48 year old female presented to Dr. Pashman with a long history of low back pain. The patient had been treated with a microdiscectomy, epidurals, physical therapy, and medication. The patient was treated with a spinal fusion.

1. Case Review:
48 year old female
presented with progressive
Adult Idiopathic Scoliosis.
60°
Robert S Pashman, MD
Scoliosis and Spinal Deformity Surgery
www.eSpine.com

2. Patient History
• 48-year-old female
• Progressive Adult Idiopathic Scoliosis
• The patient has a long history of low back pain and is status post
microdiskectomy at L4-5 in 2003 after motor vehicle accident.
• The patient has exhausted physical therapy, epidurals, and has
taken anti-inflammatory medications.
• The patient is very active and fit.

3. Pre-op X-rays
The x-rays show that the patient has a
60° left lumbar curve with marked
rotation. She has severe degeneration of
the lumbosacral joint, L4-L5 is
significantly tilted and out of plane. The
patient has a compensatory upper
thoracic curve. The patient has severe
60° thoracolumbar kyphosis measured at
greater than 40°; this should be 0°. This
has caused significant forward
decompensation and hyperlordosis of
the lumbar spine which has led to
advanced degeneration.

4. Indications for Surgery
1. Kim/SRP type 3 progressive adult idiopathic scoliosis with
large lumbar rotated curve.
2. Sixth lumbosacral obliquity with severe degeneration.
3. Isthmic spondylolisthesis at L5-S1 with either bilateral or
unilateral pars and articularis fractures.
4. Gross instability of lumbar spine due to the above factors plus
status post micro decompression L4-5.
5. Now with unremitting low back and leg pain due to greater than
50 degree rotated lumbar curve and fixed thoracic component
including thoracolumbar kyphosis.

5. Surgical Strategy – Stage 1
• Abdominal retroperitoneal approach to the lumbosacral spine.
• Radical diskectomy L5-S1 with subtotal vertebrectomy of L5 to allow
entrance into L5-S1 space for reduction and fusion of interbody L4-S1.
• Interbody fusion after removal of disk herniation under loop and high
intensity light illumination for placement of a PEEK 8 mm device with
autogenous and putty bone centrally, and fully threaded screw over a
washer.
• Radical diskectomy L4-5 with correction of coronal plane
decompensation L4-5.
• Placement of PEEK device with autogenous bone and allograft at L4-5.
• Anterior screw fixation L4-5 and L5-S1.
• Intraoperative use of fluoro.

6. Indications for Surgery
1. KIM/SRP type 3 thoracolumbar progressive adult idiopathic
scoliosis, 65 degrees.
2. Thoracolumbar kyphosis.
3. Status post anterior interbody fusion, L5-S1, L4-5 for
horizontalization of index lumbosacral curve.
4. Progressive radiculopathy and pain due to collapsing scoliosis,
coronal and sagittal decompensation.
5. Status post hemilaminectomy, L4-5.
6. Failed conservative therapy.

7. Surgical Strategy - Stage 2
• T10-pelvis instrumentation using ¼ inch stainless steel pedicle
screw/rod construct.
• Posterior spinal fusion, T2 - sacral pelvis using locally- harvested
autogenous bone and allograft bone in a bone mill.
• Interlaminar decompression, reexploration decompression under
high- loupe magnification, L4-5, L5-S1.
• Multiple-level spinal osteotomy, Smith-Peterson osteotomy, for
recontouring, thoracolumbar kyphosis, T12-L1, L1-L2, L2-L3, L4-L5
with bilateral facetectomy and mobilization.
• Intraoperative O-arm neuronavigation.
• Intraoperative somatosensory evoked potential motor evoked
potential use.
• Plastic closure of wound.

8. Post-op Films
• The patient's plumb line
improved post-operatively.
• Her sagittal plane is perfect.
• All the instrumentation looks
great.

9. Pre-Op/Post-op Comparison
60°