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Coronal and sagittal deformity with back pain (adult idiopathic)


Introduction

Adult degenerative scoliosis (ADS), or de novo degenerative lumbar scoliosis, is a spinal deformity diagnosed in individuals with a coronal curve of >10 degrees, beginning after the age of 50, and without a prior history of scoliosis. It differs from adult idiopathic scoliosis in that the latter is a result of unrecognized/untreated adolescent idiopathic scoliosis. ADS develops secondary to degenerative changes occurring over an individual’s lifetime, typically presenting at the age of 70.

Although not previously recognized, ADS is believed to be more prevalent than previously thought; it is reported to be 68% in asymptomatic individuals and the incidence increases with age. McCarthy et al. have shown an increase in surgeries performed for ADS in the Medicare population, creating an increasing economic burden. With increasing life expectancy, prevalence and cost are expected to further increase for this condition.

  • Ciaran Bolger, MD

  • Royal College of Surgeons

  • Catherine Moran, MD

  • Neurosurgery

  • Tallaght University Hospital

  • Dublin, Ireland

  • Benjamin D. Elder, MD, PhD

  • Neurosurgery

  • Mayo Clinic

  • Rochester, Minnesota, United States

  • Hamid Hassanzadeh, MD

  • Orthopaedic Surgery

  • University of Virginia

  • Charlottesville, Virginia, United States

  • Baron Zarate Kalfopulos, MD

  • Orthopaedic Surgery

  • Instituto Nacional de Rehabilitacion

  • Medica Sur

  • Mexico City, Mexico

Preoperative
Additional tests requested

  • MRI C-spine

  • DEXA

  • MRI C-spine

  • DEXA

  • Supine scoliosis x-rays

  • Vitamin D levels

  • Nicotine tests

  • MRI C-T spine

  • DEXA

  • L-spine flexion-extension x-rays

  • Nutrition evaluation

  • Anesthesia evaluation

  • Medicine evaluation

  • L-spine flexion-extension x-rays

  • EMG lower extremities

Surgical approach selected L3-4 laminectomy based on preop symptoms that locate to nerve root

  • If meets all criteria (BMI<35, negative nicotine test, pretreatment with anabolic therapy)

  • Stage 1: L5-S1 ALIF

  • Stage 2: T10 vs. 11-sacrum instrumented fusion with pelvic fixation

L4-S1 TLIF, L4-S1 posterior column osteotomies, T10-S1 sublaminar decompression, T10-pelvis fusion L3-4 and L5-S1 TLIF, L1-5 posterior fusion, L3-S1 laminectomy

  • Surgical approach if 21

  • Surgical approach if 80

  • Correct sagittal imbalance and scoliosis

  • Same approach

  • Same approach with sparing of some levels

  • Same approach

  • Same approach

  • L4-S1 TLIF

  • Same approach

  • Same approach

Goal of surgery Decompress neural elements, relieve leg pain/paresthesias, relieve stenosis, improve walking distance Decompress neural elements, correct sagittal and coronal deformities, stabilize spine Decompress neural elements, correct sagittal and coronal deformities, stabilize spine Decompress neural elements, correct sagittal and coronal deformities, stabilize spine
Perioperative
Positioning Prone

  • Stage 1: supine on flat Jackson table with arterial line bag inflated transversely across lumbosacral junction

  • Stage 2: prone on Jackson table with pins

Prone Prone
Surgical equipment

  • Fluoroscope

  • Surgical microscope

  • Stage 1: vascular surgery, abdominal retractor system, fluoroscopy, osteotomes, IOM (SSEP/EMG)

  • Stage 2: surgical navigation, osteotomes, BMP-2, allograft, cell saver

  • IOM (MEP/SSEP/EMG)

  • Fluoroscopy

  • Osteotomes

  • Fluoroscopy

  • IOM

Medications None Tranexamic acid Tranexamic acid Tranexamic acid
Anatomical considerations Thecal sac, nerve roots, pedicles, pars interarticularis, disc space at appropriate levels

