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

Oswestry Score

Pre-treatment Images

Figures 1A and 1B: Upright x-rays showing curve measurements

Figures 2A and 2B: Left and right side bender x-rays

Figure 3: Supine x-ray

Figure 4: Push prone x-ray

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

Figures 5A and 5B

Figure 5C: SCM = 22°

Diagnosis

Right thoracic scoliosis

Selected Treatment

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

Spinal instrumentation was used.

Post-treatment Images

Figures 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.

Figures 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

Figures 8A and 8B

Figures 9A and 9B

Figures 10A and 10B

Figures 11A and 11B

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

Pre-operative to Post-operative Oswestry Scores

Case Discussion

David W. Polly, Jr., MD

Professor and Chief of Spine Surgery

University of Minnesota, Department of Orthopaedic Surgery

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.