Progressive Lumbar Deformity in a 57-year-old Female

Patient History

The patient is a highly motivated 57+3-year-old female with progressive lumbar deformity. She was referred by a local spine surgeon for a definitive reconstructive procedure.

The patient's pain has been gradually increasing, although it's not disabling. She has no leg pain or symptoms of spinal claudication. There is previous documentation of a 37-degree lumbar curve at age 42.

Examination

The patient had a normal neurological exam and normal station and gait. There was mild lumbar deformity with waistline asymmetry.

Images

Figure 1A. Standing x-ray

Figure 1B. Standing x-ray

Figures 2A and 2B show fixed tilt at L4-L5. There is rotatory subluxation at L3-L4. MRI shows substantial disc degeneration at L4-S1.

Figure 2A

Figure 2B

Figure 3. SRS-22 broken into domains.

Diagnosis

Progressive adult lumbar scoliosis

Selected Treatment

The patient underwent posterior fusion / PSSI from T9 - sacrum and pelvis. Anterior spinal fusion through a paramedian approach L2 - sacrum. All performed with local bone graft and rhBMP-2. No harvesting of iliac or other distant sites.

The x-rays and clinical photos are 3+3 years postoperative. (Figs. 4A, 4B, 5A, 5B, 6A, 6B)

Figure 4A

Figure 4B

Figure 5A

Figure 5B

Figure 6A

Figure 6B

Figure 7. SRS scores converted to 100 point scale. Note that the patient's SRS scores have dramatically improved over what they were pre-operatively.

Figure 8. Postoperative SRS-22 broken into domains.

Outcome

At 3-and-one-half-years, the patient reports that she's able to function at a higher level than what she was able to do before surgery and is very happy with result and would do it again.

Case Discussion

This patient is a 57-year-old female with a progressive lumbar scoliosis that has progressed from 37- to 55-degrees over a 15 year period who has additional listhesis / rotatory subluxation at L3-L4 and back pain. Overall spinal balance is good. The pain is not presently disabling.

My first goal with this patient would be to understand her motivation for seeking an evaluation and potential treatment at this point in time. My second goal would be to fully define the nature of her condition before discussing treatment options. Certainly, the deformity alone is significant and, by itself, warrants a discussion of surgical treatment options. However, further definition of the source of back pain would be appropriate. I would probably obtain an MRI and bone scan with SPECT imaging to fully evaluate all the lumbar discs and facets as a source of inflammation and pain.

If this patient were to choose nonoperative treatment, these studies may be helpful in guiding conservative treatment. For example, increased uptake at the left L4-L5 facet on bone scan, with reasonably well-preserved discs on MRI, might lead me to suggest a facet injection for diagnostic / therapeutic purposes. If the listhetic L3-L4 level were to demonstrate significant increased uptake on bone scan in the facets, plus or minus the disc, I would be less interested in injections but might suggest a lumbar brace to provide external support for this relatively unstable level. Other nonoperative treatment options would be discussed with the goal of providing all options to this patient. These would be discussed in the context of a progressive deformity and pain that may not be well managed in the long-term without surgery. Further workup and conservative management of her pain, at the very least, represent an opportunity to get to know this patient and decide whether or not she is a reasonable candidate for surgical treatment.

Of the surgical treatment options listed above, I would favor an anterior spinal fusion L2-S1 with a subsequent posterior spinal fusion T9-sacrum / ilium. Structural allograft and BMP (3-4mg per level) would be used anteriorly with pedicle screws and local bone augmented with crushed cancellous allograft. No iliac crest bone graft.

A surgical option not discussed above involves preservation of the lowest lumbar level L5-S1. Clinical localization of the back pain (lumbosacral junction, or not) and use of the MRI / bone scan, and probably even a DEXA, would be helpful in making a decision whether to preserve this level. This is a relatively young patient but postmenopausal. Thus, bone quality may be an issue. With good bone quality and little evidence of pain or degeneration at L5-S1, in the setting of good overall sagittal balance, I would consider stopping the fusion at L5 with appropriate counseling regarding the risk of subsequent degeneration at this level. My threshold for including L5-S1 would be relatively low, however.