Adult Scoliosis Case 49

Case Review #49: 48 year old female with progressive Adult Idiopathic Scoliosis from Robert Pashman

48 year old female presented to Dr. Pashman with Adult Idiopathic Scoliosis and a long history of low back pain. The patient had been treated with a microdiscectomy, epidurals, physical therapy, and medication. The patient was treated with a spinal fusion.

    Case Review:

    48 year old female presented with progressive Adult Idiopathic Scoliosis.

    Patient History:

    48-year-old female
    Progressive Adult Idiopathic Scoliosis
    The patient has a long history of low back pain and is status post micro diskectomy at L4-5 in 2003 after motor vehicle accident.
    The patient has exhausted physical therapy, epidurals, and has taken anti-inflammatory medications.
    The patient is very active and fit.

    Pre-op X-rays:

    The x-rays show that the patient has a 60° left lumbar curve with marked rotation. She has severe degeneration of the lumbosacral joint, L4-L5 is significantly tilted and out of plane. The patient has a compensatory upper thoracic curve. The patient has severe thoracolumbar kyphosis measured at greater than 40°; this should be 0°. This has caused significant forward decompensation and hyperlordosis of the lumbar spine which has led to advanced degeneration.

    Indications for Surgery:

    1. Kim/SRP type 3 progressive adult idiopathic scoliosis with large lumbar rotated curve.
    2. Sixth lumbosacral obliquity with severe degeneration.
    3. Isthmic spondylolisthesis at L5-S1 with either bilateral or unilateral pars and articularis fractures.
    4. Gross instability of lumbar spine due to the above factors plus status post
    micro decompression L4-5.
    5. Now with unremitting low back and leg pain due to greater than 50 degree rotated lumbar curve and fixed thoracic component including thoracolumbar kyphosis.

    Surgical Strategy – Stage 1:

    Abdominal retroperitoneal approach to the lumbosacral spine.
    Radical diskectomy L5-S1 with subtotal vertebrectomy of L5 to allow entrance into L5-S1 space for reduction and fusion of interbody L4-S1.
    Interbody fusion after removal of disk herniation under loop and high intensity light illumination for placement of a PEEK 8 mm device with autogenous and putty bone centrally, and fully threaded screw over a washer.
    Radical diskectomy L4-5 with correction of coronal plane decompensation L4-5.
    Placement of PEEK device with autogenous bone and allograft at L4-5.
    Anterior screw fixation L4-5 and L5-S1.
    Intraoperative use of fluoro.

    Indications for Surgery:

    1. KIM/SRP type 3 thoracolumbar progressive adult idiopathic scoliosis, 65 degrees.
    2. Thoracolumbar kyphosis.
    3. Status post anterior interbody fusion, L5-S1, L4-5 for horizontalization of index lumbosacral curve.
    4. Progressive radiculopathy and pain due to collapsing scoliosis, coronal and sagittal decompensation.
    5. Status post hemilaminectomy, L4-5.
    6. Failed conservative therapy.

    Stage 2:

    T10-pelvis instrumentation using ¼ inch stainless steel pedicle screw/rod construct.
    Posterior spinal fusion, T2 – sacral pelvis using locally- harvested autogenous bone and allograft bone in a bone mill.
    Interlaminar decompression, reexploration decompression under high- loupe magnification, L4-5, L5-S1.
    Multiple-level spinal osteotomy, Smith-Peterson osteotomy, for recontouring, thoracolumbar kyphosis, T12-L1, L1-L2, L2-L3, L4-L5 with bilateral facetectomy and mobilization.
    Intraoperative O-arm neuronavigation.
    Intraoperative somatosensory evoked potential motor evoked potential use.• Plastic closure of wound.

    Post-op Films:

    The patients plumb line improved post-operatively.
    Her sagittal plane is perfect.
    All the instrumentation looks great.