10-7-05 69+11 - 258413772373414384.s3.amazonaws.com · 7/31/2012 1 Jacob M. Buchowski, M.D., M.S....

7/31/2012

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Jacob M. Buchowski, M.D., M.S.

Associate Professor of Orthopaedic and Neurological Surgery

Director, Center for Spinal Tumors

Washington University in St. Louis

St. Louis, Missouri

Degenerative Lumbar Scoliosis: Presentation

and Treatment Options

VuMedi Webinar: Multi-Center Grand Rounds Spine Deformity Case Discussion

July 31, 2012

Disclosures

• Consultant:

• Stryker, Inc. (<$10,000 per year)

• CoreLink, Inc. (<$10,000 per year)

• Globus Medical, Inc. (<$20,000 per year)

• Teaching Arrangements:

• Stryker, Inc. ($10,000-20,000 per year)

• Globus Medical, Inc. (<$10,000 per year)

• DePuy, Inc. (<$20,000 per year)

• K2M, Inc. (<$10,000 per year)

• Institutional Research Support:

• CSSG/K2M, Inc.

What is Degenerative Lumbar

Scoliosis

• Spinal deformity in a skeletally mature patient

• Cobb angle >10° in coronal plane

• Deformity due to asymmetric degenerative changes affecting:

• Discs

• Facet joints

10-7-0569+11

7/31/2012

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Etiology

• Asymmetric degeneration, which then leads to:

• Increased asymmetric load

• Progression of degeneration and deformity

• Scoliosis

• Kyphosis

• May create mono- or multisegmental instability and finally spinal stenosis

• Deformity progression supported by osteoporosis

• Particularly in post-menopausal women

Patient Presentation

• Most often with back pain

• Often with leg pain and claudication symptoms

• Rarely with neurological deficit

• Limited exercise/activity tolerance

• Imbalance - coronal and/or sagittal

• Usually not with questions related to cosmesis

Radiographic Features

• Curve is mid-lumbar spine (L2-L3)

• Fractional lumbosacral curve present (L4-Sacrum)

• Hallmark is “rotatory subluxation” of adjacent vertebrae

• >10º Cobb measurement

• Sagittal plane variable but often hypolordotic/kyphotic

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Spinal Stenosis

• Spinal stenosis can be:

• Central

• Lateral recess

• Foraminal

• Foraminal stenosis most common in:

• Concavity of mid-lumbar curve

• Fractional lumbosacral curve

Surgical Treatment

• When nonoperative treatment fails

OR

• Documented curve progression (especially

if substantial)

• Wide spectrum of surgical treatment options

Surgical Treatment Decisions

• Clinical complaints

• Radiographic features

• Subluxation

• Imbalance

• Osteoporosis

• Overall health of patient

• Patient expectations/desires

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Surgical Treatment Options

1. Decompression alone

2. Limited PSF ± Decompression

3. PSF lumbar curve ± Decompression

4. PSF lumbar curve ± ASF ± Decompression

5. PSF lumbar and thoracic spine ± ASF ± Decompression

6. PSF lumbar and thoracic spine + osteotomy(ies) ± ASF ± Decompression

Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management.

Neurosurg Focus 2010;28(3):E1.

PSF ≠ Formal Posterior

Approach

• Increasing role of

minimally invasive

options

• Percutaneous screw

fixation and deformity

correction

• Hybrid open/muscle

splitting approaches

• Increasing role for

biologics

ASF ≠ Formal Anterior Approach

• Wide array of options to perform an anterior fusion • Formal

anterior/anterolateral approach (i.e. TA/Retroperitoneal approach)

• TLIF/PLIF

• Far lateral approach (i.e. XLIF/DLIF)

