the post-op film is not drawn from C7 and the true C7PL in fact falls a fair way anterior to the sacrum. This is despite evidence of the patient compensating - the sacrum is vertical implying excessive pelvic tilt and I suspect her knees are bent in the post-op Xray. The surgery has not addressed the sagittal imbalance and unfortunately the patient is at risk of developing progressive proximal junctional kyphosis.
A nice coronal correction has been achieved but as we know this is much less important than correcting sagittal imbalance. Open posterior surgery would have allowed a better restoration of lower lumbar lordosis. The axiaLIF has created distraction but no lordosis at the lumbosacral junction.
Nice coronal balance, but i feel that the sagittal balance is a bit off and sagittal balance is the most important one. I feel that axiaLIF has created distraction at the lumbosacral junction, ( it would have been better if there is lordosis )
but the patient after 3 years post surgery is well and not complaining of any claudication then everything is good.
Nice coronal balance, but i feel that the sagittal balance is a bit off and sagittal balance is the most important one. I feel that axiaLIF has created distraction at the lumbosacral junction, ( it would have been better if there is lordosis )
but the patient after 3 years post surgery is well and not complaining of any claudication then everything is good.
I tend to agree with Dr. Koski. Sagittal balance under corrected, despite what looks like a t3 plumb line. I add iliac screws for any construct above l2, especially if poor bone. While I like lateral access(x/dlif) for deformity, my experience is you don't quite get as much lordosis as you think, and likely have to add at least a few smith-Pete osteotomies, especially for someone who started with pretty good lumbar lordosis. MIS is sexy, but open allows iliac screws, osteotomies, and standing upright.
Agree with surgeon's concern above regarding lack of adequate lower lumbar lordosis leading to junctional kyphosis, back pain due to pelvic compensation, and risk of S1 screw failure. Most reliable way for me to restore L/S lordosis in these multiply operated patients is combined alif/psf with iliac screws. Also usually direct neural decompression necessary particularly at L5 lateral recess and foramens. Surprised this patient has done as well as described without this, but perhaps less L/S lordosis has actually kept foramens open. These cases are becoming epidemic and I would prefer a less invasive method with predictably good results, but so far haven't found it.
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