Adolescent Idiopathic Scoliosis Case 3

Case Review #3: 27 year old female with Adolescent Scoliosis, Pseudoarthrosis, and Flatback from Robert Pashman

A 27 year old female with adolescent idiopathic scoliosis, failed to fuse (pseudoarthrosis), and developed Flatback Syndrome. Post status two scoliosis surgeries. Dr. Pashman treated the patient with a posterior spinal fusion T3-L2.

Case Review:

Adolescent Idiopathic Scoliosis Revision Surgery16° for Psuedoarthrosis and Flatback Syndrome

Patient History:

27 year old female from Dubai, United Arab Emirates
Adolescent Idiopathic Scoliosis
Status post posterior instrumented fusion in 2000 for a 45° right Lenke-type II curve which resulted in significant correction from 45° to 16°.
The patient then had instrumentation from T4 to T12 and was fused short from T6 to T12 on the right-hand side. The patient awoke from surgery with seering left-sided pain and ultimately had revision for removal of some instrumentation distally which improved the patients symptoms somewhat, but she continues to have left-sided flank pain.

CT scan and bone scan indicated that the patients pseudoarthrosis of the plate type centered approximately around T10, 11, 12 areas. The patient had increasing rotation and because she was fused to T12 it was my impression that the patient had subjacent “adding on” phenomenon with a short fusion at T12 which had caused a spinal imbalance and a significant disability from the subjacent curve. Moreover, the patient had some imbalance of her shoulders. This was due to a fusion short proximally, and although the patient had been followed conservatively, she had increasing pain. The only solution as far as I was concerned was to remove the hardware, explore the fusion mass to fuse her in a supra and subjacent way to stabilize the residual curve.

Pre-op Films

Indications for Surgery:

Status post posterior instrumented fusion for Adolescent Idiopathic Scoliosis.

Status post revision instrumentation for Adolescent Idiopathic Scoliosis.
Now with “adding on” subjacent degeneration and increased curve with rotation, thoracic spine.
Increasing pain/instrumentation, status post posterior instrumentation for adolescent idiopathic scoliosis.
Shoulder imbalance, status post posterior instrumented fusion.
Presumed pseudoarthrosis, thoracic spine, status pos tposterior instrumented fusion.

Surgical Strategy:

Thoracic 3 to lumbar 2 segmental spinal instrumentation with stainless steel 5.5 pedicle screw-rod contrast.
Posterior spinal fusion, thoracic 3 to lumbar 2, using combination of locally harvested autogenous bone and recombinant human bone morphogenic protein.
Interlaminar decompression under the microscope, placement of screws and nerve root decompression, thoracic 12-lumbar 1 and thoracic 11-thoracic 12 on the right-hand side.
Repair pseudoarthrosis, thoracic 10-11 and thoracic 10-12.Spinal osteotomy, thoracic 4-5 and thoracic 5-6, for recorrection of proximal curvature.
Removal of retained hardware.
Intraoperative motor evoked potentials.
Intraoperative fluoroscopy.

Post-Op Films:

At the time of operation, significant residual subjacent rotation and curvature was found. The joints were somewhat arthritic subjacent to T12-L1, L1, and pseudoarthrosis was also found which was repaired. She has minimal back pain on the left. This is a radicular distribution. This is probably from ongoing irritation or from healing. Instrumentation looks good. Her posture is excellent.

Pre-Op/Post-op Comparison:

Alignment issues were discussed with the patient. She does not have significant amount of sway in her low back. This is on a congenital basis, but she is well-balanced in frontal and sagittal plane. Instrumentation looks good.

Related links:
Scoliosis overview
Adolescent Idiopathic Scoliosis
Adult Idiopathic Surgical Cases performed by Dr. Pashman
Patient journal of scoliosis surgery, Patient follow-up journal four years after surgery
Bracing for Scoliosis
Scoliosis FAQ’s
Books about Scoliosis