• AxiaLIF/TranS1

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Surgical Options

• Decompression alone

• Decompression w/limited PSF

• Decompression w/PSF lumbar curve

• ± Decompression w/PSF lumbar curve + ASF

• ± Decompression w/PSF lumbar & thoracic spine ± ASF

• ± Decompression w/PSF w/lumbar osteotomy(ies) ± ASF



59 y.o. male w/ LBP and Left Leg

Pain

59 y.o. male w/ LBP and Left Leg

Pain

Rx: Microdiscectomy

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Indications for Decompression

Alone

• Central and lateral recess stenosis

• “Stable” spine radiographically

• Minimal/absent rotatory subluxations

• Osteophytes present



Surgical Options









73 y.o. Woman with L Leg Pain

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73 y.o. Woman with L Leg Pain

PSF L4-L5 and Decompression


with Limited PSF

• Central/lateral recess/foraminal stenosis

• Rotatory subluxations at stenotic levels

• Lack of stabilizing osteophytes

• Minimal back pain/deformity complaints

• Disadvantage: risk of transition syndrome



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Surgical Options









73 y.o. Female with Back and

Right Leg Pain

Foraminal

stenosis

L4-L5

73 y.o. Female with Back and

Right Leg Pain

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PSF T11-L5, Decompression L2-L5


with PSF Lumbar Curve

• ± stenosis

• Severe rotatory subluxations/“unstable”

spine

• ↑ back pain/deformity complaints

• Adequate sagittal alignment (lordosis)

• Adequate bone stock (osteoporosis)



Surgical Options









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PSF T10-S1 and TLIFs L3-S1

Indications for PSF lumbar curve

+ “ASF”

• ± stenosis

• Severe rotatory subluxations - “unstable”

spine

• ↑ Back pain/deformity complaints

• Lumbar hypolordosis/sagittal imbalance

• Remember ASF doesn’t necessarily mean

formal anterior approach



Surgical Options









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PSF T4-S1/ASF L4-S1

Indications for PSF Lumbar and

Thoracic Spine + ASF

• ± stenosis

• Severe rotatory subluxations - “unstable” spine

• ↑ Back pain/deformity complaints

• Lumbar hypolordosis/sagittal imbalance

• Remember ASF doesn’t necessarily mean formal anterior approach

• Thoracic kyphosis

• Global coronal and/or sagittal imbalance



Surgical Options









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Revision PSF & L3 PSO, ASF

Indications for ± PSF w/lumbar

osteotomy(ies) ± ASF

• ± Stenosis

• Unstable spines

• Poor regional and global sagittal balance

• Thoracic hyperkyphosis

• Fixed deformity



Conclusions

• Degenerative scoliosis has a broad spectrum of presenting symptoms and radiographs

• Separate out treatment of stenosis vs. treatment of deformity

• Surgical treatment revolves around choosing the right operation for the right patient at the right time

• Sometimes there is more than one “correct” surgical option

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Conclusions

• Six types of surgical procedures are possible with many factors determining the best treatment for each patient:

• Decomp alone

• Decomp w/limited PSF

• Decomp w/PSF lumbar curve

• ± Decomp w/PSF lumbar curve + ASF

• ± Decomp w/PSF lumbar & thoracic spine ± ASF

• ± Decomp w/PSF w/lumbar osteotomy(ies) ± ASF

Conclusions

• ASF doesn’t always mean anterior approach

• Increasing role for minimally invasive

approaches (both posterior and anterior)

• Increasing reliance on biologics to achieve

fusion

Case Example

• 62 y.o. ♀ presents with de novo scoliosis

and left L4-L5 lateral recess stenosis with

associated left L5 radiculopathy

• Failed nonoperative treatment and would

like to proceed with surgery

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2-12-93

62+3

4-93

62+5

Left L4-L5 Lateral

Recess Stenosis

Case Example

• She undergoes PSF L1-L5 with

decompression at L4-L5

• Does very well postop with resolution of

left leg pain

4-3-98

67+5

4-3-98

67+5

Five Years Postop. Doing well!

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12-6-02

72+1

9+6 yr

PO

12-6-02

72+1

9+6 yr

PO

Almost 10 Years Postop. Develops a long sweeping

junctional deformity above w/ increasing back pain.

