Adult Scoliosis Case 8

Case Review #8: 44 year old woman presented with a Double Major Scoliosis Curvature from Robert Pashman

A 44 year old female presented with Adult Idiopathic Scoliosis with a double major curve.  Dr. Pashman treated the patient with a Posterior Spinal Fusion T3-L4.  KIM/SRP Classification 1.

    Case Review:

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

    Patient History:

    38-year-old female presented with a double major cure measuring thoracic 40°, lumbar 44° curvature
    The patient was diagnosed with Adolescent Idiopathic Scoliosis at age 9, and wore a Milwaukee brace until age 16.
    During this time, her curvature progressed from 17° to 45 °
    When she initially presented, she was well balanced in the frontal sagittal plain, maybe a cm decompensated to the left but the shoulders and pelvis were level. The patient was sent for intensive physical therapy and told to return for repeat x-ray every three to four months to monitor for progression of the curve.
    Six years later – the patient presented with 50° right and 46° left curve.

    Pre-op X-rays:

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

    Indications for Surgery:

    Adult idiopathic scoliosis double major curve, measuring 52 and 48,respectively, thoracolumbar spine.
    Rigid kyphosis, thoracolumbar junction
    Severe superimposed degenerative disk disease and facet arthropathy, with mid lumbar degeneration causing rigid compensatory curve witht horacolumbar kyphosis.
    Low back/lower extremity symptoms, with spinal stenosis, neural foraminal stenosis lumbar spine.
    Failed conservative therapy.

    Surgical Strategy:

    Segmental spinal instrumentation, thoracic 3 to lumbar 4; this is a 13-level instrumentation, with 5.5 stainless steel screw-rod construct.
    Posterior spinal fusion, thoracic 3 to lumbar 4, with autogenous bone and Rh bone morphogenic protein.
    Because of the rigidity of this curve, it required significant mobilization,which necessitated multiple-level osteotomies for correction of the curve in a posterior only basis. Ponte osteotomy, radical mobilization of the spine,with complete facetectomy resection, thoracic 5 to lumbar 3-4. This is a 10-level osteotomy, with correction of coronal and sagittal plane deformity.
    Subtotal laminectomy, thoracic 12 to lumbar 1, lumbar 1-2, lumbar 2- 3, and lumbar 3-4 under loupe magnification for spinal canal decompression and spinal stenosis.
    Intraoperative motor evoked potential interpretation.
    Intraoperative fluoroscopic interpretation.
    Plastic closure.

    Post-Op Films:

    The patient is doing quite well. Her balance is excellent, the incision is well healed. She has minimal pain, and has no radiculopathy. X-rays show excellent balance in the frontal and sagittal plane. This is a very good result early on.

    Pre-Op/Post-op Comparison:

    An excellent correction was achieved. The patient’s curve was reduced approximately 60%, from 52° to 20°. The patient is well balanced in the frontal and sagittal plane.

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