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Degenerative scoliosis with radiculopathy


Introduction

Adult degenerative scoliosis (ADS), or de novo degenerative lumbar scoliosis, is a form of 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. Unlike adult idiopathic scoliosis (see Chapter 41 ), which results from unrecognized/untreated adolescent idiopathic scoliosis, ADS results from degeneration over an individual’s lifetime. This condition typically occurs as a result of degenerative changes due to uneven loss of disc height that occurs over an individual’s lifetime and results in coronal changes, which is typically recognized after the age of 70. Although not previously recognized, ADS is believed to be more prevalent than previously thought and reported to be present in 68% of asymptomatic individuals; this number increases with age. McCarthy et al. have shown an increase in surgeries performed for ADS in the Medicare population, which creates an increasing economic burden. With increasing life expectancy, the prevalence, need for treatment, and overall cost for treatment, ADS is expected to further increase in prevalence and incidence.

Example Case

  • Chief complaint: mid and low back pain

  • History of present illness: A 67-year-old female with progressive back pain and new-onset left leg pain when she ambulates that follows an L5 distribution. She underwent imaging that was concerning for adult degenerative scoliosis ( Figs. 40.1–40.2 ).

    Fig. 40.1, Preoperative magnetic resonance image. Axial T2 image demonstrating.

    Fig. 40.2, Preoperative x-rays. (A) Anteroposterior and (B) lateral images demonstrating coronal and sagittal deformity with the apex of the curvature at L2-3.

  • Medications: oxycodone, gabapentin

  • Allergies: no known drug allergies

  • Past medical and surgical history: none

  • Family history: noncontributory

  • Social history: retired, no smoking or 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: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation intact to light touch

  • Mohamed El-Fiki, MBBCh, MS, MD

  • Neurosurgery

  • Alexandria University

  • Alexandria, Egypt

  • Hamid Hassanzadeh, MD

  • Orthopaedic Surgery

  • University of Virginia

  • Charlottesville, Virginia, United States

  • Yasuaki Tokuhashi, MD

  • Orthopaedic Surgery

  • Nihon University

  • Oyaguchi Kamicho, Itabashi-ku, Tokyo, Japan

  • Michael Y. Wang, MD

  • Yingda Li, MBBS

  • Neurosurgery

  • University of Miami

  • Miami, Florida, United States

Preoperative
Additional tests requested

  • L-spine flexion-extension x-rays

  • L-spine supine x-rays with traction

  • Scoliosis x-rays

  • CT L-spine high resolution

  • MRI L-spine

  • Full electrophysiological study

  • L-spine flexion-extension x-rays

  • DEXA

  • Physical therapy evaluation

  • Pain management evaluation with left L5 steroid injection

  • Nutritional evaluation

  • Anesthesia evaluation

  • Medicine evaluation

  • L-spine flexion-extension x-rays

  • Right and lateral bending x-rays

  • 3D CT

  • DEXA

  • Echocardiogram

  • Pain drawing

  • Parasagittal MRI views to assess L5-S1 foramen

  • L-spine lateral flexion-extension x-rays

  • Selective epidural steroid injection, SPECT scan to refine LBP pain generators

  • DEXA if long-segment deformity correction

Surgical approach selected L4-5 and possibly L3-4 TLIF and possible L3-4 pedicle subtraction osteotomy if needed, and L2-5 posterior fusion L4-S1 TLIF, L4-S1 posterior column osteotomies, T10-S1 sublaminar decompression, T10-pelvis fusion

  • Stage 1: L2-5 OLIF

  • Stage 2: T10-iliac posterior correction and fusion

MIS endoscopic transforaminal decompression at L4-5 and/or L5-S1 as incrementalist approach
If patient is 25 years of age Same approach L5-S1 fusion Same approach Same approach
If patient is 80 years of age MIS percutaneous surgery L4-S1 TLIF, T10-pelvis fusion Same approach with reinforcement of pedicle screws Same approach
Goal of surgery Stabilize spine, correction of sagittal alignment, prevent deformity progression Relief of pain and disability, correction of sagittal alignment, deformity correction Improve global alignment and lower extremity pain Decompress neural elements, address stenosis along fractional curve, mitigate/delay long segment deformity correction, incremental approach
Perioperative
Positioning Prone Prone

  • Stage 1: right decubitus

  • Stage 2: prone on Hall frame

Prone on Jackson table with Wilson frame
Surgical equipment

  • IOM

  • Fluoroscopy

  • IOM (MEP/SSEP/EMG)

  • Fluoroscopy

  • Surgical navigation

  • Cell saver

  • Fluoroscopy

  • OLIF cage

  • IOM (for stage 2)

  • Osteotome

  • Correction device

  • Polyester tape

  • Fluoroscopy

  • Endoscope

Medications None Tranexamic acid, maintain MAP >80 None None
Anatomical considerations Dura, nerve roots, end plates Spinal cord, nerve roots, dura, SI joint

  • Stage 1: major vessels, intestine, ureter, psoas

  • Stage 2: facet joints, pedicles, iliac bone

Dorsal root ganglion, dura
Complications feared with approach chosen Durotomy, nerve root injury, extensive blood loss CSF leak, lower extremity weakness, infection

  • Stage 1: injury to major vessels, intestines, ureters

  • Stage 2: nerve root injury, facture

DRG irritation, inadequate decompression
Intraoperative
Anesthesia General General General Conscious sedation
Exposure L2-5 T10-S2