10 Years Postop. Develops a long sweeping junctional

deformity above w/ increasing back pain.

What to do now?

• Appropriate surgical treatment for this patient is:

① Extend fusion to the upper thoracic spine

② Extend fusion to the upper thoracic spine and down to the sacrum/pelvis

③ Couple the above with SPOs

④ Couple the above with thoracic VCR or lumbar PSO

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Case Example

• Because the patient’s symptoms were

thought to be due to the degenerative

changes above AND to avoid the morbidity

of extending someone to the sacrum/ilium,

the fusion was extended to the upper

thoracic spine only

• She tolerated the procedure well with no

complications

12-20-04

74+1

1 yr po

12-20-04

74+1

1 yr po

One Year Following Revision.

Doing well!

Postop SRS-22 Scores Broken Into Domains One Year

Following Revision To Upper Thoracic Spine

0

5

10

15

20

25

30

Pain Function Self-Image Mental

Health

Satisfaction

21 19

28

25

10

25 25

30

25

10

Score Potential Scores

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Postop Oswestry Score One Year Following Revision

To Upper Thoracic Spine

0

25

50

75

100

Preop

16

100

Score Potential

12-6-02

72+1

9+6 yr

PO

12-20-04

74+1

1 yr po

One Year Following Revision.

Doing well!

12-6-02

72+1

9+6 yr

PO 12-20-04

74+1

1 yr po

Preop Preop Postop Postop

1-23-06

75+2

2 yr po

1-23-06

75+2

2 yr po

Two Years Following Revision

Starting to have LBP and left leg pain

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1-23-06

75+2

2 yr po

1-23-06

75+2

2 yr po

Recumbent Laterals

Vacuum Disc at L5-S1

What to do now?

5-12-08

77+4

2 yr po

5-12-08

77+4

2 yr po

Two Years Following Extension to S1/Ilium with ALIF at L5-S1

Doing well.

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4-3-98

67+5

5 yrs po

index

op 5-12-08

77+4

2 yr po

5-12-08

77+4

2 yr po

4-3-98

67+5

5 yrs po

index

op

Result At 16 Years Following Index Procedure



Acknowledgements

• Larry Lenke, M.D.

• Keith Bridwell, M.D.

7/31/2012

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Thank You!

7/30/2012

1

Multicenter Deformity Case Rounds

Vumedi-Sagittal Plane Cases

Christopher Ames MD

Associate Professor

Director of Spine Tumor and Deformity Surgery

UCSF Department of Neurosurgery

http://spinedeformityblog.com/

Disclosures

Consultant Medtronic, Stryker, Depuy

Purpose

To bring a comprehensive spinal deformity

curriculum to the web

To allow discussions simulating preop case

rounds format

Part 2 of 3

7/30/2012

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Schwab SRS ASD

Angular changes at base of spine

Ondra

Technique

for PSO

planning

Ondra Spine 2006

SDSG Radiographic

Measurement Manual

Pelvic

Parameters

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Reciprocal Changes of Pelvis

PT and planning

Location of Osteotomy and Impact

PSO level correlated to PT correction but not to SVA correction

PSO degree correlated to LL change, TK change and PT change

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Taking Thoracic Change into Account?

Schwab Osteotomy Classification

Clinically Relevant x-ray parameters

Alignment Objectives

SVA < 5cm

PT < 25 degrees

PI – LL < 10

Heterogeneous study designs

Prospective multi-centric (SVA)

Prospective mono-centric (PT)

Retrospective multi-centric (LL-PI)

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Case 1

52 female with NF 1

Multiple prior fusion surgeries

Severe standing imbalance

No Hip Flexion Contracture

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Ondra Formula Example

SVA 12cm

PI 68

LL 18

PT 38

Sagittal Planning Case 2

62 yo female

Severe LBP

Fatigue in PM leaning

farther forward

Maintains retroversion

when ambulating

PI 72

SVA 11 (11cm)

