The Spine Journal 7 (2007) 428–436                                                                Review Article          ...
A. Ploumis et al. / The Spine Journal 7 (2007) 428–436                                  429degenerative scoliosis. The adj...
430                                       A. Ploumis et al. / The Spine Journal 7 (2007) 428–436diverging; that means righ...
A. Ploumis et al. / The Spine Journal 7 (2007) 428–436                                               431the size of the ca...
432                                                 A. Ploumis et al. / The Spine Journal 7 (2007) 428–436horizontal dista...
A. Ploumis et al. / The Spine Journal 7 (2007) 428–436                                   433                              ...
434                                              A. Ploumis et al. / The Spine Journal 7 (2007) 428–436Fig. 3. (A) Anterop...
A. Ploumis et al. / The Spine Journal 7 (2007) 428–436                                              435Table 2            ...
436                                                 A. Ploumis et al. / The Spine Journal 7 (2007) 428–436[12] Murata Y, T...
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  1. 1. The Spine Journal 7 (2007) 428–436 Review Article Degenerative lumbar scoliosis associated with spinal stenosis Avraam Ploumis, MD*, Ensor E. Transfledt, MD, Francis Denis, MD Twin Cities Spine Center, 913E 26th Street, Minneapolis, MN 55404 USA Received 16 March 2006; accepted 29 July 2006Abstract BACKGROUND CONTEXT: Degenerative de novo scoliosis is commonly present in older adult patients with spinal pain. The degenerative process including disc bulging, facet arthritis, and lig- amentum flavum hypertrophy contributes to the appearance of symptoms of spinal stenosis in these patients. PURPOSE: The etiology, prevalence, biomechanics, classification, symptomatology, and treat- ment of degenerative lumbar scoliosis in association with spinal stenosis are reviewed. STUDY DESIGN: Review study. METHODS: Retrospective analysis of studies focused on all parameters concerning degenerative scoliosis associated with stenosis. RESULTS: There is a variety of treatment methods of degenerative scoliosis based on symptom- atology and radiologic measurements of scoliosis and stenosis. Satisfactory clinical results reported in relevant retrospective studies after operative treatment range from 83% to 96% but with increased percentage of complications. An algorithm for operative treatment corresponding to a newly pro- posed classification system of degenerative lumbar scoliosis with associated canal stenosis is presented. CONCLUSIONS: There is an increasing prevalence of degenerative scoliosis in the aged popula- tion. Even though the exact percentage of patients with symptomatology of spinal stenosis is not known, the main goal is to provide pain relief and improved functional lifestyle with minimum intervention. Ó 2007 Elsevier Inc. All rights reserved.Keywords: Degenerative scoliosis; Spinal stenosis; Decompression; FusionIntroduction consisting of axial rotation on the vertical axis, lateral translation toward the convexity of the curve, and anterior Adult scoliosis is defined any curvature of the spine translation in the sagittal axis. Trammell et al. [4] originallymore than 10 in a skeletally mature individual. The term described rotatory olisthesis as the apparent lateral sublux-degenerative de novo scoliosis (DDS) refers to scoliotic ation of one vertebral body upon another seen in the ante-curves developing after skeletal maturity without previous roposterior films. Other terms used in the past for the samehistory of scoliosis. Scoliosis occurs de novo in later life pathology are lateral spondylolisthesis, translatory shift,and is associated not only with severe back or leg pain lateral olisthesis, and lateral subluxation. It occurs most fre-but also with complicated surgical outcomes [1]. quently at the L3–L4 level, in women, and increases with Degenerative spondylolisthesis is very common in cases age and magnitude of the curve.of degenerative scoliosis. In a study of patients with degen- Lumbar spinal stenosis is a common problem in the oldererative scoliosis, 55% of them had additional degenerative adult population. It is defined as a pathologic conditionspondylolisthesis [2]. Rotatory olisthesis coexists in 13% to in which the neural elements are compressed by bone, soft34% of adult scoliosis cases [3,4]. It is a triaxial deformity tissue, or both resulting in ischemia of nerve roots [5]. It is distinguished in central stenosis, when there is abnormal FDA device/drug status: not applicable. narrowing of the spinal canal, and lateral stenosis, when Nothing of value received from a commercial entity related to this there is lateral recess (subarticular stenosis) or foraminalmanuscript. * Corresponding author. Twin Cities Spine Center, 913 E 26th Street, (foraminal stenosis) narrowing [6]. Symptoms of neuro-Minneapolis, MN 55404. Tel.: (612) 775-6200; fax: (612) 775-6222. genic claudication and radiculopathy predominate. Fre- E-mail address: (A. Ploumis) quently, it is accompanied by degenerative olisthesis and1529-9430/07/$ – see front matter Ó 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.spinee.2006.07.015
  2. 2. A. Ploumis et al. / The Spine Journal 7 (2007) 428–436 429degenerative scoliosis. The adjuvant scoliosis complicates facet joints lack the second most significant factor of inter-neural compression and makes surgical treatment more dif- vertebral stability in the horizontal anteroposterior Z andficult [7]. longitudinal vertical Y axis of the global reference system. Aging affects bony structures, discs, ligaments, facet Therefore, the vertebra above in the spinal unit progressjoints, and muscles. This causes wedging of both vertebral gradually to forward olisthesis and rotation that leads tobodies and discs and may ultimately lead to a domino-like rotatory scoliosis and stenotic symptoms caused by theeffect of rotation and translation into the upper lumbar and kinking of the neural elements by the malrotated pediclessometimes thoracolumbar spine. Degenerative scoliosis, [13–15].reduced lumbar lordosis, and neural element compressionis the final end result. Also, the combination of ligamentumflavum hypertrophy, facet hypertrophy, disc collapse, and Prevalence and natural historyolisthesis cause neural compression. The prevalence of degenerative scoliosis is reported to The purpose of this article is the in-depth analysis of be from 6% to 68% [8,11,16,17] and increases with agedegenerative scoliosis associated with symptoms of canal [2]. Pritchett and Bortel [2] studied 200 patients more thanstenosis. A comprehensive and simple classification system 50 years old (70% women) with late-onset scoliosis. Theywith corresponding algorithm for operative treatment for found that most of the lumbar degenerative curves did notdegenerative lumbar scoliosis associated with spinal steno- exceed 60 and progressed an average 3 per year. Factorssis is presented. for curve progression were Nash- Moe grade 3 apical rota- tion, a Cobb angle more than 30 , lateral vertebral transla- tion of 6 mm or more, and the prominence of the L5Etiology vertebra in relation to the intercrest line. On the contrary, Murata et al. [12] showed in the early phase of degenerative Decreased bone density was initially considered to be curves they might also regress after consequential wedgingthe cause of degenerative scoliosis [8,9], but this has in the disc space or the vertebral bodies for compensatingchanged after finding that no significant difference exists the bone density between patients with degenerative sco- The mean age of patients with degenerative scoliosisliosis and patients with adolescent scoliosis of the adult was less than 60 years in 38% of Perennnu’s study and[10]. Actually, degenerative changes, especially of the disc, 33% in Kostuik’s study, whereas 41% of scoliotic patientsvertebral body wedging, and facet joint arthrosis are were younger than 64 years old in Robin’s study. In Tram-responsible for the appearance of ‘‘de novo’’ scoliosis and mell’s study, the average age of patients with rotatory sco-degenerative rotatory scoliosis [11,12]. liosis was 41 years. Right-sided degenerative scolioses A cadaver study of 19 lumbar spines with degenerative worsen with aging twice as much than left-sided scoliosisolisthesis without scoliosis showed it was mostly associated [3,17]. This is associated also with deterioration of rotaryto disc degeneration and osteophytosis of apophyseal joints olisthesis.and less to fractured endplates. The joint capsules become There are no studies estimating what percentage of pa-attenuated as a new false articular surface is created on the tients with degenerative scoliosis will need evaluation andlamina next to the inferior articular process. In the same treatment for their symptoms, axial back pain, or symptom-study, canal constriction was not found because of olisthe- atology of spinal stenosis. It is also unknown