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Kyphoscoliosis in a 71-year-old Female

Should You Fuse to the Sacrum or Pelvis?

History

The patient is a 71-year-old female. She presents with complaints of progressive loss of standing balance, severe back pain and buttock pain, and moderate neurogenic claudication.

Examination

She is a healthy-appearing Caucasian female.

Notes from the exam:

  • Ambulates with kyphotic posture and lists to the left
  • Tolerates flexion, resists extension
  • Pain to buttocks R>L, no radiculopathy
  • Motor 5/5 bilaterally, NL sensory exam
  • NL ROM hips and knees without pain

Pre-treatment HRQOL scores:

  • ODI: 42
  • Back pain NRS: 8/10
  • Leg pain NRS: 8/10

Prior Treatment

The patient reports progressive symptoms despite the following treatment over the past 2 years:

  • Rest
  • Restriction of activities
  • NSAIDs
  • Physical therapy including water exercise
  • Epidural blocks

Pre-treatment Images

Kyphoscoliosis in 71-year-old Woman: Pre-op ClinicalsFigure 1: Pre-treatment clinical photos

PA and Lateral X-rays of Kyphoscoliosis PatientFigure 2: PA (left) and lateral 36” standing x-rays. There is a 70° thoracolumbar scoliosis, and a mild coronal list to the left. The left shoulder is slightly low. There is (+) sagittal balance, but magnitude is poorly defined. Please note: The hips are not visualized, so pelvic incidence in not known.

Pre-op Lateral CT (Myelogram) of Lumbar Spine in Kyphoscoliosis CaseFigure 3: Lateral myelogram/CT scan. Note spondylolisthesis at L5-S1.

Figures 4 and 5 are axial myelograms/CT scans of L3-L4 (Figure 4) and L4-L5 (Figure 5).  Note the spinal stenosis at L4-L5.

Pre-op Axial CT L3-L4 in Kyphoscoliosis PatientFigure 4

Axial CT L4-L5 (Pre-op) in Kyphoscoliosis PatientFigure 5

Diagnosis

Despite suboptimal 36” x-rays (Figure 2) which don’t allow measurement of pelvic incidence, severity of (+) sagittal balance can also be evaluated on the PA x-ray (Figure 2) and the lateral clinical photo (Figure 1).

Extent of pelvic retroversion, in an attempt to compensate for loss of lumbar lordosis, can be seen on the PA view of the pelvis (champagne glass pelvis—see below in Figure 6).

Champagne Glass Pelvis on PA X-rayFigure 6

Most importantly, the lateral clinical photo reveals loss of lumbar lordosis, loss of the normal buttock contour, and need to bend the knees in order to maintain an upright standing balance. Figure 7 (below) demonstrates this.

All of these factors demonstrate a poorly compensated (+) sagittal balance which may be underestimated on the standing x-rays.

Pre-op Clinical Photo: Loss of Lumbar Lordosis in 71 yofFigure 7

Suggest Treatment

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Selected Treatment

Decompression and fusion T10-pelvis with multiple osteotomies and iliac fixation for correction of coronal and sagittal plane deformities

Post-treatment Images

Post-op (Decompression and Fusion) PA and Lateral X-rays in Kyphoscoliosis PatientFigure 8: PA and lateral 36” standing x-rays 2 years post-operative demonstrate correction of the scoliosis and restoration of lordosis. Mild kyphosis above T10 endpoint raises the question as to risk for PJK and whether fusion to T4 would have been preferable. No progression noted at 2 years post-op.

Outcome

Surgical correction resulted in improvement in back and leg pain, standing balance, and walking tolerance.

In Figure 9 (below), note lateral standing posture with restoration of lumbar lordosis, restoration of buttocks contour, and ability to stand with knees straight.

Pre-op vs. Post-op Clinical Photos Showing Restoration of Lumbar LordosisFigure 9

Post-operative HRQOL scores:

  • ODI: 16
  • Back pain NRS: 2/10
  • Leg pain NRS: 0/10

Case Discussion

This case of adult degenerative scoliosis illustrates a common patient presentation to the adult spine surgeon, which will only increase in frequency as the population ages further.  A working knowledge of this condition and the various corrective techniques with which to address it are nicely illustrated in this case presentation.

Although we prefer true 36” standing cassette films with adequate visualization of the femoral heads in order to properly assess and record pelvic incidence and sagittal imbalance, we are aware that this is not always feasible in every surgeon’s practice.  We agree with the author that the degree of pelvic retroversion, a clear indication of partially compensated imbalance, can be appreciated on both the radiographs and the photos of patient posture.

No mention is made in this case of minimally invasive techniques when discussing treatment options. This may be deliberate, as the author may have felt that they were inapplicable to this particular patient. For those experienced in such techniques, an alternate approach to the perfectly acceptable treatment modalities listed may have been a hybrid procedure involving both MIS and open techniques.

On the minimally invasive side, this would entail both multi-level anterolateral interbody cage placement (utilizing an appropriate retractor system and neuromonitoring) as well as posterior percutaneous pedicle screw fixation. This would achieve both indirect decompression of neural elements and robust construct stabilization.

Anterior longitudinal ligamentous release could be performed at the time of anterolateral interbody fusion, with placement of hyperlordotic cages, in order to restore lordosis in the same manner as posterior osteotomies.

Finally, the L5-S1 level would be addressed with either an open/MIS TLIF or an anterior lumbar interbody fusion.

Given the degree of sagittal imbalance present, however, we feel that the treatment modality selected by the author was the most appropriate, and his post-operative radiographs and results are to be commended. We would caution that attempting to apply MIS techniques to such patients can be quite challenging and should not be attempted by surgeons in the initial phase of the learning curve.

One final pearl that we can offer is the need for pre-operative bone quality assessment via a DEXA scan in these patients prior to any surgical intervention. We find this invaluable in preventing both screw pullout intraoperatively and the late onset of proximal junctional kyphosis.

Although we prefer true 36” standing cassette films with adequate visualization of the femoral heads in order to properly assess and record pelvic incidence and sagittal imbalance, we are aware that this is not always feasible in every surgeon’s practice.  We agree with the author that the degree of pelvic retroversion, a clear indication of partially compensated imbalance, can be appreciated on both the radiographs and the photos of patient posture.

No mention is made in this case of minimally invasive techniques when discussing treatment options. This may be deliberate, as the author may have felt that they were inapplicable to this particular patient. For those experienced in such techniques, an alternate approach to the perfectly acceptable treatment modalities listed may have been a hybrid procedure involving both MIS and open techniques.

On the minimally invasive side, this would entail both multi-level anterolateral interbody cage placement (utilizing an appropriate retractor system and neuromonitoring) as well as posterior percutaneous pedicle screw fixation. This would achieve both indirect decompression of neural elements and robust construct stabilization.

Anterior longitudinal ligamentous release could be performed at the time of anterolateral interbody fusion, with placement of hyperlordotic cages, in order to restore lordosis in the same manner as posterior osteotomies.

Finally, the L5-S1 level would be addressed with either an open/MIS TLIF or an anterior lumbar interbody fusion. 

Given the degree of sagittal imbalance present, however, we feel that the treatment modality selected by the author was the most appropriate, and his post-operative radiographs and results are to be commended. We would caution that attempting to apply MIS techniques to such patients can be quite challenging and should not be attempted by surgeons in the initial phase of the learning curve. 

One final pearl that we can offer is the need for pre-operative bone quality assessment via a DEXA scan in these patients prior to any surgical intervention. We find this invaluable in preventing both screw pullout intraoperatively and the late onset of proximal junctional kyphosis.

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