PT 52 (30 )

LL 0

TK 18 (+13)

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Schwab Osteotomy Classification

PI 72

SVA 0

PT 18

LL 70

TK 35

7/30/2012

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Coronal Plane Recontruction

Vumedi

Vedat Deviren MD

Associate Professor

Spine Center

UCSF Department of Orthopaedic Surgery

Disclosures

Consultant Nuvasive, Stryker, Depuy

Each case is unique and requires individual attention

Most often they are

tri-dimensional

Adult Deformity

7/30/2012

2

Adult Scoliosis Unlike AIS secondary

curves usually stiff

Balance is a significant concern in Adult with less compensatory ability in this plane

Coronal

Decompensation

Increased pain/dysfunction

Coronal imbalance (>5cm from C7 plumb line)

Lumbar hypolordosis (<35 degrees of lordosis)

Sagittal imbalance (>4cm from C7 plumb line)

Disability was an independent of the magnitude of curve

Ploumis et al, Spine 2009

58 patients

Correlating Radiographs and

Function

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76 F non surgical

SF-12 Vitality SRS-30 Activity ODI Walking

Nonsurgical 45.9 57.8 3.5 3.5 16 0

Surgical 28.4 47.7 2.1 1.6 60 3

73 F surgical

Predicting Health Status

Modifying Factors for Surgical

Strategy

Presenting clinical symptoms

Magnitude and Rigidity of Deformity

Release/osteotomies

Fixation Strategies

Medical Comorbidities Osteoporosis

Cardiopulmonary disease

Frailty

Modifying Factors for Surgical

Strategy

Presenting clinical symptoms

Magnitude and Rigidity of Deformity

Release/osteotomies

Fixation Strategies

Medical Comorbidities Osteoporosis

Cardiopulmonary disease

Frailty

7/30/2012

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Adult Deformity

Anterior release/Posterior osteotomy

Posterior extension osteotomy (SPO)

Pedicle subtraction osteotomy (PSO)

Vertebral column resection (VCR)

Flexibility

1) Flexible Deformity

deformity corrects simply by being in a supine or prone position

2) Rigid Deformity:

totally inflexible deformity with no correction in the recumbent position,

3) Some where between

a deformity that partially corrects through mobile segments, but not entirely

Dynamic Radiographic Studies

Lateral Bending

Less flexible than adult idiopathic scoliosis

Traction

Can reveal extent of autofusion from

degeneration

Evaluating Flexibility

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Flexibility

Preoperative evaluation

Structural characteristic

Major curve

Compensatory curve

Rigidity of curve

Anterior release ?

Approaches

PSF or ASF

Determination fusion levels

distal

proximal

Predictors of Flexibility in

Thoracolumbar and Lumbar

Idiopathic Scoliosis

,

Spine2003

Objective: Evaluate possible predictors of flexibility in patients

with TL and L curve by side bending X-rays

14 years

47° to 10°

78 %

Predictors of Flexibility in Thoracolumbar and

Lumbar Idiopathic Scoliosis

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34 year

55° to 22°

60%



47 year old

65° to 35°

46%



Conclusion

Age and Curve magnitude are the main

predictors of flexibility

Aging and degeneration of spine

significantly decrease lumbosacral

curve flexibility

7/30/2012

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Case study: Double major curve

treated with posterior spinal fusion

Case study:

13 yo female

Progressive

T:78 degree

L: 85 degree

Flexible curve

8 years follow up

Case: Semi rigid Deformity

43 yo

female

Progressive

deformity

Facet release

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Anterior (lateral) release 68 / female

Chronic back/leg pain/15 years

Treatment Options

Posterior Instrumentation/Fusion

TLIF/Posterior I/Fusion

ALIF/Posterior I/Fusion

XLIF/Posterior I/Fusion

7/30/2012

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Degenerative Scoliosis

Plan L2-L5 XLIF/T10-S1 PSF

Plan? Do you stick to plan?