what is thesis, but this was without acknowledging the possible steno- natural history of these symptoms without treatment. How-sis of soft tissues (ligamentum flavum, facet capsules, and ever, the symptoms of spinal stenosis irrespective of scoli-so on) [13]. osis have been found to be improving over time in 15% of Kobayashi et al. [11] studied the prevalence of degener- cases, deteriorating during the initial 2 to 3 yeas of follow-ative de novo scoliosis in normal-aged people and con- up requiring surgical intervention in 40% of the patientscluded that more than 5 mm lateral osteophyte of an and maintaining their status over long-term in the restendplate or more than 3 asymmetric tilt of a disc space 45% of the cases [6,18].are risk factors for development of degenerative scoliosis.This confirms the notion that degenerative scoliosis startsas disc degeneration [11,12]. Biomechanics In addition, aging may induce ‘‘degenerative myopathy’’leading to rupture of the equilibrium and kyphotic deforma- It is known that the kinematics and the coupling patterntion of the spine. Repetitive torsional loads may progres- are different from one spinal region to another. The cou-sively provoke rotational deformation of the posterior pling pattern of lateral bending and axial rotation is con-vertebral elements and lead to degenerative rotatory scolio- verging in the lumbosacral junction meaning that rightsis [14]. lateral bending coincides with right axial rotation of L5 Iatrogenic instability caused by iatrogenic facetectomies vertebra on the sacrum. However, in the lumbar spine, theis another cause of rotary olisthesis. The vertebrae without coupling pattern of lateral flexion and axial rotation is
  3. 3. 430 A. Ploumis et al. / The Spine Journal 7 (2007) 428–436diverging; that means right axial rotation results in left lat- pain and degenerative rotatory olisthesis especially at L3–eral bending [19,20]. L4 and L4–L5 levels. However, the mean age of patients In scoliosis, thoracic spine motion is balanced but the was 62 years in Perennou’s study and 23 years in Tram-coupling mechanism is abnormal. Instead of axial rotation mel’s be toward the concavity, it is occurs into the convexity Velis and Thorne [30] and Kostuik et al. [31] describedof the curve [21]. It is unknown what the etiology is of this lateral olisthesis as an important prognostic factor for theabnormal coupling motion pattern. development of back pain and curve deterioration after On the contrary, Veldhuizen and Scholten [15] found skeletal maturity. Scwab et al. [32] comparing radiographicthat the coupling mechanism of axial rotation and lateral parameters with VAS scores in adult scoliotic patientsbending does not differ in normal and scoliotic spines. found that pain correlates with L3 and/or L4 obliquity, lat-However, they supported that there exists a special coupling eral rotatory olisthesis, lumbar lordosis, and thoracolumbarmechanism between sagittal plane motion and axial rota- kyphosis. Curve magnitude and number of levels involvedtion in the scoliotic spine. in the curvature were unrelated to pain. Degenerative insta- Disc and facet degeneration leads to increased axial bility is the cause of pain and a common pathway in therotation of the functional spinal unit. The increase in axial progression of all types of adult scolioses.rotation caused by spinal degeneration was more pro- The etiology of the pain might be mechanical or neuro-nounced than the increase of motion in flexion-extension genic [33]. Commonly, mechanical back pain presents in[20]. Degenerative scoliosis is also followed by decreased cases with longstanding idiopathic scoliosis. It appears withlumbar lordosis and, subsequently, low back pain [2,12]. muscle pain because of fatigue of spinal muscles (along the There have been described various methods for determi- whole length of the spine and specifically in the convexnation of vertebral rotation [22–24]. The most widely used side of the curve) and is attributed to the loss of lumbar lor-method of radiographic determination of vertebral rotation dosis. The pain in the concavity of the scoliosis is causedis the pedicle method (grade 0–IV) introduced by Nash and by facet arthritis and degenerative changes of the discMoe [22]. Grade 0 defines the neutral vertebra when there spaces (disc changes, ligament tension and tears, spurs,is no asymmetry between the anteroposterior pedicle pro- and so on).jection in the convex and the concave side. Grade IV is The sagittal gravity line passes