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Coronal deformity


Introduction

Adult spinal deformities may be caused by progressive degenerative disease, iatrogenic changes, or progression of adolescent curves. It is most commonly seen in patients older than 65 years, which is also the fastest growing population in the United States. The management of adult deformity hinges upon the etiology of the condition. The most common symptom in the adult population is pain. The chief complaints of the patient must be taken into consideration, as radicular symptoms may need treatment regimens that differ from those with only back pain. The global balance of the patient must also be thoroughly investigated, both in the coronal and sagittal planes. Dynamic radiographic films may be employed to determine the flexibility of the patient’s curve(s) and can aid in surgical planning of osteotomies and corrective maneuvers. Even though the effectiveness of conservative management has not been well established, it has been used as the first-line treatment in patients with mild and nonworsening symptoms. However, coronal deformity is a dynamic condition and early identification of patients who may benefit from surgery is crucial for good outcomes and cost-efficiency. Both open and minimally invasive techniques may be used to correct coronal imbalance and decompress neural elements, without a high level of evidence to suggest efficacy of one method of correction over another.

Example case

  • Chief complaint: neck pain and weakness

  • History of present illness: This is a 50-year-old female with mid and low back pain that has progressed over the last year. She does not have any leg pain or genitourinary symptoms. Imaging findings are shown in Fig. 35.1 that were concerning for scoliosis.

    Fig. 35.1, Preoperative standing scoliosis films. (A) Lateral standing scoliosis 36-inch x-ray imaging showing a positive C7-S1 sagittal vertical axis (SVA) of less than 5 cm ( blue arrows ), because the patient compensated for her sagittal imbalance with pelvic retroversion as evidenced by the positive pelvic tilt (PT) angle of more than 19 degrees. There is also a grade I L5-S1 anterolisthesis. (B) Anteroposterior standing scoliosis 36-inch x-ray imaging demonstrating significant thoracolumbar levoscoliosis (B) and widening of sacroiliac joints and sclerosis.

  • Medications: acetaminophen, aspirin

  • Allergies: no known drug allergies

  • Past medical and surgical history: depression, anxiety

  • Family history: none

  • 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

Within this chapter, we present the case of a 50-year-old female patient with progressive low back pain over the course of a year with a spinal deformity.

  • Pedro Luis Bazán, MD

  • Spine Surgeon

  • HIGA San Martín La Plata (Chief Orthopaedic)

  • Hospital Italiano La PlataInstituto de Diagnóstico La Plata

  • La Plata, Buenos Aires, Argentina

  • Esteban F. Espinoza-García, MD, MSc

  • University of Valparaíso

  • San Felipe, Chile

  • Hamid Hassanzadeh, MD

  • Orthopaedic Surgery

  • University of Virginia

  • Charlottesville, Virginia, United States

  • Timothy F. Witham, MD

  • Neurosurgery

  • Johns Hopkins

  • Baltimore, Maryland, United States

Preoperative
Additional tests requested

  • T-L spine AP/lateral/flexion-extension x-rays

  • T-L spine MRI

  • T-L spine CT

  • CT and MRI T-spine

  • DEXA

  • No operative: medial branch block

  • MRI T-L spine

  • Physical therapy evaluation

  • Pain management evaluation for medical brain block and/or radiofrequency ablation

  • MRI T-L spine

  • Scoliosis x-rays

  • DEXA

  • Calcium, vitamin D, PTH serum levels

Surgical approach selected

  • Stage 1: L1-2, L2-3, L3-4 LLIF

  • Stage 2: percutaneous L1-4 posterior fusionHounsfield Units in CT.

T5-S1 posterolateral fusion and correction of deformity

  • Stage 1: L1-4 LLIF

  • Stage 2: percutaneous L1-4 posterior fusion

  • After nonsurgical treatments have been maximized,

  • Stage 1: T10-pelvis fusion with multilevel Ponti osteotomies, cement augmentation of T9-10

  • Stage 2: Retroperitoneal L5-S1 discectomy, L5-S1 ALIF

  • Surgical approach if 21

  • Surgical approach if 80

  • Same approach

  • Same approach

  • Same approach

  • Nonoperative management

  • Same approach

  • Same approach

  • Same approach but stopping at L4

  • Same approach

Goal of surgery Relieve pain, avoid progression of deformity Relieve pain, avoid progression of deformity Relieve pain, deformity correction Relieve pain and improve disability, deformity correction, stabilization
Perioperative
Positioning

  • Stage 1: lateral decubitus

  • Stage 2: prone

Prone

  • Stage 1: lateral decubitus

  • Stage 2: prone

  • Stage 1: prone on Jackson table

  • Stage 2: supine on Jackson table with flat adapter

Surgical equipment

  • IOM

  • Fluoroscopy

Fluoroscopy

  • IOM (MEP/SSEP)

  • Fluoroscopy

  • Stage 1: IOM, fluoroscopy, osteotomes, O-arm, cement augmentation

  • Stage 2: fluoroscopy, sagittal saw

Medications Maintain MAP Maintain MAP None Tranexamic acid for stage 1
Anatomical considerations Transverse processes, psoas, disc space, pedicles, vertebral body Pedicles Psoas, nerve roots Neural elements, iliac vessels, iliolumbar vein, ureter, bowels
Complications feared with approach chosen Progression of deformity Screw misplacement Lumbar plexus injury, psoas injury Proximal and distal junctional failure, pseudoarthrosis, proximal junctional kyphosis
Intraoperative
Anesthesia General General General General
Exposure