Shorter Fusion

Post-op x-rays (AP and lateral)

62 y F

75 degree curve

Severe back pain

Significant disability

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47 degree after XLIF

7/30/2012

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2009

2010

57 yo female

22 degree

57 Degree

Selective fusion T12-L5

7/30/2012

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1 year later

Less surgery may lead to more surgery

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Attention to LS curve

69-year-old

woman

complaining of

low back, bilateral

hip and left leg

pain.

Rigid LS curve

Preop

5.2 cm

Post-XLIF

7.4 cm

7/30/2012

14

Post PSF

2.2 cm

Conclusion

Evaluating flexibility is critical on surgery

planning

Attention to Rigid Lumbosacral rigid curve

Balance is more important than curve it self.

1

Complications and Revision Cases

Christopher I. Shaffrey, MD

Harrison Distinguished Professor

Departments of Neurosurgery and Orthopaedic Surgery

University of Virginia

VuMedi Webinar

Multi-Center Grand Rounds Spine Deformity Case

Discussions

Disclosures

• Medtronic- Consultant, royalties

• Depuy- Consultant

• Biomet- Consultant

• Nuvasive- Consultant

• AO- Fellowship support, Grant support

• NIH- Grant support

• Department of Defense- Grant support

• NACTN- Grant support

• 65 y/o woman with history of minimally invasive decompression at L3-4 and L4-5 for back pain and mild radicular pain in 2004

• Back pain increased and in 2007 underwent redo decompression and L2-5 fusion complicated by durotomy

• Progressive difficulty standing upright

• ODI=72, VAS=9, SRS-22= 56

Case 1.

2

11.1 cm

10.4 cm

PI=540

PT=280

Neutral Extension

Flexion

Case 1.

3

Solution

• Removal of prior L2-5 instrumentation

• Repair of dural laceration with patch

• T10 to iliac instrumentation

• L5S1 TLIF

• L2 extended PSO

4

Case 2.

• 53 y/o female with history of untreated thoracolumbar scoliosis

• In 2006 underwent 2 stage; anterior thoracoabdominal fusion followed by T2 to iliac instrumentation and fusion

• Surgery complicated by deep wound infection treated by irrigation and debridement X 5 (staph aureus)

• Over next two years draining sinuses opened on multiple occasions despite suppressive antibiotics

• Instrumentation eventually removed with wound healing

• After removal, significant postural abnormality developed

5

Case 2.

• Surgical Intervention Planned – Stage 1: L5-S1 followed by placement of posterior

instrumentation T2 to ilium with intraoperative culture

– Stage 2: Multiple thoracic SPOs and L2 vertebral column resection procedure

• What type of prophylactic antibiotics?

• What type of spinal instrumentation?

• What bone fusion substrate?

• Value of TPN between stages?

6

Case 2.

• Cultures after stage 1 negative

– Value of pulse lavage irrigation?

– Duration of prophylactic antiobiotics after each stage

– Need for suppressive antibiotics?

7

Case 2.

• What Now? 1. Open wound with I and D

2. Open wound, I and D, pack wound

3. Open wound, I and D, remove implants

4. Open wound, I and D, VAC

• What to do about graft material?

• What to do about anterior implant and graft?

05/05/05

• 67-year-old man who has longstanding history of LBP for >30 years

• Former special forces officer

• In 2004, he underwent L3-4 laminectomy for his back and leg pain

• CTM multilevel central canal and neural foraminal stenosis

• VAS back 7-9/10, ODI 48

Case 3.

9

06/28/2005

• L2 partial inferior laminectomy, L3 and L4 redo laminectomies, right sided L5S1 laminectomy, left L3-4 and L4-5 TLIF right L5S1 TLIF with allograft spacers

• T11 to iliac instrumentation (5.5 titanium rods)

• T11 to iliac fusion using iliac crest bone graft, allograft and Infuse rh-BMP-2 (6 mg at each TLIF site, 18 mg posteriorly)

Case 3.