in front of the S1 verte-the total disappearance of the pedicle in the concave side, bral body and back musculature is over functioning forwhereas the pedicle on the convex side migrates past keeping an upright position. The notion that clinical symp-midline. toms of back pain increase linearly with the degree of positive sagittal imbalance is supported by the findings of Glassman et al. [34] in a retrospective review of 752Clinical presentation patients with adult scoliosis. The incidence of low back pain in patients with degener- Neurogenic pain is mainly a feature of patients with deative scoliosis is not significantly more common than in the novo scoliosis. It is possible, although, to be present ingeneral population. Paraspinal muscle electrodiagnostic ex- cases of adult idiopathic scoliosis. Neurogenic pain isamination has helped to define the association between radio- caused by either foraminal nerve root or dorsal root gaglionlogical spinal stenosis and back pain [25]. Lumbar scoliosis compression (concave side of the curve) or central spinalwith degenerative changes most prominent at the scoliotic stenosis leading to neurogenic claudication.apex can produce lumbar stenosis resulting in disabling It is imperative to distinguish the neurogenic claudica-low back pain and leg pain in a neurogenic claudication mode tion symptoms from the pain caused from vascular claudi-[26]. However, sometimes leg symptoms appear from the cation. The pain in neurgenic claudication is reduced if thecontralateral side because of the lumbosacral curve [27,28]. patient acquires a forward flexed (like bicycling) or sittingLiu et al. [29], in their study of patients with degenerative position. The pain in vascular claudication is relieved bylumbar scoliosis and stenosis, concluded that L3 and L4 standing still and accompanied with peripheral vascularnerve roots are compressed in the foramen or extraforami- loss and skin changes.nally on the concave side of the main curve, whereas the The accompanying medical comorbidities in these el-L5 and S1 roots are affected more by lateral recess stenosis derly patients should not be overlooked. It should be keptat the convex of the lumbosacral fractional curve. in mind that the patient is being operated on is a whole per- However, rotatory olisthesis does correlate with back son, not just a spine. Keeping the surgical intervention aspain associated with idiopathic scoliosis. It is significantly minimal as possible should be the ideal goal.associated with increasing age and magnitude of the curve[4]. Smaller Cobb angles and lateral and rotatory olisthesis Lumbar spinal stenosisare more frequently seen in degenerative scoliosis than inadult idiopathic scoliosis. Spinal stenosis is the narrowing of the spinal canal and can On the contrary, Perennou et al. [3] showed that there is be local, segmental, or generalized. It is divided into the con-definitely correlation between anterior femoral radicular strictive stenosis caused by bony or ligamentous reduction in
  4. 4. A. Ploumis et al. / The Spine Journal 7 (2007) 428–436 431the size of the canal and the restrictive stenosis, which is at- nerve roots because of vertebral rotation and subluxation.tributed to intracanal fibrosis (i.e., arachnoiditis) restricting Additionally, hypertrophy of ligamentum flavum, discthe mobility of neural elements [35]. Usually, it is acquired degeneration and protrusion, facet joint osteophytosis, andas in degenerative diseases or spondylolisthesis and less com- cysts of the facet joints are significantly decreasing themonly is congenital. The degenerative disease of the spine functional capacity of the spinal canal.leads to constrictive-compressive type stenosis. It reducessubstantially the spinal reserve capacity; this is the ratio Classificationbetween the horizontal distance of posterior middle of thelamina from the posterior end of the vertebral body and the The only classification system that exists for degenera-anteroposterior diameter of neural canal measured in CT tive lumbar scoliosis addresses only the existence of rota-transverse sections. Spinal reserve capacity is actually a func- tion or/and lumbar lordosis loss. It does not includetional factor of spinal canal and is better than other static rotatory olisthesis or stenosis. Simmons characterized asmeasurements like the AP canal diameter [35]. It is com- type I the degenerative scoliosis with no or minimal rota-monly admitted that absolute stenosis exist when AP canal tion, whereas type II was