  • Stage 1: L2-5

  • Stage 2: T10-sacrum

L4-5 and/or L5-S1
Levels decompressed L2-5 T10-S1

  • Stage 1: L2-5

  • Stage 2: None

L4-5 and/or L5-S1
Levels fused L2-5 T10-pelvis

  • Stage 1: L2-5

  • Stage 2: T10-iliac

None
Surgical narrative Position prone, confirm levels, midline skin incision with muscular retraction to expose lumbar lamina, insert bilateral L2-5 pedicle screws under fluoroscopy, distract under fluoroscopy to confirm reducibility, may need to extend screws up to T11, TLIF with expandable cage at L4-5 and possible L3-4, perform pedicle subtraction osteotomy at L3-4 as needed, assess if correction is acceptable based on AP and lateral x-rays with distraction on the right-sided screws and compression on the left-sided screws, insert expandable cases, shape rods, rotate the rods to distract and reduce lordosis and translation into acceptable position, tighten screws and remove distractor and compressor, consider connectors, add bone grafts to all fused levels, layered closure Position prone after IOM, midline posterior incision, enter through fascia paraspinally down to laminas from T10-S2, dissect all the way lateral to find transverse process for each level, posterior column osteotomies and partial facetectomies to release spina and better visualization of anatomical landmarks, pedicle screw placement from T10-pelvis with S2 alar-iliac screws, sublaminar decompression at appropriate levels using osteotome and Kerrison rongeur, TLIF at L5-S1 and L4-5 from left side, x-rays to evaluate alignment, contour rods for correction of sagittal and coronal alignment, x-rays to confirm alignment, segmental compression and distraction at appropriate levels for correction of coronal and sagittal deformity, decorticate posterior element with osteotome/bur/Leksell, bone graft over decorticated area, place drains, layered closure

  • Stage 1: right decubitus position, check levels with fluoroscopy marking L2-5 vertebral bodies, 7–10 cm incision 6 cm anterior vertebral marking, dissect abdominal muscles and expose retroperitoneal space, retract psoas and expose L2-3 to L4-5 discs, curettage each disc, insert lateral lumbar interbody cage with graft bone, closure with drain

  • Stage 2: 3–7 after stage 1, prone position, midline longitudinal incision from T10-sacrum, expose facets from T10-sacrum, posterior release by fascectomy, T10 transverse hooks, T11-S1 pedicle and iliac screws, left L5 root exposure if pain not improved following stage 1, polyester tape reinforcement if osteoporotic, prebending rod set up by cantilever technique assisting correction device from left T10 hook to left iliac screw, correction with derotation technique, compress between screws, right rod in situ is set up after left corrected rod placed, decorticate lamina and facets, bone tip from fascectomy and hydroxyapatite granule graft is placed, closure with drain

Conscious sedation, position prone on Jackson with Wilson frame, AP fluoroscopy to determine trajectory and entry point usually 10–14 cm from midline, spinal needle to access Kambin triangle, interchange with nitinol wire and then sequential dilation, dock onto superior articular process with AP and lateral fluoroscopy, passage of endoscope, foraminal and lateral recess decompression with endoscopic drill and rongeurs, done while under constant antibiotic irrigation, single-layer tissue closure
Complication avoidance Distract under fluoroscopy to confirm reducibility, perform pedicle subtraction osteotomy as needed, correct coronal deformity with compression on one side and distraction on another Early posterior column osteotomies and partial facetectomies to release spina and better visualization of anatomical landmarks, surgical navigation if available, TLIF for anterior column support and fusion, segmental compression and distraction at appropriate levels for correction of coronal and sagittal deformity OLIF at three levels during first stage, retroperitoneal approach, stages separated by 3–7 days, reevaluate L5 pain after stage 1, polyester tape if osteoporotic, prebending rod with cantilever technique, derotation technique Conscious sedation to assess dorsal root ganglion irritation, constant AP and lateral fluoroscopy
Postoperative
Admission Floor ICU Floor Floor
Postoperative complications feared CSF leak, neurological injury, vascular injury, wound infection CSF leak, lower extremity weakness, infection

  • Stage 1: injury to intestines, ureters, or vasculature

  • Stage 2: CSF leak, pedicle screw malposition, pedicle fracture

Failure to improve, DRG/nerve root injury
Anticipated length of stay 3–6 days 5–7 days 2–3 weeks 4 hours
Follow-up testing

  • L-spine x-rays 2 weeks, 1 month, every 3 months for 1–2 years after surgery

  • CT L-spine 3 months after surgery

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

  • CT 7 days and 6 months after surgery

  • Bending x-rays 6 months after surgery

Physical therapy as needed
Bracing None None Hard corset for 6 months None
Follow-up visits 2 weeks, every 3 months for 1–2 years after surgery 3 weeks, 3 months, 6 months, 12 months after surgery after surgery 4 weeks after surgery 2 and 6 weeks 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; MIS , minimally invasive surgery; MRI , magnetic resonance imaging; OLIF , oblique lateral interbody fusion; PA , posteroanterior; SI , sacroiliac; SSEP , somatosensory evoked potential; TLIF , transforaminal lumbar interbody fusion.

Differential diagnosis

  • ▪

    Lumbar stenosis

  • ▪

    Lumbar foraminal stenosis

  • ▪

    Peripheral neuropathy

  • ▪

    Adult degenerative scoliosis

  • ▪

    Iatrogenic scoliosis

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