Case Review #31: 60 Year Old Female with Adult Idiopathic Scoliosis
Case Review:60 year old female, withAdult Idiopathic Scoliosisand Grade 2 IsthmicSpondylolisthesisRobert S Pashman, MDScoliosis and Spinal Deformity Surgerywww.eSpine.com
Patient History & Pre-op X-rays 60-year-old female Kim/SRP type 3 curved thoracic lumbar Grade 2 Isthmic Spondylolisthesis of L5-S1. The patient has significant lumbosacral obliquity.
Indications for Surgery1. Kim/SRP type 3 adult idiopathic scoliosis.2. Grade 2 isthmic spondylolisthesis L5-S1.3. Severe frontal and sagittal plane decompensation of thoracolumbar spine.4. Osteopenia of thoracolumbar spine.5. Failed conservative therapy with low back and leg pain.
Surgical StrategyAn anterior interbody fusion is indicated for the followingreasons: 1) spondylolisthesis, 2) there is significant rotation andcurvature, 3) the frontal and sagittal plane decompensation, 4)and the need for horizontalization of the primary L4-5 and L5-S1 interspace to gain posterior coronal balance.Characteristic of the KIM 3 SRP classification, the patient willneed T3 to sacral pelvic fixation. Bilateral fixation is necessarybecause of the high instability with the isthmic spondylolisthesis.The patient has multiple challenges including some pulmonarydisease as well as osteopenia. The instability and progressivecurvature which is greater than 80 degrees, thoracic lumbar withsignificant degeneration, facet arthropathy necessitatesosteotomy at multiple levels to induce flexibility of the spine toguarantee sagittal and coronal plane balance.
Surgical Strategy – Stage 1Subtotal vertebrectomy L5 for introduction of anterior lumbarinterbody fusion graft L5-S1.Interbody complete evacuation of disk and diskectomy L5-S1.Radical diskectomy L4-5.Interbody fusion L4-5, L5-S1 with polyetheretherketone deviceAlphatec 8-mm with allograft and recombinant human bonemorphogenetic protein centrally.Anterior screw fixation L4-5, L5-S1.Intraoperative fluoroscopic control.
Surgical Strategy – Stage 2Segmental spinal instrumentation, T3, to the sacral pelvis using titaniumscrew, cobalt chrome instrumentation.Sacral pelvic fixation, bilaterally, through separate incisions.Posterior spinal fusion, T3 to the sacral pelvis, using locally- harvestedautogenous bone and allograft putty.Spinal osteotomy, Smith-Peterson osteotomy T12-L1, L1-2, L2-3, L3- 4,L4-5.Bilateral neural foraminotomy with complete facetectomy and a lateralrecess decompression, L1-2, L2-3, L3-4, L4-5 using high- intensityillumination.Reduction spondylolisthesis, L5-S1, using a reduction screw, pediclescrew, and sacropelvic fixation of grade 2 isthmic spondylolisthesis.Intraoperative somatosensory-evoked potential and motor-evokedpotential processing.Neuro-navigation with stealth/O-arm intraoperative navigation.Plastic closure of wound.
Post-Op Films The patient is well balanced in the sagittal and coronal plane. She gained approximately 2 inches in height, and is thrilled with her outcome.