Adult Idopathic Scoliosis: Case 48

Case Review #48: 58 year old female with Adult Idiopathic Scoliosis from Robert Pashman

A 58 year old female presented with Adult Idiopathic Scoliosis. Fifteen years prior, she had a thoracolumbar laminectomy which did not improve her symptoms. The patient had low back pain and leg pain despite conservative therapy. Surgery was performed and the patient returned to an active life style.

    Case Review:

    58 Year old female with Adult Idiopathic Scoliosis

    Patient History:

    58-year-old female
    Adult Idiopathic Scoliosis
    Secondary diagnosis of Multiple Sclerosis
    15 years ago, she underwent thoracic and thoracolumbar laminectomy for what appeared to be weakness in the legs. This was a misdiagnosis and did not improve the patient.
    Ultimately settled in the Kim/SRP type II curve with straight thoracic spine, fairly straight thoracolumbar spine, a plumb line neutral CVA, 0, as well as good coronal balance, and the head was not plumb forward.

    Pre-op X-rays:

    Kim SRP Type 2 curve. The patients situation became severe, despite the fact she was Kim SRP type 2 and had a long history of motivated conservative therapy. She continued to have low back and leg pain and required surgery.

    Indications for Surgery:

    1. Idiopathic Scoliosis, 50°, Kim/SRP type II, progressive.
    2. Status post laminectomy for thoracolumbar spine with gross instability.
    3. Spondylolisthesis, L3-4, with some lateral recess stenosis.
    4. Status post multiple attempts at conservative therapy for management of low back and leg pain.
    5. Collapsing lateral listhesis and severe rotation, lumbar spine, due to the above diagnosis.
    6. Osteopenia.

    Surgical Strategy:

    Segmental spinal instrumentation, thoracic 8 to sacral pelvis, using titanium pedicle screw-rod 5.5 construct.
    Exposure of right pelvis for placement of pelvic screw.
    Posterior spinal fusion, T8-S1, using locally harvested bone and allograft.
    Multiple-level Smith-Peterson osteotomy for induction of spinal flexibility at T12-L1, L1-L2, L2-L3, and L4-L5.
    Intraoperative O arm and neuronavigation monitoring, thoracolumbar spine.
    Intraoperative fluoroscopy.

    Intraoperative Findings:

    At the time of operation, laminectomy defect was found at T11-T12.  There was gross instability right thoracolumbar junction which was the stress riser. That is why the instrumentation was taken up to T8 so that multiple fixation points above the unstable segment could be achieved.  Interestingly enough, the tissues were very inflamed onto the spine and there was significant fat and replacement of muscle so that the spine was unsupported and very loose. Moreover, the tissues bled significantly, indicating hyper inflammation around the peri muscular area and around the spine. The facet joints were maximally degenerated at the apex of the rotated spine which was L2-3 and L4-5.  After osteotomy, the spine was quite flexible and could be induced into significant straightening and stabilization.

    Part Two:

    The patient needed an interbody fusion at L4-5 and L5-S1 because of the long nature of the lever arm to the pelvis. The pelvis fusion was absolutely necessary because of coronal and sagittal plane balance issues.• Abdominal retroperitoneal approach to the lumbosacral spine.
    Radical diskectomy at L5-S1.
    Interbody fusion with PEEK device with rhBMP centrally at L5- S1 with threaded screw fixation.
    Radical diskectomy at L4-5 with interbody fusion with rhBMP at L4-5. Both grafts measured 8 small.
    Intraoperative fluoroscopy.

  1. Post-op Films:

    The patient is well balanced in both the sagittal and coronal plane.
    The patient has minimal pain, no radiculopathy. She is active – bike riding or taking an aerobics class daily, and looking forward to snow skiing.

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