Adult Congenital Scoliosis: Case 42

Case Review #42: 39 year old female with Adult Congenital Scoliosis from Robert Pashman

A 39 year old female with Congenital Scoliosis presented to Dr. Pashman. The patient had a fusion at age six, and her spinal curve continued to progress. Dr. Pashman treated the patient with a posterior spinal fusion from T3-Pelvis. KIM/SRP Classification 3.

    Case Review:

    39 year old female, with progressive curvature status post posterior spinal fusion at age 6 for congenital scoliosis.

    Patient History:

    39-year-old female
    Multiple hemivertebrae with a sharp angular curvature proximally and kyphosis, treated by in situ posterior spinal fusion at age 6.
    The patient now has progressive adding on of the subadjacent thoracolumbar spine with severe rotation of the lumbar spine and multiple level anomalies including lumbosacral transitional vertebra.
    She has a high left rib hump
    The patients curve is increasing. This has been documented serially with 1996 to current films.
    The patient has significant upper and lower back pain, which has been uncontrolled with conservative therapy.
    The progressive nature of the scoliosis and junctional aspects of the previous surgery are the causative etiology.

    Pre-op X-rays:

    She has a significant T1 tilt with an oblique neck done and decompensation to the right. She has a compensatory right thoracolumbar elevated flank. She also has evidence of decreased lumbar lordosis due to what appears to be a lumbosacral transitional vertebra.

    Indications for Surgery:

    1. Progressive congenital scoliosis, thoracolumbar spine.
    2. Status post posterior in situ fusion at age 6 for congenital scoliosis.
    3. Kyphoscoliosis with frontal and sagittal plane deformity and decompensation.
    4. Increasing back pain with junctional degeneration between previous posterior spine and residual thoracolumbar spine.
    5. Multiple vertebral anomalies including proximal thoracic hemivertebrae with hemi-metameric shift, multiple level lumbosacral anomalies with spina bifida occulta and lumbosacral transitional vertebrae.
    6. Failed conservative therapy with now progressive lumbar rotation, pain, and decompensation.

    Surgical Strategy:

    T3 through sacropelvic fusion using cobalt-chrome 5.5 titanium pedicle screw/rod construct.
    Posterior spinal fusion, T3 to pelvis, using locally harvested autogenous and allograft bone.
    Multiple level spinal osteotomies, Smith-Petersen, with radial facetectomy and removal of joint to produce harmonious sagittal and coronal contouring, T4-5, T5-6, T6-7, T7-8, T9-10, T10-11, L1-2 and L2-3.
    Repair of junctional pseudarthrosis, T6,T7, with locally harvested autogenous bone.• Intraoperative exposure of right hemipelvis with placement of pelvic instrumentation.

    Repair of bilateral pars interarticularis fractures, L5-S1, with locally harvested autogenous bone and open reduction internal fixation.
    Intraoperative O-arm neuronavigation interpretation.
    Intraoperative somatosensory-evoked and motor-evoked potentials intraoperative interpretation.
    Plastic closure of T3 to sacropelvic wound.

    Post-op Films:

    The patient is well balanced in the sagittal plane. She is thrilled with her outcome and new body image.