SpineUniverse Case Study Library

Adult Degenerative Lumbar Spinal Deformity

History

The patient is a 71-year-old female who presented with mechanical back pain, neurogenic claudication and worsening posture. Her primary complaint was progressive forward posture as noticed by her and family.

She was otherwise healthy without a history of neuromuscular disorders or Parkinson’s disease.

Examination

  • Obvious hyperkyphosis of the upper back with mild truncal shift.
  • Shoulders and hips were even; no hip or knee contractures.
  • Neurological exam reveal no focal weakness; no pathologic reflexes.

DEXA scan revealed a normal T-score.

Prior Treatment

She tried epidural injections, physical therapy and oral analgesics, none of which provided adequate relief.

Pre-Treatment Imaging

The MRI of the lumbar spine revealed multilevel spondylosis with severe central canal stenosis at L2-L3 (Figure 1).

Lumbar MRI, multilevel spondylosis with severe central stenosis at L2-L3Figure 1. Sagittal lumbar MRI reveals multilevel spondylosis with central canal stenosis at L2-L3.

Standing scoliosis films (Figures 2 and 3 below) demonstrated the following parameters:

standing scoliosis imaging measures; SVA, lumbar lordosis, pelvic tilt, pelvic incidence, Cobb angle

standing scoliosis imagesFigures 2, 3: Standing scoliosis imaging includes the following measurements: sagittal vertical axis, lumbar lordosis (LL), pelvic incidence (PI), LL-PI mismatch, pelvic tilt, and lumbar coronal Cobb angle.

Diagnosis

Adult degenerative lumbar spinal deformity

Suggest Treatment

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Selected Treatment

Posterior L2-L3 decompression, posterior column osteotomies, and long-segment thoraco-pelvic fusion.

Surgeon’s Rationale
Decision-making in adult degenerative deformity is challenging. Decompression and fusion is typically indicated but choosing the approach and the upper/lower instrumented vertebra is controversial. Furthermore, severe spinal stenosis alone can sometimes cause back pain and “poor posture,” thus confounding the true etiology of the deformity.

In this case, decompression was warranted given the severe spinal stenosis and neurogenic claudication. A more focal approach, in my opinion, would not have afforded the opportunity to correct the patient's significantly positive SVA, LL-PI mismatch and coronal deformity.

Given that her main complaint was her forward posture, I felt that was the primary goal of the surgery. As she wasn’t fused in the lumbar spine, posterior column osteotomies were sufficient to induce lordosis and correct the deformity with a long construct. No interbody devices were implanted given robust bone stock and multilevel fixation.

Outcome

The patient tolerated the procedure exceptionally well with excellent post-operative clinical and radiographic results (Figures 4 and 5).

pre- and post-operative SVA, LL, PI, LL-PI mismatch, pelvic tilt and lumbar coronal Cobb angle measurements

post-operative imaging with SVA, LL, PI, LL-PI mismatch, pelvic tilt, lumbar coronal Cobb angleFigures 4, 5: Lateral and posteroanterior post-operative x-rays includes SVA, LL, PI, LL-PI mismatch, pelvic tilt and lumbar coronal Cobb angle measurements.

Close follow-up is mandatory to watch for development of proximal junctional kyphosis (PJK), proximal junctional failure (PJF), and distal junctional failure (DJF) among other potential complications in these types of extensive surgeries.

Peer Discussion

Leslie Robinson MD, PharmD, MBA
Neurosurgery Spine Fellow
University of California, San Francisco (UCSF)

Praveen Mummaneni MD
Joan O'Reilly Professor in Spinal Surgery & Vice Chair of Neurological Surgery 
Director of Minimally Invasive and Cervical Spine Surgery
Director, Minimally Invasive and Complex Spine Fellowship Program
Co-director, Spinal Surgery and UCSF Spine Center

Dr. Baaj discusses a case of adult degenerative lumbar deformity. The patient received appropriate work-up with standing scoliosis x-rays to measure spino-pelvic parameters, MRI to evaluate the neural elements, and DEXA scan to evaluate bone quality. The patient also received an adequate trial of conservative treatment prior to discussions regarding surgery.

While the options of lumbar decompression or a short-segment fusion will address her lumbar stenosis, they will unlikely be able to adequately address her main complaint of progressive forward posture. We agree with the author that a long-segment thoraco-pelvic fusion was necessary to adequately address her positive SVA and LL-PI mismatch as well as coronal deformity. The facet osteotomies performed did an excellent job of helping to restore appropriate lumbar lordosis. We would have done an anterior approach (ALIF) at L4-S1 as a stage 1 surgery to restore lordosis and enhance chances for fusion at the base of a long construct. A subsequent T10-S1 posterior fusion with pelvic fixation would have been our stage 2 surgery plan.