  • Stage 1: L1-4

  • Stage 2: L1-4

T5-S1 L1-4

  • Stage 1: T9-S2

  • Stage 2: L5-S1

Levels decompressed

  • Stage 1: L5-7

  • Stage 2: L1-2

all levels where ponti osteotomies are completed along the coronal curve L1-4

  • Stage 1: None

  • Stage 2: L5-S1

Levels fused

  • Stage 1: L1-4

  • Stage 2: L1-4

T5-S1 L1-4

  • Stage 1: T10-pelvus

  • Stage 2: L5-S1

Surgical narrative

  • Stage 1: position lateral, preoperative x-ray to determine level, percutaneous discectomy, disc replacement with arthrodesis at L1-L4, x-ray to confirm hardware, standard closure

  • Stage 2 (after 1 week): position prone, preoperative x-ray to determine levels, percutaneous placement of pedicle screws under biplanar fluoroscopy L1-4, possible increase to T10 depending on prestage 2 alignment, placement of rods, system shutdown, standard closure

Intubated, prone positioning, x-ray to confirm localization, midline incision, subperiosteal bilateral dissection from T5-S1, x-ray to confirm levels, thoracic and lumbar pedicle screw placements, rods connected sequentially to each pedicle screw one by one to progressively correct deformity, subfascial drain placement

  • Position lateral decubitus with left side up, break table in midline, posterolateral accessory incision off of multifidus musculature, sharply incise 3 cm through skin, monopolar cautery down to fascia levels, enter through fascia, bluntly retract down to level of psoas, retract peritoneal contents anteriorly, incise obliquely over L3 vertebral body and dissect down into retroperitoneal space, laterally incise and dock tube over L3-4 disc space, bluntly place all dilators and retractors under EMG of psoas, sweep posteriorly to stay out of lumbar plexus, confirm position on fluoroscopy, stimulate surgical field, annulotomy and discectomy, prepare end plates, dilate disc space and size it starting L3-4 with bone graft, confirm position with x-ray, repeat with L2-3 followed by L1-2, place tube between 11 and 12th ribs, layered closure

  • Stage 2: position prone on Jackson table, stab incision over lateral aspect of each pedicle using fluoroscopy, incise through fascia, insert Jamshidi needle through pedicle and traverse from medial to lateral, perform bilaterally L1-4, place screws under EMG stimulation, insert rods on both sides, layered closure

  • Stage 1: position prone on Jackson table to promote lumbar lordosis, expose T9-S2, preserve T9-10 facet joints and posterior soft tissue envelope, perform osteotomies along the area of the coronal curve bilaterally, place pedicle screws from T10 to S2AI, leave one screw in T10 out for cement, placement cement at T9-10, O-arm spin to confirm screw and cement placement, place rods and correct deformity, decorticate, layered closure with drain

  • Stage 2 (6–8 weeks after stage 1): position supine, vascular surgeon to expose using retroperitoneal approach to L5-S1, place Syn frame, confirm with x-ray, L5-S1 discectomy, endplate preparation, size and cut femoral ring allograft, fill with demineralized bone matrix and place, place screw and washer at L5-S1, x-ray, layered closure

Complication avoidance Two-staged approach, percutaneous lateral approach, percutaneous pedicle screw and posterior fixation Progressive sequential deformity correction Break table slightly in midline, EMG of psoas for tubular retractor placement, sweep tubular retractor posteriorly to avoid lumbar plexus, percutaneous pedicle screw and posterior fixation Two-staged procedure, preserve T9-10 facet joints and posterior soft tissue envelope, multilevel osteotomies along coronal curve, cement augmentation, O-arm spin, vascular surgery to expose L5-S1, place screw and washer to prevent kick out
Postoperative
Admission Floor Floor Floor

  • Stage 1: ICU

  • Stage 2: floor

Postoperative complications feared Infection, hardware failure CSF leak, spinal instability, subcutaneous hemorrhage Neural injury, lower extremity weakness, pseudoarthrosis Proximal junctional kyphosis, distal junction pseudoarthrosis, CSF leak, instrument failure
Anticipated length of stay 5–7 days 5 days 2–3 days 7–9 days total
Follow-up testing

  • T-L spine x-rays within 1 day after surgery

  • T-L flexion-extension x-rays 1 month after surgery

  • T-L spine CT 3 months after surgery

T- and L-spine CT 1 day and 3 months after surgery, x-rays 3 months after surgery

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

  • Physical therapy evaluation

  • CT T-L spine after stage 1

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

Bracing None Jewett brace for 3 months None None
Follow-up visits 2 weeks, 1 month, 2 months, 3 months, 6 months, 1 year after surgery 3 weeks, 3 months, 6 months, 1 year after surgery 3 weeks, 3 months, 6 months, 12 months after surgery 2 weeks, 6 weeks, 3 months, 6 months, 1 year after surgery
ALIF , Anterior lumbar interbody fusion; CSF , cerebrospinal fluid; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; EMG , electromyography; ICU , intensive care unit; IOM , intraoperative monitoring; LLIF , lateral lumbar interbody fusion; MAP , mean arterial pressure; MEP , motor evoked potential; MRI , magnetic resonance imaging; PTH , parathyroid hormone; SSEP , somatosensory evoked potential.

Differential diagnosis

  • ▪

    Adult degenerative scoliosis

  • ▪

    Progression of adolescent scoliosis

  • ▪

    Lumbar spondylolisthesis

  • ▪

    Lumbar stenosis

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