Adult Scoliosis Case 38

Case Review #38: 22 year old female status post spinal fusion with pseudoarthrosis from Robert Pashman

A 22 year old female presented status post a posterior spinal fusion for Adolescent Idiopathic Scoliosis. Following a car accident, she experienced back pain. A pseudoarthrosis, or failure of fusion, was found on CT scan. Dr. Pashman did the revision surgery from T4-L2.

    Case Review:

    22 year old female, status postposter spinal fusion, now with hardware failure and pseudoarthrosis

    Patient History:

    22 year old female
    Status post posterior spinal fusion at age 22 for what appears to be a double thoracic curve.
    The patient had a car accident but was feeling increasing pain and feelings of instability and came to Dr. Pashman for consultation.
    The patient had a CT scan which showed a possible pseudarthrosis.
    There was increasing of the curve indicating pseudarthrosis

    Pre-op X-rays:

    There is a structural proximal curve with depression at the right shoulder. This resulted in a compression convex distraction concave attempt with interval sublaminar or Wisconsin wires through pedicle screws distally.

    Indications for Surgery:

    1. Status post posterior instrumented fusion for adult idiopathic scoliosis.
    2. Double thoracic curve, now with possible pseudarthrosis, hardware failure.
    3. Adding on with significant increase in thoracic and lumbar scoliosis.
    4. Increasing pain, failed conservative therapy, status post motor vehicle accident.
    5. Some co-morbidities including chronic illness.

    Surgical Strategy:

    Removal of retained hardware.
    Repair of multiple level pseudarthrosis, T4-5, T5-6, T6-7, T7-8,T9- 10, T10-11, L1-L2.
    Remove granulation tissue and corrosion residue.
    Reinstrumentation, segmental spinal instrumentation, T2 to L3, using cobalt chrome pedicle screw rod construct.
    Posterior spinal fusion, T2 to L3, using locally harvested autogenous bone and rhBMP with allograft.
    Intraoperative O-arm neuro-navigation.
    Plastic closure of wound.
    Multiple level spinal osteotomy for correction of residual curveT10, T11, T12 and L1.

    Post-Op Films:

    The patient is well balanced in both the coronal and sagittal planes. At six months post-op she is doing well, and has no complaints.

    Pre-Op/Post-op Comparison:

    At the time of operation, a full- thickness fracture was found in the left rod.  Also on the right- hand side, the patient had a pull- out of the instrumentation through the Penultimate pedicle screw. The nut was lying free in the wound. The distal right screw was completely pulled out at L2 and so the failure was a circumferential through the right screw pull-out and failure of the instrumentation through the fracture of the left rod underneath the cross-link.

    The patient had multiple level pseudarthrosis completely through the thoracic and lumbar spine, and this needed to be repaired completely. There were elements of significant black tissue that was consistent with corrosion of the inflammatory tissue around the pedicle screws and nuts. The patient did not have any evidence of infection. There was no purulence or inflammation around the wound. The fusion mass was wispy proximally and distally, and the pedicles on the concave side in the upper thoracic curve on the right-hand side as seen through the O- arm navigation were atretic and small.