08/15/05

10/15/05

• Was doing well with minimal pain and neurologically intact

• Two week history of right greater than left progressive lower extremity weakness with gradual loss of the ability to ambulate

• Now using walker to ambulate

10

10/17/05

• Removal of prior T11 pedicle screws, right-sided intraoperative T11 vertebroplasty

• T5 through T11 instrumentation with end to end connectors

• T10 and T11 laminectomies with wide decompression

• T5 through T11 arthrodesis using a combination of local bone graft, allograft bone, and InFUSE rh-BMP-2 (12 mg)

Case 3.

11

03/19/07

• Gradually regained strength in legs and was ambulating without assistance

• One month prior to presentation heard a

“pop” and has had increasing back pain and inability to stand in an upright posture

03/19/07

04/11/2007

• ALIF L4-L5 and L5-S1 with removal of prior TLIF spacers and placement of femoral ring allograft spacers using Infuse rh-BMP-2 (6 mg per level)

• Posterior re-exposure, replacement of several loose screws with L1 through S1 and iliac instrumentation revision, removal of broken rods, reinstrumentation of L1 through S1 with replacement of iliac screws

• L2 through sacral additional fusion using Infuse rh-BMP-2 (12 mg)

12

05/17/07

10/23/08

11/24/2011

• Presents again with progressive myelopathy with difficulty walking, now using walker again

• One year history of increasing back pain and increasing forward posture

13

11/29/2011

• Removal of entirety of previously placed T5 through sacral instrumentation removal of bilateral iliac screws

• Re-instrumentation T3 through S1 including placement of new bilateral iliac screws (6.0 mm CoCr rods)

• SPO at T12-L1 level with T5 and T6 partial laminectomies for decompression of the spinal cord with T3 through S1 posterior and posterolateral arthrodesis using Infuse rhBMP 2 (6 large kits- 72 mg BMP plus master graft)

14

03/28/12

Thank You

7/30/2012

1

Pediatric Deformity

Amer F. Samdani, MD

Chief of Surgery

Shriners Hospitals for Children--Philadelphia

Philadelphia, PA

Disclosures

• Consultant:

• Depuy

• Stryker

• Zimmer

• SpineGuard

Outline

• Case(s) #1- Adolescent Idiopathic Scoliosis:

Level Selection

• Case #2- Severe Syndromic Scoliosis: Surgical

Approaches

• Case #3- Congenital Scoliosis and Intraspinal

Anomalies

7/30/2012

2

AIS: Level Selection

• 13 yo girl with

progressive scoliosis

• PT: T2-T5= 39º

• MT: T6-L1= 52º

• Lumbar: L1-L4= 28º

• Sagittal: T5-12= 25º

• Physical examination

• Trunk shift to right

• Left shoulder> right

• Inclinometer=18º

Lenke 1AN

18 26

Lenke Classification: Fuse Structural Curves

Surgical Plan

• T2 to L2 PSF using cobalt chrome rods

• T2- left shoulder higher than right

• L2- touched by CSVL

• Ponte osteotomies T5 to T12

• Direct vertebral body derotation

7/30/2012

3

Postop Films

Selecting Upper Level

Case Example

• 12 year old girl w/

juvenile idiopathic

scoliosis

• From Puerto Rico

• Followed for 2 years

• Left hip dysplasia/Leg

length discrepancy

7/30/2012

4

Pre-operative Radiographs

Surgical Plan

• T2-L3 PSF

• 6 level Ponte osteotomies

• Bilateral thoracoplasties (rib osteotomies)

• 2 posterior disc releases

• Rod derotation, direct vertebral body derotation, compression/distraction

• Cables

Post-operative Standing Films

7/30/2012

5

UIV = T2

• L shoulder high pre-

op (absolute)

• PT curve structural

• Marked correction

planned for MT

curve

• Proximal kyphosis

present (T2-T5 >20º)