defined as the degenerative scoli-diameter is less than 11 mm [36]. However, the use of subjec- osis with rotational deformity and reduced lumbar lordosistive criteria to characterize spinal stenosis by radiologists and [1,43,44].relevant clinical physicians (spine surgeons, neurologists, Schwab et al. [32] recently published a classification ofand physiatrists) led to high variability of results for the same adult scoliosis based on radiographic measurements inpatients [37]. Radiologists specialized in spine imaging sub- anteroposterior and lateral standing radiographs. Theyjectively grade the stenosis as mild, moderate, and severe, measured the lordosis L1–S1 and the obliquity of L3 verte-according to the degree. bral body and divided the population in three types of The criteria for central and lateral stenosis are difficult to severity with decreasing lordosis and increasing L3define. Verbiest [38] was the first to introduce the terms of obliquity [32].absolute and relative value of spinal stenosis. The shape of There is need for a classification system that it will ad-the spinal canal, the facet joints, and the measured spinal dress the segmental type of deformity, the sagittal spinaldimensions (interpedicular distance, sagittal diameter of contour, and the symptomatology. The proposed classifica-the dural sac, and pedicle length) are some of the measure- tion system is shown in the Table 1. However, the validityments evaluating spinal stenosis [39]. Hypertrophy of the and reliability of this system are still under investigation,ascending facet is the main cause of lateral stenosis [7]. and this is a best-guess approach based on our experience.Biomechanical studies of the foramen of the lumbar spineproved that during flexion and contralateral lateral bending Radiographic evaluationof the spine the foraminal cross sectional area increases,whereas in extension or ipsilateral lateral bending the Plain full-spine standing AP and lateral radiographs areforaminal area decreases. Distraction may increase the fo- necessary to evaluate case of degenerative scoliosis associ-raminal height, but the osteophytic changes continue to ap- ated with rotary olisthesis. In the coronal plane, useful pa-ply pressure to the nerves in the stenotic foramen [40]. In rameters are the following: 1) C7PL (plumbline from thehistologic studies of the neural foramen, it was found that center of C7 vertebral body) horizontal distance fromthe nerve root and ganglion are within the upper pole of CSVL (central sacral line), 2) scoliosis Cobb angle (major,the foramen above the disc and never occupy more than hemicurve, and proximal thoracic), 3) proximal stable and35% of the cross-sectional area. In foraminal morphometric distal stable vertebra of the major curve, 4) L3 endplatestudies of cadaveric spines, it was found that the foramen obliquity, 5) L4 endplate obliquity, 6) maximal lateral olis-have variable size between 40 and 160 mm2 and defined thesis (mm), and 7) maximal vertebral rotation (Nash-Moethe normal limits of foraminal cross-sectional area in the grades).sagittal plane [41]. Measurement of vertebral foramina In the sagittal plane, parameters to be measured are theusing calipers is superior to that with CT scan [42]. following: 1) sagittal Cobb angle (thoracic [T1–T12], thor- Often, the radiological findings are more severe than the acolumbar [T10–L2],and lumbar [T12–S1], 2) PLC7-Spatients’ symptoms. Studies of patients with lumbar spinalstenosis have shown that there is no statistically significant Table 1correlation between the intensity of pain and the degree ofstenosis. Most commonly, the radiologic image of stenosis Type I: minimal or no rotation Type II: rotatory olisthesis (intersegmental rotation and translation)was more extensive than expected from the clinical picture Type III: rotatory olisthesis and structural coronal (O4cm distance from C7[39]. Therefore, spinal stenosis can be either radiographic- plumbline) or positive sagittal imbalance (O2cm from anterior sacralonly spinal stenosis or symptomatic spinal stenosis with corner)a combination of clinical and radiographic characteristics. A: back pain without radicular sx It is mentioned earlier in the etiology of rotatory scolio- B: sciatic pain (from the lumbosacral hemicurve) 6back pain C: femoral pain (from the major curve) 6back painsis that there is compression of the dura and traction of the
