Case Review:

Adult Idiopathic Scoliosis treated with a posterior fusion from T3 to L4 fusion

Robert S Pashman, MDScoliosis and Spinal Deformitywww.eSpine.com

52°

48°

Patient History3838--yearyear--old female presented with a double major cure measuring thoracicold female presented with a double major cure measuring thoracic4040°°, lumbar 44, lumbar 44°° curvaturecurvature

The patient was diagnosed with Adolescent Idiopathic Scoliosis aThe patient was diagnosed with Adolescent Idiopathic Scoliosis at age 9, t age 9, and wore a Milwaukee brace until age 16. During this time, her and wore a Milwaukee brace until age 16. During this time, her curvature curvature progressed from 17progressed from 17°° to 45 to 45 °°

When she initially presented, she was well balanced in the frontWhen she initially presented, she was well balanced in the frontal sagittal al sagittal plain, maybe a cm decompensated to the left but the shoulders anplain, maybe a cm decompensated to the left but the shoulders and pelvis d pelvis were level. The patient was sent for intensive physical therapywere level. The patient was sent for intensive physical therapy and told to and told to return for repeat xreturn for repeat x--ray every three to four months to monitor for progression ray every three to four months to monitor for progression of the curve.of the curve.

Six years later Six years later –– the patient presented with 50the patient presented with 50°° right and 46right and 46°° left curve.left curve.

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Pre-op X-rays

There was significant rotation in both There was significant rotation in both curves, and actually the thoracolumbar or curves, and actually the thoracolumbar or lower lumbar curve was more deforming lower lumbar curve was more deforming in that she had a significant elevation of in that she had a significant elevation of her left flank. This was due to fractional her left flank. This was due to fractional kyphosis at the thoracolumbar junction. kyphosis at the thoracolumbar junction. There was no question that the spinal There was no question that the spinal fusion and reconstruction need to fusion and reconstruction need to traverse both curves.traverse both curves.

52°

48°

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Bending X-raysL R

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Indications for SurgeryAdult idiopathic scoliosis double major curve, measuring 52 and Adult idiopathic scoliosis double major curve, measuring 52 and 48, 48, respectively, thoracolumbar spine. respectively, thoracolumbar spine.

Rigid kyphosis, thoracolumbar junction Rigid kyphosis, thoracolumbar junction

Severe superimposed degenerative disk disease and facet arthropaSevere superimposed degenerative disk disease and facet arthropathy, with thy, with mid lumbar degeneration causing rigid compensatory curve with mid lumbar degeneration causing rigid compensatory curve with thoracolumbar kyphosis. thoracolumbar kyphosis.

Low back/lower extremity symptoms, with spinal stenosis, neural Low back/lower extremity symptoms, with spinal stenosis, neural foraminal foraminal stenosis lumbar spine. stenosis lumbar spine.

Failed conservative therapy.Failed conservative therapy.

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Surgical StrategySegmental spinal instrumentation, thoracic 3 to lumbar 4; this iSegmental spinal instrumentation, thoracic 3 to lumbar 4; this is a 13s a 13--level level instrumentation, with 5.5 stainless steel Legacy screwinstrumentation, with 5.5 stainless steel Legacy screw--rod construct. rod construct.

Posterior spinal fusion, thoracic 3 to lumbar 4, with autogenousPosterior spinal fusion, thoracic 3 to lumbar 4, with autogenous bone and bone and Rh bone morphogenic protein. Rh bone morphogenic protein.

Because of the rigidity of this curve, it required significant mBecause of the rigidity of this curve, it required significant mobilization, obilization, which necessitated multiplewhich necessitated multiple--level osteotomies for correction of the curve in level osteotomies for correction of the curve in a posterior only basis.a posterior only basis. Ponte osteotomy, radical mobilization of the spine, Ponte osteotomy, radical mobilization of the spine, with complete facetectomy resection, thoracic 5 to lumbar 3with complete facetectomy resection, thoracic 5 to lumbar 3--4. This is a 104. This is a 10--level osteotomy, with correction of coronal and sagittal plane dlevel osteotomy, with correction of coronal and sagittal plane deformity. eformity.

Subtotal laminectomy, thoracic 12 to lumbar 1, lumbar 1Subtotal laminectomy, thoracic 12 to lumbar 1, lumbar 1--2, lumbar 22, lumbar 2-- 3, and 3, and lumbar 3lumbar 3--4 under loupe magnification for spinal canal decompression and 4 under loupe magnification for spinal canal decompression and spinal stenosis. spinal stenosis.

Intraoperative motor evoked potential interpretation. Intraoperative motor evoked potential interpretation.

Intraoperative fluoroscopic interpretation. Intraoperative fluoroscopic interpretation.

Plastic closure.Plastic closure.

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Post-Op Films

The patient is doing quite well. Her The patient is doing quite well. Her balance is excellent, the incision is balance is excellent, the incision is well healed. She has minimal pain, well healed. She has minimal pain, and has no radiculopathy. and has no radiculopathy.

XX--rays show excellent balance in the rays show excellent balance in the frontal and sagittal plane. This is a frontal and sagittal plane. This is a very good result early on.very good result early on.

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Pre-Op/Post-op Comparison

48°

52° 20°

An excellent correction was achieved. The patient’s curve was reduced approximately 60%, from 52° to 20°.

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Pre-Op/Post-op Comparison

The patient is well balanced in the frontal and sagittal plane.

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