86

50

42

22

UIV = T3 • Shoulders level

pre-op/ slight

right shoulder

evaluation

• PT curve

structural

• Marked

correction of MT

curve planned

• Mild proximal

kyphosis present

(T2-T5 10-20º) Level shoulders

Courtesy of Dr. Lenke

UIV = T4/T5

• Right shoulder high pre-op

• Non structural PT curve

• No proximal kyphosis noted

Right shoulder

high

Courtesy of Dr. Lenke

7/30/2012

6

Patient IP

• 14 yo girl with a

progressive idiopathic

scoliosis

• PE

• Marked trunk shift to

the right

• Inclinometer of 24

• Left shoulder higher

than right

Preoperative Bends

70

68 51

58

Preop Plan

• T2 to L3 PSF

• Concern • Not enough correction of

upper curve and drive left shoulder very high

• Plan • T2 to L3 PSF

• Ponte’s T4,5,6 and T9,10,11

• Tip • Worked on upper curve

first and placed short concave distraction rod

7/30/2012

7

Postoperative Films

68

70

Selecting Distal Level

LIV Selection

• Generally, touched by CSVL

• Suk: End/neutral vertebra analysis

• Spine 2003

7/30/2012

8

Dr. Suk’s Method

• NV = or >1 level below EV

• Fuse to NV

• NV ≥ 2 levels below EV

• Fuse to NV - 1

EV

NV

1

Distal Level Selection

• 13 yo with Lenke 3C

pattern

• T4 to T10 72 degrees

• T11 to L4 56 degrees

• Inclinometer

• Thoracic 18

• Lumber 14

12

12

12 12

12

7/30/2012

9

Summary

• Proximal level

• Shoulder heights

• Kyphosis

• Magnitude of main thoracic curve

• Distal level

• Generally, touched by CSVL

• Try hard for selective fusion or stop at L3

• Junctional kyphosis

Case Presentation:

Neurofibromatosis

K.B.

• 16 y.o. with NF

• Severe scoliosis

• 140°

• Marked trunk

shift

7/30/2012

10

Surgical Plan

• Thoughts?

• T2 to L4 PSF

• Stage 1

• Ponte osteotomies

• Placement of pedicle screws

• Halo-Gravity traction in between stages

• Stage 2

• VCR T9

• Neuromonitoring

• Stable SSEPs/MEPs both procedures

Halo Gravity Traction

• Improves

• Nutritional/pulmonary status

• Curve correction?

• Timing?

• Usually 2-6 weeks

• Nutritional or pulmonary compromise

• Start at onset

• May not aid with curve correction unless prior release

Koller et al, Eur Spine J 2012

Sponseller et al, Spine 2008

7/30/2012

11

Case Presentation:

Severe Scoliosis and

Intraspinal Anomalies

L.K.

• 19 y.o. woman with severe congenital scoliosis

• Diastematomyelia

• Large syrinx

• Age 10 partial removal of diastematomyelia

• Loss of signals, operation aborted

• Inability to walk for one month

• Full recovery

Clinical Photos

7/30/2012

12

October 2011

CT

MRI April 2011

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Surgical Plan

• Thoughts?

• Remove diastematomyelia?

• Shen et al SRS 2010

• 95 patients with diastematomyelia

underwent deformity surgery

• None prophylactically removed

• No neurological injuries

• Syringomyelia?

• Consider spinal cord shortening procedure

Outcome of Operative Treatment for

Spinal Deformity in Patients with

Syringomyelia: A Comparison Study to

AIS Patients Sucato et al, SRS 2011

• 38 patients with syringomyelia and scoliosis

compared with 82 patients with AIS

• Less reliable rate of obtaining signals and

more alerts but similar correction

• However, no quantification of syrinx size

Intraoperative

• T2 to L4 PSF

• Osteotomies

• Rib mass resection

• Intraoperative small MEPs, SSEPs

• T7 vertebrectomy with cage

• Prepared for

• D-wave monitoring

• Multiple wake-ups

• After instrumentation

• Correction

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Postoperative

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