  5. 5. 432 A. Ploumis et al. / The Spine Journal 7 (2007) 428–436horizontal distance of the C7 plumb line starting in the cen- Nonoperative treatmentter of C7 body and the anterosuperior corner of S1, 3) max- Requirement for surgical treatment of degenerative sco-imal anteroposterior olisthesis (mm), and 4) sagittal pelvic liosis is the application and failure of nonoperative treat-tilt index [32]. ment. The first step of pain management is the use of The most predictive radiologic parameters for the asso- nonsteroidal antiinflammatory drugs and nonnarcotic anal-ciate clinical presentation of the patients with adult scolio- gesics as well as the avoidance strenuous spinal motions. Asis are the upper endplate obliquities L3 and L4, lateral session of oral administration of methylprednizolone is pre-olisthesis, lumbar lordosis, and thoracolumbar kyphosis scribed in cases of acute onset severe pain. Tricyclic antide-[32]. The positive sagittal balance has been shown to corre-late statistically significantly with the clinical presentation, pressants (amitriptylin) and anticonvulsion (carbapentin) drugs are preserved for cases of chronic pain. In case ofpreoperatively and postoperatively [34]. symptoms persistence, the use of custom-made spine im- In order to assess the degree of spinal stenosis it is im- mobilization and vertebral joints’ injections follow. Epidu-perative to review a CT scan or MRI of the lumbar spine. ral steroid injections may provide short- or long-term reliefEspecially the T2 sequense of the MRI shows the size of of symptoms. They are performed mainly for radiculopathythe spinal canal and the existence or intrathecal fluid in but also for back pain with radiographic spinal stenosis.the transverse sections, whereas the patency of the foramen Translaminar injections should be done always under fluo-is better shown in the sagittal views. The myelography isnot used so often nowadays because of its side effects; how- roscopy in order to avoid missing the target. Transforaminal epidural injections are indicated for one-level stenosis withever, the CT myelogram gives a profound demonstration of unilateral symptoms and are certainly more selective to thethose levels with spinal stenosis (Figs. 1–3). location of spinal stenosis than translaminar injections. TheFig. 1. (A) Anteroposterior and (B) lateral view full spine of a patient with degenerative rotary scoliosis with the apex to the left. Note the lateral olisthesis atL2–L3 and L3–L4 and the positive sagittal imbalance.
  6. 6. A. Ploumis et al. / The Spine Journal 7 (2007) 428–436 433 the 3-year follow-up [46]. Furthermore, the systematic side effects (gastrointestinal, circulatory, haematological, and re- nal) from the prolonged use of nonsteroidal anti-inflamma- tory drugs should be kept in mind and their prescription be limited only for short-term use. Operative treatment All nonoperative ways of treatment should be exhausted before considering surgical treatment. The aim of the sur- gery is to decompress the comprised neural elements, in case of symptomatic spinal stenosis and to end with a bal- anced and stable spine in the coronal and sagittal plane, when there is imbalance. However, these patients are el- derly patients with other comorbidities, and surgical treat- ment should be performed in a safe and effective way. The ideal is to proceed with only the least aggressive pro- cedure, usually posterior only, that would involve both decompression and stabilization, if needed, of the spine. The most frequent indication of surgical treatment is pain [31,48,49]. However, the degree of any individual pa- tient is very objective and cannot be measured indepen- dently. Usually, the most important question that a patient has to answer is how much his/her symptoms affect his/ her life. The patients who present with back pain only should be warned that they would not be completely pain free, especially after a fusion surgery. Progressive neurologic deficit is another indication for surgery. Increasing leg weakness and paresthesias that are not caused by vascular pathology should make the surgeon to suspect spinal stenosis. Symptoms originating from spinal stenosis typically appear between the 5th and 7th decade of life (40–60 years) [50]. Blood loss should be controlled to minimum amounts. Finally, bone quality should be exam- ined before undertaking a surgical procedure, especially in aged patients, in case of instrumented fusion. Patients who present with symptoms of spinal stenosis and have degenerative scoliosis less than 20 and withoutFig. 