  • Stage 1: ureter, aorta, inferior vena cava, iliac vessels

  • Stage 2: prior laminectomy defect, aorta, inferior vena cava, iliac vessels

Nerve roots, dura, SI joint Pedicle rotation at apex of deformity, venous plexus
Complications feared with approach chosen CSF leak, nerve root injury, instability Anterior expulsion of graft, pseudoarthrosis, proximal junction failure, instrumentation failure, sagittal/coronal imbalance, durotomy CSF leak, neurological injury, pseudoarthrosis Nerve root injury, proximal junctional kyphosis, lumbar plexus injury
Intraoperative
Anesthesia General General General General
Exposure L3-4

  • Stage 1: L5-S1

  • Stage 2: T10-sacrum

T10-S2 L1-S1
Levels decompressed L3-4 None T10-S1 L3-S1
Levels fused None

  • Stage 1: L5-S1

  • Stage 2: T10-sacrum

T10-pelvis L1-S1
Surgical narrative Position prone, x-ray to guide incision, 3 cm midline incision through previous laminectomy scar at appropriate level, dissect on more affected side to expose ipsilateral facet joint, undercut the joint, expose and decompress ipsilateral traversing root along length from disc space level to ipsilateral pedicle and foramen using high-speed drill with direct visualization, dissect scar free from root using microdissection, extend bone removal superiorly and laterally if needed to expose and decompress exiting nerve root, care is taken to expose and preserve the pars, dissect and excise scar lateral to medial to expose thecal sac to midline and onto contralateral side, contralateral facet undercut to expose and decompress contralateral neural elements from disc space to pedicle and foramen under direct visualized, closure in layers

  • Stage 1: position supine with arterial line bog transversely across lumbosacral junction, IOM to assess reduced signals with prolonged retraction of great vessels, vascular surgery exposure with left retroperitoneal approach and mobilization of iliac vessels below bifurcation to expose L5-S1 disc space, localization x-rays, resection of L5-S1 disc and anterior/posterior osteophytes, bilateral vertebral body distractors to mobilize segment, preparation of end plates and placement of cage (16–24 degrees), deflate arterial line bag, place integrated fixation screws or buttress screw/washer to prevent anterior expulsion, intraoperative x-ray

  • Stage 2 (1–2 days later): expose T10 vs. T11 to sacrum, maintain supraspinous/interspinous ligament at top two levels and facet capsules at upper instrumented vertebrae, expose S1-2 dorsal foramen, multilevel posterior column osteotomies with sublaminar decompression from L1 to S1, placement of pedicle screw fixation with navigation from T10 to 11 to sacrum with bicortical fixation in sacrum, placement of S2-alar-iliac screws at least 9 x 90 mm, placement of 5.5 titanium rods with use of reduction clamps, in situ bending to correct sagittal and coronal plane deformities with compression/distraction, intraoperative scoliosis x-rays to check correction, pulse lavage, decortication of posterior elements including facet joins and residual lamina, place local autograft and morcellized allograft on decorticated surfaces, closure with incisional wound vac and 2 subfascial drains

Position prone after IOM, x-rays to confirm levels, midline skin incision, enter through fascia paraspinally down to lamina of T10-S2, dissect lateral to pedicles to find transverse process for each level, confirm level, place pedicle screws and S2 alar-iliac screws with fluoroscopy, bilateral inferior facetectomy from L1 to L5, sublaminar decompression and posterior column osteotomies at L5-S1 and L4-5 and place TLIF cages at these levels from left side, continue sublaminar decompression to T12-L1 level, x-ray to check alignment, can perform L2-3 and L3-4 posterior column osteotomies if more correction is needed, place rods, confirm alignment with x-rays, compress left side L4-S1 and right side L2-4, place drains, layered closure Position prone, standard posterior midline incision, subperiosteal dissection and exposure of L1-S1, pedicle screw placement from L1-S1, initiate decompression by inserting interspinous spreader, decompress with laminectomy/flavectomy/bilateral facetectomy, identify thecal sac and existing nerve root identification, gentle mobilization of neural structures medially to identify disc space, create a window on the disc and enlarge with box osteotomes, obtain local bone from surgical field and demineralized bone matrix, place in disc space, place banana cage filled with demineralized bone matrix, decorticate articular and transverse processes, enhance with local bone graft and demineralized bone matrix, restore lordosis with rod contouring and compression from caudal to cephalad direction, layered closure with subfascial drain
Complication avoidance Decompress only symptomatic nerve roots, bilateral decompression from a unilateral approach, preserve pars, dissect and excise scar lateral to medial to expose thecal sac, directly visualize decompression Arterial line bag to maximize L5-S1 lordosis, IOM to assess effects of retraction, vertebral body distractors to maximize lordosis, maintain supraspinous/interspinous ligament, navigation, intraoperative scoliosis x-rays, incisional wound vac Fuse down to S2 alar-iliac level, sublaminar decompression to T10, increase levels of posterior column osteotomies if more sagittal correction is needed, lateral correction with lateral compression One stage, avoid lateral approach, identify thecal sac and nerve root early, avoid BMP because of economic constraints, increase lordosis by compression from caudal to cephalad
Postoperative
Admission Floor

