SpineUniverse Case Study Library

Nun with Progressive Deformity: Fuse or Not Fuse?

History

The patient is a 24-year-old female who reports progressive deformity. She says she had a 45° right thoracic curve at age 17. She has more back pain than 5 years ago, but it is certainly not “excruciating.”

She is a nun.

Pre-treatment SRS-22 Average Broken into Domains

Pre-op SRS-22 Domains for Progressive Spinal Deformity Case

Oswestry Score

Pre-op Oswestry Score for Progressive Spinal Deformity Case

Pre-treatment Images

Progressive Spinal Deformity Case:  Upright X-raysFigures 1A and 1B: Upright x-rays showing curve measurements

Left and Right Side Bender X-rays:  Pre-op in Progressive Spinal Deformity CaseFigures 2A and 2B: Left and right side bender x-rays

Progressive Spinal Deformity: Pre-op Supine X-rayFigure 3: Supine x-ray

Push Prone X-ray: Pre-op Image in Progressive Spinal Deformity CaseFigure 4: Push prone x-ray

Figures 5A, 5B, and 5C are clinical photos showing the deformity.

Clinical Photos Showing Spinal DeformityFigures 5A and 5B

Forward Bending Clinical Photo Showing Spinal DeformityFigure 5C: SCM = 22°

Diagnosis

Right thoracic scoliosis

Suggest Treatment

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Selected Treatment

No iliac bone graft was used, and no thoracoplasties were performed.

Spinal instrumentation was used.

Post-treatment Images

Post-op X-rays from Spinal Deformity CaseFigures 6A and 6B: 5 years post-operative AP (Figure 6A) and lateral (Figure 6B) x-rays

Figures 7A, 7B, and 7C are post-operative clinical photos.

Post-op Clinical Photos of Spinal Deformity CaseFigures 7A, 7B, and 7C

Outcome

At her 5-year follow-up visit, the patient's SCM was 12°.

Pre-operative Images Compared to Post-operative Images

Compare Pre-op to Post-op X-rays in this Spinal Deformity CaseFigures 8A and 8B

Lateral X-rays:  Pre-op to Post-op in Spinal Deformity CaseFigures 9A and 9B

Clinical Photos Comparing Pre-op to Post-op in Spinal Deformity CaseFigures 10A and 10B

Lateral Clinical Photos in Spinal Deformity Case: Pre-Figures 11A and 11B

 

Pre-operative to Post-operative SRS-22 Average Broken Into Domains

Pre-op to Post-op SRS-22 Comparison in Progressive Spinal Deformity Case

Pre-operative to Post-operative Oswestry Scores

Oswestry Scores: Pre-op and Post-op in Spinal Deformity Patient

Case Discussion

This case presents challenges in the surgeon's decision-making about choosing to do or not do surgery. The surgery itself is relatively straight forward, but very nicely executed.

The challenge of when to operate for deformity in a young adult is substantial. Determining progression is hard as it is rare to have the x-rays from the treatment period during adolescence. Therefore, determining progression is challenging.  A particularly useful strategy in older patients is to look for change in height. If it occurs, then it is probably a good indicator of progression. How much height loss is necessary? Probably, 1-2 inches. We have never determined the reliability of height measurement.

The next question is, does the patient want the deformity correction? If they do, and the curve is greater than 50-degrees, then it is probably reasonable. If this patient desires deformity correction. it is certainly reasonable.

In terms of surgery technique, this case follows the fusion selection rules for adolescent idiopathic scoliosis. She has generously-sized pedicles so segmental pedicle fixation can be achieved. This can be judged by looking at the L1 pedicles. If they are large, it will be easy; if they are small, it will be hard. Sometimes the bending films show these pedicles better than the AP.

Bone graft choices remain challenging in this scenario.  This becomes a shared decision with the patient, who is provided with every choice, and the advantages and disadvantages.

In this case the operating surgeon has achieved a superb result.

Community Case Discussion (1 comment)

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


THIS TYPE OF DEFORMITY CAN BE HELPED WITH SPINAL ADJUSTMENT (WITH SPECIAL ANALYSIS AND CARE DURING ADJUSTMENT) --- AS YOU CAN SEE ONE OF THE X-RAYS THAT DID SHOW REDUCTION OF THE CURVE BY CHANGING THE POSITION ( OF THE PATIENT) X-RAYS --- DO NOT FORGET THAT YOU NEED TO STRENGTHEN AND BALANCING CERTAIN MUSCLES DURING THE TREATMENT TO ACHIEVE LONG LASTING EFFECT OF THE TREATMENT .
IN GOOD HEALTH
DR. M.M. HASSAN ,DC

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