Flatback Case 5

Case Review #5: 67 year old woman with flatback syndrome following 5 spinal surgeries from Robert Pashman

A 67 year old female presented to Dr. Pashman with severe Flat back Syndrome after 5 previous spine surgeries for Adult Idiopathic Scoliosis. Dr. Pashman treated her with a Posterior Spinal Fusion from T8 to S1.

    Case Review:

    67 year old Femalepresented with Flatbackafter five previous ScoliosisSurgeriesRobert S Pashman, MD Scoliosis and Spinal Deformity Surgery

    Patient History:

    67-year-old femaleApproximately 5 previous operations for Adult Idiopathic ScoliosisPseudoarthrosis, multiple times at L5-S1Ultimately the patient had been fused up to T8, which had resulted iniatrogenic flatback deformity with severe forward decompensation. Thepatient could not walk upright, but necessarily needed to flex hips andknees to maintain upright gait.The patient also has severe cervical stenosis found on MRI, although shedoes not have upper motor neuron symptoms. Clearly her sagittalimbalance is causing more neural compression as the patient attempts tohyper-lordose her neck to compensate for the severe decompensation.Forward decompensation is causing significant buttock and posteriorthigh painThe patients past medical history is significant for treatment for breastcancer including chemotherapy and radiation.

    Pre-op X-rays:

    The patient’s head is approximately 14 cm anterior to the sacrum.

    Indications for Surgery:

    Iatrogenic flat-back, status post multiple operations for adult idiopathicscoliosis.Severe low back and leg pain due to forward decompensation.Significant radiculopathy due to nerve stretch symptoms includingneurapraxia.Multiple co-morbidities including factor V deficiency, hypertension,cervical stenosis.Failure to function because of forward decompensation, low back pain.Status post breast cancer treatment including chemotherapy andradiation.

    Surgical Strategy:

    Segmental spinal instrumentation, T8 to sacrumPosterior spinal fusion, T8 to S1 using locally-harvested autogenous boneand osteotomy bone.Complete laminectomy, L1, L2 and L3.Lateral recess decompression, L2-3, L3-4 and L1-2 for isolation of nerves.Complete vertebrectomy, kyphectomy, pedicle subtraction osteotomy toinduce realignment of flat-back syndrome, lumbar 2. Spinal osteotomy, T8-T9, T9-T10, T11-T12 for removal of retained hardware and harvesting autogenous bone.Intraoperative CT management using O-arm and neuronavigation forplacement of pedicle screws through fusion mass.Intraoperative motor-evoked potential management and SSEPmanagement.Plastic closure, status post multiple operations, lumbar spine.Removal of retained hardware, T8 to S1 previously placed, producingiatrogenic flat-back.

    Post-Op Films:

    The patient is well balanced in both frontal and saggital planes.

    Pre-Op/Post-op Comparison:

    The patient is very happy with her outcome. Her symptoms resolved, and she returned to work at 3 months post-op, and