Revision of Adult Idiopathic Scoliosis with hardware failure: Case 23

Case Review #23: Scoliosis Revision Surgery for Hardware Failure from Robert Pashman

A 38 year old female presented with severe pain after a thoracoabdominal surgery several years prior. She required a revision surgery for a broken screw.

    Case Review: 

    Revision of Adult Idiopathic Scoliosis with hardware failure treated with posterior spinal fusion from T2-Pelvis

    Patient History:

    38-year-old female
    Status post anterior spinal fusion through the thoracoabdominal approach for scoliosis in 2004.
    The patient did well, but then had increasing pain at the proximal triple major, distal lumbosacral and lumbar curvature. This was a rigid curvature with thoracolumbar kyphosis necessitating a multiple level osteotomy.
    Patient had distal screws in the anterior reconstruction broke
    Patient had been smoking post-operatively, and gained significant weight

    Pre-op X-rays:

    The patient has a upper thoracic, leftward, and middle thoracic to mid lumbar rotational 59° curve,  rightward with a compensatory L4-S1 curve of 16°.   Her left hip is slightly elevated in comparison to the right on standing films.

    Indications for Surgery:

    1. Adult Idiopathic Scoliosis, triple major curve.
    2. Status post anterior spinal fusion through thoraco abdominal approach on the right-hand side for thoracolumbar curve, T9 to L3, now with increasing thoracic and compensatory lower lumbar curvature.
    3. Thoracic kyphosis.
    4. Severe back and lower extremity pain due to the above diagnosis.
    5. Failed conservative therapy.
    6. Multiple level degeneration causing decompensation involvement, necessitating multiple level osteotomy.
    7. Asymmetrical slip lateral listhesis, L3-4, L4-5.
    8. Multiple comorbidities including past history of smoking.

    Surgical Strategy:

    Segmental spinal instrumentation, thoracic 2 to pelvis 16 level, 5.5 stainless steel pedicle screw, rod construct.
    Pelvic instrumentation with exposure of iliac crest on right and left separately.
    Intralaminar laminotomy; lateral recess stenosis decompression under themicroscope; neural foraminotomy, L1-2, L2-3, L3-4, L4-5, L5-S1 bilaterally for lateralrecess stenosis.
    Two column Smith-Peterson spinal osteotomy with mobilization for rigid adult lumbar idiopathic scoliosis, thoracic 9 to lumbar 4, for mobilization of rigid scoliosis. This is a 6-level radical facetectomy and osteotomy.
    Posterior spinal fusion using combination of locally harvested autogenous bone allograft, T2 to the pelvis.
    Intraoperative somatosensory evoked potential, motor evoked potential interpretation.
    Intraoperative fluoroscopy.
    Multiple level thoracic osteotomy, Smith-Peterson, for compression of thoracic kyphosis and rigid proximal curvature, T3 to T6. This is a 6-level proximal osteotomy, 2 column.

    Post-Op Films:

    The original surgery was done anteriorly. The original instrumentation broke, and was not removed because the revision was done posteriorly.

 

Related links:

Scoliosis overview
Adult Idiopathic Scoliosis
Patient journal of scoliosis surgery, Patient follow-up journal four years after surgery
Scoliosis FAQ’s
Books about Scoliosis