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Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis, affecting 2% to 4% of adolescents with an occurrence rate of 0.5 to 5.2%. Although the pathophysiology is unclear, there are some studies that suggest a genetic component. While the presence of smaller curvature is similar in males and female at similar rates, there is a higher prevalence of larger curvatures seen in women.
The treatment of AIS has been significantly advanced since the introduction of Harrington rods in the 1960s. While this technique represented a significant development during its time, it was limited in its ability to correct overall scoliosis and has led to a large number of patients who suffer from flat back syndrome and back pain as they have matured. The introduction of pedicle screws has led to better outcomes and correction of the three-dimensional deformity associated with AIS and improving upon the pitfalls of Harrington rods including neurological deficit and infection. As AIS patients mature into adulthood, many symptoms develop as a result of flat back resulting from Harrington rods, as well as progression of deformity and adjacent level degeneration at the lower levels, including back and radicular pain due to degenerative changes leading to foraminal stenosis and lateral recess stenosis. Treatment of these complex patients involves innovative thinking and treatment options to address the patient’s symptoms and correction of any progressive deformity.
Chief complaint: back pain
History of present illness: This is a 45-year-old female with a history of Harrington rods for spinal deformity as a teenager who presents with progressive back pain for several months. She denies any leg pain or genitourinary symptoms. She unfortunately has had no response to pain medications and/or physical therapy. She underwent imaging that was concerning for flat back syndrome ( Figs. 41.1–41.2 ).
Medications: oxycodone, prednisone, antidepressants
Allergies: no known drug allergies
Past medical and surgical history: Harrington rod placement as a teenager
Family history: noncontributory
Social history: none
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: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation intact to light touch
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Preoperative | ||||
Additional tests requested |
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Surgical approach selectedNo implant removal |
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If pseudarthrosis detected, L2-ilium posterior instrumented arthrodesis, L4-5 and L5-S1 transforaminal lumbar interbody fusion |
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Goal of surgery | Pain control and fusion | Solid bony arthrodesis | Solid bony arthrodesis | Solid bony arthrodesis |
Perioperative | ||||
Positioning |
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Prone on Jackson table | Prone on Jackson table |
Surgical equipment | Fluoroscopy |
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Medications | None | None | Tranexamic acid | Tranexamic acid |
Anatomical considerations | Left iliac vein |
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S1-2 foramen, S2 venous plexus | Spinal cord and conus, nerve roots, cauda equina |
Complications feared with approach chosen | Coronal imbalance, Ogilvy syndrome | Iliac or gluteal artery injury | Global coronal malalignment | |
Intraoperative | ||||
Anesthesia | General | General | General | General |
Exposure |
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L3-pelvis | L2-pelvis |
Levels decompressed |
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None | None |
Levels fused |
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L3-pelvis | L2-ilium |
Surgical narrative |
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Stage 1: position lateral with left side up, axillary roll under right chest wall, hip and knee flexed to relax psoas muscle, x-ray to localize incision and able to obtain true AP and lateral projection, 8–10 cm oblique incision centered over L3-4 disc, bluntly split each muscular layer in line with fibers, carefully split transversalis fascia, identify peritoneum, bluntly dissect peritoneum off lateral and posterior abdominal wall, identify psoas, confirm level of exposure, gently elevate psoas, confirm level with x-ray, dock MIS retractor system at middle to anterior 1/3 of disc space, L3-4 discectomy making sure to release contralateral annulus, clean cartilage from end plates and leveled with rasp to punctate bleeding subchondral bone, fluoroscopy to confirm instruments do not pass beyond contralateral annulus, size and place neutral or slightly lordotic cage filled with allograft wrapped in rhBMP-2, impact disc space under fluoroscopy, remove retractor, layered closureStage 2 (same day): sandwich in Jackson frame and position prone, x-ray to confirm location of lateral cage, standard posterior midline exposure, using robot and navigation place pedicle screws bilaterally from L1-5 and bilateral iliac bolts over wire, cut with bur and remove if prior instrumentation in the way otherwise leave intact, contour and insert rods, decorticate exposed bone, spinous processes harvested for autograft and combined with allograft or other extender and placed over decorticated bone, layered closure with drain | Position prone, place reference ray over iliac crest, posterior midline incision from L3-S2, work in different areas and pack to minimize blood loss, identify previous hardware and confirm quality of posterolateral fusion, cut previous rods and leave 5 mm segment free of rod to allow connection, pack this area and work on placing pedicle screws from L4-S2, advance S2 screw through iliac cancellous bone using fluoroscopy with tear drop landmark or navigation guidance, place cobalt chrome rod and connect to previous Luque rod using dominoes, decorticate exposed bony elements (laminas, facets, transverse processes, sacrum), irrigate surgical site, remove L4-5 spinous processes and mix with allograft and vancomycin and pack along decorticated site, layered closure with subfascial drain | Position prone on Jackson table, fluoroscopy to mark incision, expose upper lumbar spine to sacrum, expose PSIS bilaterally, confirm levels with fluoroscopy once exposed, place pedicle screws L4-S1 bilaterally and on left L2 and L3, place bilateral iliac bolts, L4-5 and L5-S1 transforaminal lumbar interbody fusions place rods bilaterally and connect rod on the right (and possible rod on the left) directly to Luque rods with connectors for added stability, intraoperative long-cassette AP x-ray to assess global coronal alignment and adjust with coronal in situ benders as needed, placement of graft material for arthrodesis, wound closure with two subfascial drains |
Complication avoidance | Two-staged approach, anterior lordotic cage based on preoperative angle, percutaneous minimally invasive pedicle screw placement | Two-staged approach, MIS retractor system, make sure to release contralateral annulus during discectomy, BMP, cut with bur and remove if prior instrumentation in the way | Work in different areas and pack to minimize blood loss, domino to previous fusion construct, surgical navigation to guide pedicle screw placement, endovascular team on standby if vascular injury | Intraoperative long-cassette x-rays to assess coronal alignment, anchoring of rods to Luque rods for added stability, BMP for arthrodesis |
Postoperative | ||||
Admission | Floor | Stepdown unit | Floor | ICU |
Postoperative complications feared | Coronal imbalance, Ogilvy syndrome | Pseudoarthrosis, overcorrection of sagittal balance, loss of fixation, infection, incisional hernia | Pseudoarthrosis, adjacent segment disease, hardware failure, infection | Pseudarthrosis, rod fracture, global coronal malalignment |
Anticipated length of stay | 6–7 days | 3 days | 4 days | 6–7 days |
Follow-up testing | Standing full spine x-rays prior to discharge, 2 months, 6 months, 12 months after surgery |
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Standing AP/lateral L-spine and scoliosis x-rays prior to discharge, 1 month, 3 months after surgery |
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Bracing | None | None | None | None |
Follow-up visits | 2 months, 6 months, 12 months after surgery | 2 weeks, 6 weeks, 3 months, 6 months, 12 months, 24 months after surgery | 2 weeks, 1 month, 3 months after surgery | 10–14 days, 6 weeks, 1 year, 2 years after surgery |
Iatrogenic scoliosis
Degenerative scoliosis
Adolescent idiopathic scoliosis
Adjacent segment disease
Hardware failure
Lumbar stenosis
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