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Iatrogenic kyphoscoliosis


Introduction

Kyphoscoliosis is the loss of the normal thoracolumbar curvature resulting in increased kyphosis as a result of either increased thoracic kyphosis or thoracolumbar kyphosis. This can result in significant amount of disability due to pain drastically altering the patient’s quality of life. Many present with back pain, inability to stand erect, and leg pain. The pain is the result of loss of normal posture requiring more expenditure of energy to stay upright. The causes of kyphoscoliosis can be varied but iatrogenic causes are frequently seen following decompressive thoracic/lumbar surgery or failed surgical fusion. Patient can also develop kyphoscoliosis following a traumatic event that results in compression or burst fractures that have been managed with decompression alone or with fusion. A significant number of these patients typically also have underlying osteoporosis that was undiagnosed at their index surgery. Hardware failure as a result of poor bone quality, loss of anterior column support, and/or loss of the posterior column integrity begins to propagate iatrogenic kyphoscoliosis, which ultimately results in severe deformity.

Example case

  • Chief complaint: back pain and postural change

  • History of present illness: This is a 58-year-old female with a history of motor vehicle accident a few years prior. She suffered a fracture and underwent a T10-L3 decompression and instrumentation. The instrumentation was removed due to hardware complications. She ultimately developed kyphosis. She has now severe back pain with kyphosis focused with the apex at T12-L1. She is on oral pain medication and has a spinal cord stimulator without significant improvement of her symptoms. She has a history of osteoporosis and has been on pain medications for 5 months. She underwent imaging that was concerning for progressive kyphoscoliosis ( Figs. 42.1–42.3 ).

    Fig. 42.1, Preoperative magnetic resonance images. (A) T2 sagittal and (B) T2 axial images demonstrating thoracolumbar kyphosis and T12 compression fracture and a L1 burst fracture.

    Fig. 42.2, Preoperative computed tomography scans. (A) Sagittal and (B) axial images demonstrating thoracolumbar kyphosis and T12 compression fracture and a L1 burst fracture.

    Fig. 42.3, Preoperative x-rays. (A) Anteroposterior (AP) and (B) lateral x-rays demonstrating regional and global sagittal imbalance.

  • Medications: amlodipine, levothyroxine, Xanax

  • Allergies: no known drug allergies

  • Past medical and surgical history: osteoporosis, fracture, hypothyroidism, hypertension, laminectomy, fusion with hardware removal, spinal cord stimulator placement

  • Family history: noncontributory

  • Social history: disabled, nonsmoker

  • 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

  • Ahmed S. Barakat, MD

  • Orthopaedic Surgery

  • University of Cairo

  • Cairo, Egypt

  • Fabio Cofano, MD

  • Neurosurgery

  • University of Turin

  • Spine Surgery Unit Humanitas Gradenigo Hospital Turin, Italy

  • James S. Harrop, MD

  • Neurosurgery

  • Jefferson University

  • Philadelphia, Pennsylvania, United States

  • Lawrence G. Lenke, MD

  • Orthopaedic Surgery

  • Columbia University

  • New York City, New York, United States

Preoperative
Additional tests requested

  • T- and L-spine dynamic x-rays

  • CTA T-L spine

Endocrinology evaluation for osteoporosis

  • DEXA, optimize bone density (i.e., teriparatide)

  • Lumbar flexion-extension x-rays

  • Supine x-rays while laying on bump

  • Nonoperative management: PT, acupuncture, chiropractor, pain management

  • CT C-T spine with 3D reformat

  • MRI C-T spine

  • Supine long cassette AP/lateral x-rays

  • Cardiology evaluation

  • Lower extremity dopplers

Surgical approach selected T12-L1 corpectomy, T6-sacroiliac fusion

  • Stage 1: T4-Pelvis posterior fusion with T12-L1 osteotomy

  • Stage 2: T11-L2 lateral plate and discectomy for interbody fusion

L1 VCR, T4-iliac fusion Revision T4-sacrum/ilium with T12/L1 VCR and T11-L2 anterior spinal fusion with cage, L5-S1 TLIF

  • Surgical approach if 21

  • Surgical approach if 80

  • Same approach

  • Conservative management

  • T12-L1 corpectomy with expandable cage with T4-L4 posterior fusion

  • Same approach

  • Same approach

  • Same approach

  • T9-L3 or L4

  • Same approach except no VCR, with four rods and posterior column osteotomies

Goal of surgery Correct sagittal and coronal imbalance Restore alignment, achieve solid fusion Correct thoracolumbar kyphosis Realign sagittal and coronal regional and global malalignment, relieve current symptoms
Perioperative
Positioning Left lateral up, then prone Stage 1: prone on Jackson table, no pinsStage 2: lateral approach Prone on Jackson table Prone on Jackson table, with Gardner-Wells tongs
Surgical equipment

  • Fluoroscopy

  • Surgical navigation

  • IOM

  • Fluoroscopy

  • IOM (MEP/SSEP)

  • Aquamantys® bipolar

  • O-arm

  • Surgical navigation

  • Instrumentation

  • IOM (MEP/SSEP/EMG)

  • Fluoroscopy

  • O-arm

Medications Tranexamic acid I think this equipment is not strictly considered a medication according to the english term, then probably better cancel. Write please tranexamic acid as well Tranexamic acid Tranexamic acid, steroids
Anatomical considerations Aorta, segmental vessels, dura, lung Posterior bony anatomy, ribs, pleura, lung, diaphragm, vascular structures Aorta, spinal cord Prior distorted anatomy
Complications feared with approach chosen Vascular injury, lung injury, neurological injury Durotomy, excessive bleeding, inadequate correction, neurological injury, pleural injury, spinal cord infarct Paralysis, adjacent level disease, medical complications Nerve root injury, adjacent segment disease, medical complications
Intraoperative
Anesthesia General General General General
Exposure T6-sacrum

