Adult Onset Scoliosis
The patient is a 31-year-old male with back and right lower extremity pain. His pain started 6 months ago and is unrelated to trauma. He feels the pain is 20% back-related and 80% leg-related and involves the right buttock, lateral thigh and leg, and dorsum. The patient notices he leans to the left, which worsens when walking and sitting. Pain and leaning is lessened with ibuprofen and lying down.
The patient has no previous medical history of back or lower extremity pain. He does not experience bowel or bladder dysfunction. The patient owns a car dealership.
The patient is alert and oriented, well nourished and well developed, and demonstrates a normal gait. The C7 plumb line fell 2cm to the left. There is a left TL prominence of 1.5cm. There is no leg length discrepancy from the anterior superior iliac crest to the medial malleolus. The examination revealed no motor or sensory deficit except right TA 4+ and right EHL 4. His reflexes were bilaterally symmetric and the straight leg raise test was negative.
The patient obtains partial symptom relief with ibuprofen.
Adult onset scoliosis.
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The patient underwent an L4-5 discectomy, which lasted approximately 5 hours. During surgery, he lost about 50cc of blood. Surgery was otherwise uneventful.
Currently, the patient is doing well, exercises regularly, and has returned to work full-time. He is completely satisfied and the postoperative radiographs demonstrate a positive surgical outcome.
This 31-year-old male’s chief complaints are back and leg pain with thoracolumbar scoliosis and decompensation to the left. The patient’s lower extremity symptoms are radicular in nature and correlate his weakness to the L5 nerve root. The fact the patient’s pain and trunk shift improves when lying indicates a nonstructural problem.
The patient’s plain X-rays demonstrate the long, sweeping 33-degree thoracolumbar scoliosis with minimal rotation, which speaks against a long-standing idiopathic type deformity. The obvious test required for the diagnosis is a lumbar MRI to demonstrate a huge L4-5 herniated nucleus pulposus.
Treatment for this patient’s neurologic problem should focus on the disc pathology. I favor a bilateral microdiscectomy because of the large disc size and to confirm that both lateral recesses are decompressed, even though his neurologic complaints are limited to the right side. With his neurogenic scoliosis deformity, the best chance for spontaneous improvement is adequate bilateral neural decompression. At this point, there is no reason to consider a longer deformity fusion, as some improvement in the alignment and decompensation should occur following the discectomy since there is minimal rotational malalignment.
In the rare circumstance the patient’s spinal posture does not improve with surgical decompression and postoperative physical therapy, then deformity correction can be discussed. However, that would be highly unusual.