  • Stage 1: floor

  • Stage 2: ICU

Intermediate care Floor
Postoperative complications feared CSF leak, infection CSF leak, ileus, urinary retention, early proximal junctional kyphosis CSF leak, neurological injury, pseudoarthrosis, medical complications, infection Wound infection, adjacent segment disease, proximal junctional kyphosis, pseudoarthrosis, loosening of pedicle screws especially at S1, cage subsidence
Anticipated length of stay 1 day 6–7 days 3–5 days 3 days
Follow-up testing None

  • Supine lumbar spine AP/lateral x-rays after stage 1

  • Standing scoliosis x-rays after stage 2

  • Standing scoliosis x-rays 6 weeks, 3 months, 6 months, 1 year after surgery

  • CT 1 year after surgery

  • T-L spine x-rays after surgery

  • Standing PA and lateral scoliosis x-rays prior to discharge, 3 weeks, 3 months, 6 months, 12 months after surgery

  • L-spine x-rays 6 weeks and every 3 months for first year after surgery

  • CT L-spine 12 months after surgery

Bracing None None None None
Follow-up visits 2 weeks, 6 weeks after surgery 6 weeks, 3 months, 6 months, 1 year after surgery 3 weeks, 3 months, 6 months, 12 months after surgery after surgery 2 weeks, 6 weeks, every 3 months for first year after surgery
AP , Anteroposterior; BMP , bone morphogenic protein; CSF , cerebrospinal fluid; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; EMG , electromyography; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP, motor evoked potential; MRI , magnetic resonance imaging; PA , postero-anterior; SSEP , somatosensory evoked potential.

Example case

Chief complaint: back pain

History of present illness: A 63-year-old female presents with back pain and radiculopathy. She underwent a laminectomy approximately 15 years ago but has had back pain for about 25 years. The patient also has right leg pain and left leg numbness that is worsened with standing and walking. More recently, the back pain has become constant over the past 3 months. She has tried physical therapy, epidural steroid injections, and selective nerve root injection without significant improvement. She also notes right leg weakness. She underwent imaging that revealed significant scoliosis ( Figs. 36.1–36.3 ).

Fig. 36.1, Preoperative magnetic resonance images. ( A ) T2 sagittal and ( B ) T2 axial images demonstrating multilevel disc degeneration with foraminal and lateral recess stenosis.

Fig. 36.2, Preoperative computed tomography scans. ( A ) Sagittal, ( B ) coronal, and ( C ) axial images demonstrating dextroscoliosis, multilevel disc degeneration, with foraminal stenosis.

Fig. 36.3, Preoperative x-rays. ( A ) Anteroposterior (AP) and ( B ) lateral x-rays demonstrating dextroscoliosis, multilevel disc degeneration with coronal deformity, and loss of lumbar lordosis.

Medications: albuterol, omeprazole, temazepam

Allergies: codeine

Past medical and surgical history: hypertension, chronic obstructive pulmonary disease, hypothyroidism, depression, laminectomy

Family history: noncontributory

Social history: previous smoker, occasional alcohol

Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

Reflexes: 3+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 3+ in bilateral patella/ankle; no clonus or Babinski; sensation intact to light touch

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