Case #1: Adult Idiopathic Scoliosis

Expert Resources for Orthopedic and Neurological Surgeons

Case #1: Adult Idiopathic Scoliosis

AUTHOR:

Lawrence G. Lenke, MD

Professor of Orthopedic Surgery;
Chief, Division of Spinal Surgery
Director, Spinal Deformity Surgery
Co-Director, Adult and Pediatric Comprehensive Spine Surgery Fellowship
Columbia University Dept. of Orthopedic Surgery
Surgeon-in-Chief, The Spine Hospital, New York-Presbyterian/Allen, New York, NY USA

HISTORY AND EXAM:

64 y/o Female with longstanding idiopathic thoracic and lumbar scoliosis and degenerative changes throughout her lumbar spine. She has primarily back symptomatology and progressive deformity, no formal leg pain. She is healthy, a non-smoker.On examination, she is a well-developed, well-nourished, thin female who is 5 feet 5 inches tall and 117 lbs. in weight. She has an obvious double major deformity with good coronal balance and slight sagittal imbalance since she is flat in her sagittal plane. She has good motion to her hips and knees. She certainly looks better prone than when upright. She has a normal dynamic and static neurologic exam, including motor, sensory, and reflex of her upper and lower extremities. Pulmonary function (FVC/FEV-1) is diminished at 48%/55%.

IMAGING:

The upright AP X-ray (Fig. 1) of her spine, shows a 29 degree proximal thoracic, 59 degree main thoracic, and 63 degree lumbar deformity. Supine and push prone x-rays (Figs. 2,3) show that she has some flexibility in those curves. On her lateral x-ray, (Fig. 4) she has only 7 degrees of overall thoracic kyphosis, -42 degrees of lumbar lordosis with a high pelvic incidence of 84 and a tilt of 37. Full length EOS x-rays show good overall coronal balance (Fig. 5) and mild sagittal imbalance (Fig. 6) due to her lack of thoracic kyphosis. She has multilevel degeneration on her MRI (Fig. 7a) and some lateral recess stenosis at L3-4 (Fig. 7b) at the site of her rotatory subluxation. Her clinical photos (Figs. 8-9) show an obvious double major deformity with good coronal balance and slight sagittal imbalance since she is flat in her sagittal plane.

(Click to view images larger)

DIAGNOSIS:

Adult idiopathic scoliosis, flattened sagittal plane, multi-level lumbar degeneration and spinal stenosis at L3-4.

SURGICAL PROCEDURE:

PSF T4-Sac/Ilium with TLIFs at L4-5 and L5-S1, PCOs (Posterior Column Osteotomies) T11-L4 and T6-T9.

OUTCOME:

Excellent. Patient very pleased with her improved alignment, as seen on her postoperative x-rays (Figs. 10, 11) and clinical photos (Figs. 12, 13).

(Click to view images larger)

DISCUSSION:

Following the preparation for the TLIFs at L4-5 and L5-S1, there was a decrease in the TCMEPs of the L4 and L5 roots bilaterally requiring additional decompression due to the marked malalignment of L3-L5, which was relieved by additional laminectomies of L3-L5. Her data returned to baseline and remained stable thru the rest of the procedure. She has bilateral S2AI screws into her ilium along with the additional left-sided iliac screw attached to the “kick stand” rod. We utilized a left-sided additional Lumbar-iliac “Kick Stand” rod to help correct the severe, stiff fractional lumbosacral curve. She awoke neurologically intact and remained so throughout the hospital course.Her postoperative course was unremarkable, she spent 1 night in the ICU, and then went to our spine care floor where she began mobilizing on POD #1 and stayed in the hospital for 5 days, going directly home following her hospitalization.