Overall, Dr Baaj did an excellent job of correcting the spino-pelvic parameters through his surgical approach. In cases with long posterior constructs, anterior approaches may also be considered in addition to the posterior fusion to help obtain the desired lumbar lordosis and provide a higher chance to achieve a successful fusion.

Author's Reply to Peer Discussion

Ali A. Baaj, MD
Associate Professor of Neurological Surgery
Co-Director, Spinal Deformity and Scoliosis Program
Weill Cornell Medical College, Cornell University

I thank Drs. Robinson and Mummaneni for their thoughtful comments.

I agree that, in many cases, anterior column realignment is necessary to optimize correction and arthrodesis. In select cases, however, I try to avoid the morbidity of an added anterior stage if I'm confident that realignment, correction and stabilization can be adequately addressed through a posterior-only approach.

Community Case Discussion (2 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.


I would have preferred to restore lumbar lordosis from L3-4,L4-5 & L5-S1 by ALIF, and also indirect decompression by DLIF/OLIF at L2-3,L1-2 and after restoring lordosis predominantly by ALIFs stage the procedure by posterior fixation from T10- L3 with decompression at L2-3.

Thank you Dr. Baaj, for sharing this Interesting case!
I think, in an elderly patient like this, undergoing such an extensive surgery, it would be nice to know parameters such as - the duration of the procedure, blood loss, immediate post-operative care (i.e. did she need ICU care), the length of hospital stay, duration of pain medication, and length of rehab.
Also, when we evaluate sagittal alignment, is the normal for a 71-year-old female, same as what is normal for a 17-year-old female?
You pointed out that the main complaint was worsening posture and, that was the main reason for the surgery. But why was the patient’s posture worsening? Looking at the X-Ray images and the one sagittal view of lumbar MRI, the patient has no evidence of fracture. Given the collapse of all the lumbar discs and the scoliotic deformity, the structural malalignment must have been there for years! Now, we all know that elderly patients who present with such severe degenerative stenosis of the lumbar spine progressively develop flexed posture to reduce symptoms of neurogenic claudication! I wonder if this important fact has been taken into consideration in planning surgical approach!
It would be helpful to know if the patient’s radicular symptoms were unilateral or bilateral! Also, was the epidural injection interlaminar or transforaminal? If transforaminal, which side was injected, and was local anesthetic agent injected along with the steroid? That would have given immediate answers regarding the symptomatic nerve root and shade some light on the etiology of progressive postural deterioration, at least for the duration of the local anesthetic.
Based on the available data, and my experience with such patients, the postural deterioration of this patient was secondary to spinal stenosis and neurogenic claudication. This is how I’d have approached this case:
1. Use anatomic classification of spinal motion-segment disease to define the severity of patho-anatomy at each relevant segment;
2. Based on the clinical and imaging data, I’d perform diagnostic/therapeutic transforaminal injection at the suspected level of symptomatic nerve root. If this relieves radicular pain, axial pain and improves posture, but the relief is temporary, I’d proceed to endoscopic transforaminal decompression at the relevant level(s). This is done under mild sedation and local anesthesia, as outpatient procedure!
3. If following the injection, radicular pain improves but the axial pain persists, my interpretation would be, symptoms are both neurogenic and arthrogenic, from the facet joints. I’d then proceed to facet block and see if this eliminates axial pain. If both injections are positive, but temporary, I’d have defined the limits of the symptomatic levels and would proceed to decompression and fusion of the relevant segments. The decompression approach depends on what the axial MRI view looks like! If there is severe central and foraminal stenosis, I’d use hybrid approach – limited laminectomy/facetectomy, (percutaneous) transforaminal discectomy and interbody fusion, and percutaneous pedicle screw instrumentation, limited to symptomatic levels. If stenosis is mainly foraminal and lateral recess, then the approach to decompression would endoscopic and fusion would be endoscopically-assisted, with percutaneous instrumentation.
Endoscopic decompression alone is an outpatient procedure. In a healthy 71-year-old, 2-3 level fusion (hybrid) would take about 3 hrs of surgery, minimal blood loss (less than 200 ml for 2-3 level fusion), no blood transfusion, average 2 days hospital stay, early resolution of surgical pain, shorter rehab, and early return to productive life! These are critical facts to observe so that a 71-year-old doesn’t suddenly turn into a 91-year-old because of extensive surgical intervention.
I don’t know all the facts about this patient, but in general this is how I’d approach an elderly patient with such presentation.

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