Adult Scoliosis Case 39

Case Review #39: 55 year old male with Progressive Scoliosis from Robert Pashman

A 55 year old male presented with Progressive Adult Idiopathic Scoliosis. While he was preparing for surgery, he lifted a heavy item, and had neck pain and pain going down his arm. The patient was found to have myeloradiculopathy and spinal cord effacement and required an Anterior Cervical Fusion prior to scoliosis surgery. The following year he had a posterior spinal fusion for Scoliosis.

    Case Review:

    55 year old male with Progressive Idiopathic Scoliosis. Found to have cervical degeneration that was addressed prior to his Scoliosis Surgery.

    Patient History:

    55-year-old male
    KIM/SRP type II Adult Idiopathic Scoliosis
    Status-post cancer
    Low back pain
    Truncal shortening
    Patient followed for progression of Scoliosis and prepared for surgery when he reported neck and arm pain after lifting a heavy item.
    A MRI of the cervical spine shows multilevel degenerative changes of the mid cervical spine with a surgical kyphosis.
    He has significant levels of stenosis behind bodies of 4 and 5.

    Severe myeloradiculopathy with impending neurological embarrassment due to significant cervical stenosis and kyphosis due to collapse and degeneration with possible congenital component from C3 to C7.
    This severe deformity is causing effacement of the spinal cord and gliosis, and the patient now is having increasing neck pain and disability with numbness and weakness in his hands consistent with myeloradiculopathy.

    Indications for Surgery:

    1. Myeloradiculopathy due to severe spinal cord compression, cervical spine.
    2. Massive cervical compression due to combination of hard and soft disks, C3-4, C405, C5-6 and C6-7.
    3. Bilateral neural foraminal stenosis due to collapsing degeneration, C3-4, C4-5, C5-6 and C6-7.
    4. Severe cervical kyphosis due to collapse, degeneration. possible congenital component with malformed vertebrae, C3, but global sagittal imbalance.
    5. Severe neck and arm pain, failed conservative therapy.
    6. Multiple co-morbidities, including scoliosis and past treatment for lymphosarcoma.

    Surgical Strategy:

    Radical diskectomy, C3-4, with epidural decompression under the microscope for spinal cord compression, removal of hard and soft disks.
    Radical diskectomy for removal of hard and soft disk and spinal cord compression under microscope, C6-7.
    Complete vertebrectomy, C5, for removal of apical compression, myeloradiculopathy and spinal cord compression.
    Radical diskectomy, C4-5 and C5-6, with epidural decompression under the microscope and bilateral neural foraminotomy.
    Interbody fusion with PEEK device at C3-4 and C6-7 with autogenous bone centrally.
    Strut graft reconstruction with Medtronic stackable PEEK device with autogenous bone centrally, C4 to C6.

    Anterior plate fixation for reconstruction of cervical kyphosis, C3 to C7 using a 10-hole Medtronic Vantage plate screw system.• Somatosensory-evoked potential management with motor-evoked potentials.
    Intraoperative fluoroscopy management.

    Pre-Op/Post-op Comparison

    The patient returned approximately one year after his cervical spine surgery to address the progression of the scoliosis. There is significant rotation, spinal stenosis at L2-3 which55° is also the apex of the sagittal and coronal plane deformity.

    Indications for Surgery:

    1. KIM/short-rib polydactyly-type II adult idiopathic scoliosis, greater than 60°, lumbar spine.
    2. Lateral listhesis translation with maximum rotation at L2-3 causing instability and significant stenosis, lumbar spine.
    3. Severe degeneration, lateral recess stenosis with increasing low back pain, lumbar spine.
    4. Thoracolumbar kyphosis due to collapsing scoliosis, thoracolumbar spine.
    5. Failed conservative therapy.
    6. Status post multiple level anterior cervical vertebrectomy for severe myeloradiculopathy.
    7. Status post treatment for lymphosarcoma, in remission.

    Surgical Strategy:

    Segmental spinal instrumentation at T10 to sacral pelvis using 5.5 cobalt chromium pedicle screw/rod construct.
    Complete vertebrectomy/kyphectomy L3 with pedicle subtraction osteotomy for sagittal plane deformity.
    Complete laminectomy at L2, 3 and subtotal laminectomy at L4 for severe spinal stenosis, decompression; all under the microscope. Posterior spinal fusion T10 to sacral pelvis with locally harvested autogenous bone.
    Intraoperative repair of incidental durotomy under the microscope, 1 x 1 mm hole at L3 on the left.
    Separate incision in sacral pelvic fixation screw for sacral pelvic fixation.
    Use of O-arm navigation and intraoperative neuronavigation interpretation.
    Intraoperative motor evoked potential interpretation.
    Multiple level Smith-Peterson osteotomy, T12, L1, L2, L3 and L4 for reduction of lumbar kyphosis.

    Post-Op Films:
    The patient is well balanced in both the sagittal and coronal planes. He traveled to Europe two months post-operatively, and reported no increase in his symptoms. He is thrilled with his outcome.

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