2. Computed tomography myelogram transverse cuts at the (A) L3– instability could be treated with spinal decompression onlyL4 and (B) L4–L5 level showing the central and subarticular stenosis. [51]. Especially, male patients with large vertebral struc- tures and stabilizing osteophytes can tolerate more thantime delay between epidural injections should be at least 3 2-level laminectomy without fusion [52].weeks, and the total number of injections allowed is no more Otherwise, patients with degenerative scoliosis morethan three to four within 6- to 12-month interval. In a recent than 15 to 20 , lateral subluxation, or dynamic instabilityrandomized prospective study to assess the efficacy of epidu- should be treated with decompression and fusion. Simmonsral steroids injections versus intramuscular steroid and anes- selects different fusion strategies according to his classifica-thetic for patients with lumbar stenosis, it was found that even tion’s types of degenerative scoliosis. For type I, he prefersthough there was a significant reduction of pain in the short- the short instrumented fusions with distraction forces ap-term the long term results did not show any difference in the plied to the concavity of the curve in order to decompressnumber of patients that needed surgery [45]. Abdominal and the nerve roots. For type II, he prefers the long instrumen-back muscle strengthening together with swimming are tation and fusion with a derotation maneuver for scoliosisconsidered other methods of pain management [1,8,46,47]. reduction. In situ rod contouring into lordosis and proper The efficacy of nonoperative treatment (analgesics, exer- patient bed positioning are methods for restoring better me-cises, and steroid injections) was studied in 49 patients with chanical alignment and lordosis. A less extensive fusionradiographic and clinical spinal stenosis. Thirty-three (67%) surgery can be preferable even though the upper and lowerpatients showed mild or significant clinical improvement at end of the fusion are not parallel to the sacrum [53,54].
  7. 7. 434 A. Ploumis et al. / The Spine Journal 7 (2007) 428–436Fig. 3. (A) Anteroposterior and (B) lateral view full spine after anterior interbody fusion L1–L4, posterior decompression L3–L5, and posterior instrumentedfusion T9–S2. Pedicle screws are considered the most appropriate fixation with 44 months average follow-up treated with decompres-method for the aged osteoporotic bone with absent posterior sion and fusion. Eighty-three percent of the patients reportedelements after decompression [55]. In case of significant severe pain before surgery, and 93% reported mild or no paindecompensation in the sagittal and coronal plane, it is often postoperatively. Scoliosis was reduced from 37 to 18 at theimperative to extend the fusion to the sacrum. Additional fix- latest follow-up. Shapiro et al. [56] reported 94% satisfactionation points in the sacrum and the pelvis reduce the increased rate at 2 years postoperatively in 16 patients treated with an-strains to the implants and help the healing of the fusion. terior and posterior surgical reconstruction for adult idio- In Table 2, an algorithm of treatment of patients with de- pathic scoliosis and stenosis. The Oswestry Disability Indexgenerative scoliosis and stenosis is presented based on the improved from 44.3 and preoperatively to 26.4 at the most re-classification system presented in Table 1. An extensive cent follow-up, and the curve correction reached of our patients treated using the aforementioned algo- Hansraj et al. [51] in a study involving 47 patients with com-rithm is under publication and showed statistically signifi- plex lumbar stenosis only (without scoliosis) and decompres-cantly improved outcomes (measured by SF-36, Oswestry, sion surgery reported 89% to 98% satisfaction rates inand VAS scores) postoperatively. different functional outcomes (ability to walk, pain, muscle strength and balance) with 92% to 94% chance of not needing revision surgery average 39 months postoperatively.Results of surgical treatment Frazier et al. [57] reported 15 patients with scoliosis and The degree of pain relief after adult scoliosis surgery is stenosis treated with lumbar decompression only. All thedebatable. There are not many studies assessing the results patients had postoperatively increased VAS score comparedof surgical treatment for adult patients with scoliosis and with preoperatively, even though the improvement of thestenosis. Simmons and Simmons [43] studied 40 patients scoliotic curve did not correlate with the outcomes.
