A 23 year old female presented with Progressive Idiopathic Scoliosis with extreme pain. She would require a posterior spinal fusion from T4 to L2.

1. Case Review:
31°
23 year old female with Progressive
Adult Idiopathic Scoliosis, double
thoracic curvature
43°
24°
Robert S Pashman, MD
Scoliosis and Spinal Deformity Surgery
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2. Patient History
23 year old female.
Upper thoracic and thoracolumbar curve with a
lumbosacral transitional vertebra.
Patient also has spina bifida occulta distally in the
lumbar spine.
Thoracic curve 31°.
Thoracolumbar curve progressed from 38° to 43°.
Compensatory curve 24°.
Patient was a ballerina at one time. Therefore, we will
get a CT scan of her lower lumbar spine to rule out the
possibility of her having a pars fracture at the transitional
vertebra, which is distal.
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3. Progressive Curvature
The patient’s curvature progressed
5° over a six month period.
31°
She has a significant
thoracolumbar curve of 43°, with
38° 43° sharp angular apical segment at
T11-T12. The patient has
unremitting low back pain,
24° discomfort, imbalance in the frontal
and sagittal plane, and wishes
surgical stabilization.
Sept, 2007 March, 2008 www.eSpine.com

4. Pre-op X-rays
The patient has a 31° upper
thoracic curve, a 43°
thoracolumbar curve, and a
31°
compensatory 24° curve.
Her sagittal balance is
negative, and she has
43° significant hyperlumbar
lordosis. This is not the issue.
24°
Due to the hyperlumbar lordosis, the patient’s
Hyperlumbar head is not balanced over her body.
lordosis
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5. Bending X-rays
On side bending to the right, her
L thoracolumbar curve is significantly R
flexible. She has a 6th lumbar
vertebra with L5-S1, which is not well
seated in the lumbar spine, and it is
also noted on left side bending that
the patient has significant flexibility of
her lumbar curve with straightening of
2 to the left of the mid plum.
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6. Bending X-rays
L R
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7. Indications for Surgery
1. Type III CN progressive 43° thoracolumbar Adult
Idiopathic Scoliosis.
2. Progressive increasing low back pain.
3. Failed conservative therapy.
4. Significant rotation, with cosmetic deformity due to rib
hump.
5. Spina bifida occulta and possible anatomic anomaly.
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8. Surgical Strategy
The strategy would be from T4 down to L2. The T4 level is because
of the depression of the right shoulder and the structural nature of
the proximal curve, and the L2 vertebra is because on side bending,
the patient horizontalized L2 over the mid sacrum and L3 is
neutrally rotated.
Segmental spinal instrumentation using CD Legacy 1/4-inch 5.5
stainless steel rod-screw construct from T4-L2. This would be a 10-
level instrumented fusion.
Posterior spinal fusion, T4-L2, using locally harvested autogenous
bone and RH BMP.
Apical spinal osteotomy, Smith-Peterson radical osteotomy, T9-T10,
T10-T11, T11-T12, T12-L1.
Intralaminar decompression for lateral recess stenosis, T12-L1, L1-
L2 bilaterally.
Intraoperative SSEP motor evoked potential analysis.
Intraoperative fluoro.
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9. Post-Op Films
Moderately flexible
thoracolumbar curve. After
the osteotomy, the curve was
highly reducible. There was
significant residual rotation at
the distal L2.
The patient is balanced in
both the frontal and sagittal
planes.
Frontal plane
Sagittal plane
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10. Pre-Op/Post-op Comparison
31°
The patient’s curve was corrected
43° 14° from 43° to 14°. She is balanced
in the frontal plane, and her rib
hump was reduced, and her
24° shoulders are now even.
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11. Pre-Op/Post-op Comparison
The patient’s hyperlumbar
lordosis has been
corrected, and her sagittal
alignment has been
restored. Her head is now
directly over her body.
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