  • Stage 1: T4-Pelvis

  • Stage 2: T11-L2

T4-sacrum T4-sacrum
Levels decompressed T12-L1

  • T11-12

L1 T12-L1
Levels fused T6-pelvis

  • Stage 1: T4-Pelvis

  • Stage 2: T11-L2

T4-pelvis T4-sacrum
Surgical narrative

  • Stage 1: position lateral with left-side up, Hogden’s approach, preserve latissimus dorsi, V-shaped osteotomy of the left 10 rib or removal, blunt dissection of peritoneum, sharp bow-shaped dissection of diaphragm, identify T12 and L1 with x-ray, identify segmental vessels and securely suture, T11-12 and T12-L1 and L1-2 discectomies, T12 and L1 corpectomies, preserve ALL, place appropriately sized expandable cage filled with autograft from ribs and excised vertebral bodies, careful correction of kyphosis, anterior lumbar plate from T11-L3, closure of wound with drain and vancomycin powder, chest tube applied

  • Stage 1: position prone with hips extended to reduce kyphosis, posterior incision, place T4-Ilium screws screws, placement of T12-L1 pedicle screws to increase posterior support or adding T12-L1 pedicles to osteotomy to enhance correction with table bending, check IOM during correction maneuvers, fluoroscopy to confirm global sagittal alignment, grafting, possible screw augmentation with cement

  • Stage 2 (same day): left lateral approach with flexion of table to increase working space, incision after fluoroscopy check, dissect and remove rib on its superior border, dissect retropleural space and avoid visceral and pleural damage, possible lung deflation, fluoroscopy to identify T12-L1 level, place tubular retractor, ligation of segmental vessels with temporary clamps to observe for IOM changes, T11-12 discectomy with bone graft from rib, plate and fix with screws, careful check of pleural integrity and use drainage if necessary, reconstruct chest wall

Baseline (SSEP/MEP), place prone, incision and exposure with Aquamantys,® screws from T4-pelvis and not in L1, L1 laminectomy and drill down L1 pedicles, placement of temporary rods, vertebrectomy and discectomy to achieve enough correction, L1 vertebral body cage, close down deficit, lock rods, two subfascial drains

  • Position prone, posterior midline incision, subperiosteal exposure from T4-sacrum/ilium, place vancomycin powder into muscle and subcutaneous tissues, L5-S1 inferior face excision except T4-5, place bilateral or dual S2 alar-iliac screws/dual headed S1 screw/reduction L5 pedicle screw, L5-S1 TLIF with lordotic cage, place pedicle screws segmentally up to T4 skipping T12 and L1 with dual-headed screws at T10-11 and L2-3 on left and T11 and L2 on right. O-arm to check hardware, temporary rods on right T10-L3

Complication avoidance Two-staged approach, two-level corpectomy to correct kyphosis, chest tube, vertebroplasty to augment pedicle screws, place rods with correct curvature T12-L1 pedicle screws vs. osteotomy in stage 1, check neuro monitoring during correction maneuvers, possible screw augmentation, dissect along superior border of rib, temporarily clamp segmental vessels to observe for IOM changes Baseline IOM, Aquamantys,® vertebrectomy if needed to achieve deformity correction All screws placed freehand, place bilateral or dual S2 alar-iliac screws freehand, L5-S1 TLIF with lordotic cage, intraoperative O-arm, maintain end plate disc integrity during VCR, save all nerve roots, keep anterior vertebral body for fusion, staggered rod construct
Postoperative
Admission ICU, then floor ICU, then floor ICU, then spine unit ICU
Postoperative complications feared Osteoporosis, neurological deficits, respiratory dysfunction CSF leak, neurological deficits, inadequate correction, infection Paralysis, neurological deficit, adjacent level disease, medical problems Medical complications
Anticipated length of stay 6–8 days 4–5 days 4–6 days 6 days
Follow-up testing Thoracolumbar x-rays within 24hours, 2 weeks, 6 weeks, 6 months, every 2 years after surgery Standing x-rays within 24hours after surgery, 1 month, 3 months, 6 months, 12 months after surgery

  • Plain x-rays prior to discharge

  • Standing scoliosis x-rays prior to discharge

Upright x-rays when drains removed
Bracing None Semirigid thoracolumbar brace for 30 days 6 weeks None
Follow-up visits 2 weeks, 3 months, 6 months, 12 months, 24 months after discharge 1 month, 3 months, 6 months, 12 months after surgery 2 weeks with APP, 6 weeks after surgery 2 weeks, 6–8 weeks after surgery
AP , Anteroposterior; BMP , bone morphogenic protein; CSF , cerebrospinal fluid; CT , computed tomography; CTA , computed tomography angiogram; DEXA , dual-energy x-ray absorptiometry; EMG , electromyogram; ICU , intensive care unit; IOM , intraoperative monitoring; MEP , motor evoked potential; SSEP , somatosensory evoked potential; TCP , tricalcium phosphate; TLIF , transforaminal lumbar interbody fusion; VCR , vertebral column resection.

Differential diagnosis

  • ▪

    Proximal junctional kyphosis

  • ▪

    Proximal junctional failure

  • ▪

    Adjacent segment disease

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