  8. 8. A. Ploumis et al. / The Spine Journal 7 (2007) 428–436 435Table 2 In the literature, there is a controversy in the question if comorbidities increase the risk for postoperative complica- Type I Type II Type III tions [60,61]. Elderly patients could safely have spine sur- gery with an outcome similar to younger patients, if we deemed that they do not have increased comorbidities [61]. The most important complications that can happen are NO Grade 1 (5mm) Grade 2 (6-10mm) or 3 CORONAL OR serious blood loss, blindness, cerebral infraction, myocar- LATERAL LATERAL (11mm) LATERAL SAGITTAL ROTATORY ROTATORY ROTATORY IMBALANCE dial infarction, paralysis, neurological deficit, infection- OLISTHESIS OLISTHESIS OLISTHESIS sepsis, failure or breakage of the implants, pseudoarthrosis, pneumonia, deep vein thrombosis, and death [59]. A special STABLE SEGMENT UNSTABLE report should be performed regarding lumbar lordosis loss 2mm motion in SEGMENT dynamic x-rays 2mm motion in or flat-back syndrome [63]. It is caused by distraction of dynamic x-rays the lower lumbar spine during fusion or translational ky- phosis of thoracolumbar spine cranially to the upper end DECOMPRESSION IATROGENIC INSTABILITY of fusion. It leads to sagittal plane imbalance of the spine, YES LONG chronic low back pain, and inability of keeping erect pos- NO SELECTIVE FUSION OF THE FUSION TO ture. Possible iatrogenic aetiology of flat back syndrome NON FUSION MAJOR CURVE OR THE TL AREA + UNSTABLE SEGMENTS + DECOMPRESSION should be avoided during thoracolumbar scoliosis surgery. DECOMPRESSION Conclusions The procedure can involve posterior only or combined Degenerative scoliosis is appearing more frequently be-anterior and posterior approach. Marchesi and Aebi [55] cause of increased life duration or iatrogenic instability.treated 27 patients with an average age of 60 and curves Nonoperative treatment should be exhausted before pro-from 22 to 82 with decompression and posterior segmen- ceeding with surgical treatment, especially in cases needingtal instrumented fusion. In 4.5 years of average follow-up, major reconstructive procedures. The optimal is to manage86% of the patients were satisfied with pain relief and in- the whole pathology with only one operation. Lumbar de-creased walking ability. The average curve correction was compression, fusion, and instrumentation are appropriate50%, and lumbar lordosis increased from 45 to 54 [55]. for most of the patients with degenerative lumbar scoliosisGrubb et al. [58] reported 40% pseudoarthrosis rate in pa- and stenosis. The main goal is to provide pain relief andtients with degenerative scoliosis treated with posterior-on- improved functional lifestyle with minimum fusions to the sacrum, whereas all the cases treated withanteroposterior approach fused uneventfully. A comprehen- Referencessive and long follow-up study of the outcomes (includingVAS, Oswestry Disability Index, or functional scores) of [1] Kostuik J. Adult scoliosis: The lumbar spine, 2nd ed. Vol. 2nd. Phil- adelphia: Lippincott-Raven, 1997; 733–75.operative treatment in a large cohort of patients with degen- [2] Pritchett JW, Bortel DT. Degenerative symptomatic lumbar scoliosis.erative scoliosis and stenosis is lacking. Spine 1993;18:700–3. [3] Perennou D, Marcelli C, Herisson C, Simon L. Adult lumbar scolio-Complications of surgical treatment sis. Epidemiologic aspects in a low-back pain population. Spine 1994;19:123–8. The complications of the surgical treatment of degener- [4] Trammell TR, Schroeder RD, Reed DB. 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