Adult Kyphoscoliosis with hemivertebra: Case 30

Case Review #30: 32 year old female with Adult Kyphoscoliosis from Robert Pashman

A 32 year old female presented to Dr. Robert Pashman with 90 degree Kyphoscoliosis and a hemivertebra.  Dr. Pashman treated the patient with a posterior spinal fusion from T2-L1. KIM/SRP Classification 1.

    Case Review:

    32 year old female with 90° Kyphoscoliosis

    Pre-op X-rays:

    33-year-old female 90 degree kyphoscoliosis due to an incarcerated hemivertebra, T6. Progressive curvature, patient reports increase in rib hump. Increasing lordosis in her neck. Patient presents decompensated forward.  At least on history, the patient had given 1 year ago that she was weak in the legs and this was associated with other neurologic symptoms, and on my physical examination in the office, the patient clearly had hyper reflexia in the lower extremities.

    Pre-Op CT Scan:

    The CT scan showed the posterolateral corner hemivertebra, which is at a very vulnerable position in the upper thoracic spine, causing both kyphoscoliosis and progressive curvature.

    Indications for Surgery:

    1. Congenital scoliosis, thoracic spine.
    2. Posterolateral corner hemivertebra, incarcerated, C6, with spinal cord compression causing #3.
    3. Kyphosis due to posterolateral corner hemivertebra, with sharp angular curve proximally measuring greater than 60 degrees.
    4. Unremitting thoracic and thoracolumbar pain radiating to the scapula, and the apex of the curve.
    5. Intermittent history of myelopathy, with weakness in the lower extremities, pain intermittently and physical examination showing hyperreflexia in the lower extremities.
    6. Failed conservative therapy, status post multiple previous orthopedic consultations.

    Surgical Strategy:

    Segmental spinal instrumentation using 1/4-inch stainless steel pedicle screw-rod instrumentation, T2-L1.Removal of hemivertebra, vertebrectomy and kyphectomy, T6 righthemivertebra.
    Bilateral thoracotomy, with costotransversectomy, T5, for removal of hemivertebra, and circumferential vertebrectomy, vertebral column resection.
    Laminectomy at T4-T6 completely for spinal cord decompression, access for hemivertebra removal.
    Complete discectomy under the microscope, proximal hemivertebra, T4- T5,T5-T6.
    Spinal osteotomy, Smith-Peterson osteotomy, for loosening of proximal compensatory and distal compensatory thoracic spine, T6- T7, T7-T8, T8-T9.  This was a 3-level osteotomy.
    Placement of Mayfield pin fixation for Jackson frame.
    Intraoperative O-Arm neuronavigation.
    Posterior spinal fusion using combination of autogenous rhBMP bone, T2L1.

    Pre-Op/Post-op Comparison:

    The patient is perfectly balanced in the coronal plane. Her head is directly over her hips. The patient did very well post-operatively: stopped taking pain medication and returned to her normal activities very quickly.

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