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C H A P T E R 5 0 e Role of Spinal Fusion and the Aging Spine: Stenosis without Deformity
F IG UR E 5 0- 9 A, Postoperative AP radio-
graph showing instrumented fusion from L2 to L5 with
wide laminectomy from L2 to the sacrum. B, Postoperative lateral radiograph showing stabilization of the
lumbar spine with screw fixation and restoration of
normal lumbar lordosis.
335
A
B
As with stenosis found elsewhere, successful surgical management of
lumbar stenosis depends on adequate decompression of the neural elements.
Fusion should be considered in cases in which:
An inherently unstable degenerative pattern is present in which a
stenotic canal is found to have rotational and translational deformity
resulting in either degenerative spondylolisthesis or scoliosis.
Greater than 50% of the facet joint is removed in the process of the
decompression.
Instability is seen on preoperative static radiographs or dynamic flex-
ion-extension radiographs.
e restoration of normal disc height will result in increased foraminal
area as well as return the ligamentum flavum back to its normal length
and tension .
Stenosis exists after prior lumbar decompression surgery.
The addition of a lumbar interbody fusion to the spinal decompression
can restore the disc space back to its normal height. This helps treat the stenosis by reducing any buckling of the ligamentum flavum as well as restoring the native cross-sectional area of the neural foramina. This interbody
lumbar fusion can be done from a variety of approaches: anterior (anterior
lumbar interbody fusion or ALIF), retroperitoneal (extreme or direct lateral lumbar interbody fusion or XLIF/DLIF), or posterior (transforaminal
lumbar interbody fusion or TLIF). ALIF and XLIF/DLIF can be used as
a standalone procedure for a spinal fusion, while TLIF must be augmented
with posterior pedicle screw instrumentation. Each of these approaches has
its pros and cons. An ALIF allows for excellent visualization of the intervertebral disc, but it often requires an access surgeon to mobilize the great
vessels off the spinal column. Additionally, since this is done in a supine
patient, the patient must be turned prone if posterior decompression and/
or instrumentation is needed. An XLIF/DLIF also requires repositioning
for a posterior approach. The TLIF allows for 360-degree fusion from a
posterior-alone approach. No access surgeon is needed, and no repositioning is required. This approach may require some manipulation of the neural
elements, thereby putting those structures at risk.
CONCLUSIONS
Spinal stenosis is primarily a condition occurring in elderly patients. It most
commonly affects the lumbar spine of patients in their sixth or seventh
decade of life. With the increasing average age of the general population as
well as the increasing levels of activity of these elderly patients, the incidence
of symptomatic spinal stenosis is increasing. Nonoperative management
can be successful, but some cases are recalcitrant to nonoperative treatment. Successful surgical treatment of spinal stenosis depends on properly
locating the area of compression, completely decompressing that area, and
fusing the spinal segment if there is instability seen preoperatively or after
decompression.
References
1. J. Hauerberg, et al., Anterior cervical discectomy with or without fusion with ray titanium
cage: a prospective randomized clinical study, Spine 33 (5) (2008) 58–64.
2. P.J. Rao, et al., Clinical and functional outcomes of anterior cervical discectomy without
fusion, J. Clin. Neurosci. 15 (12) (2008) 1354–1359.
3. H. Bertalanffy, H.R. Eggert, Complications of anterior cervical discectomy without fusion in
450 consecutive patients, Acta Neurochir. (Wien) 99 (1-2) (1989) 41–50.
4. R.D. Nandoe Tewarie, R .H. Bartels, W.C. Peul, Long-term outcome after anterior cervical
discectomy without fusion, Eur. Spine J. 16 (9) (2007) 1411–1416.
5. R.B. Raynor, J. Pugh, I. Shapiro, Cervical facetectomy and its effect on spine strength,
J. Neurosurg. 63 (2) (1985) 278–282.
6. M.A. Palumbo, et al., Surgical treatment of thoracic spinal stenosis: a 2- to 9-year follow-up,
Spine 26 (5) (2001) 558–566.
7. K. Yone, et al., Indication of fusion for lumbar spinal stenosis in elderly patients and its significance, Spine 21 (2) (1996) 242–248.
8. M. Cornefjord, et al., A long-term (4- to 12-year) follow-up study of surgical treatment of
lumbar spinal stenosis, Eur. Spine J. 9 (6) (2000) 563–570.
9. D. Grob, T. Humke, J. Dvorak, Degenerative lumbar spinal stenosis: decompression with and
without arthrodesis, J. Bone Joint Surg. Am. 77 (7) (1995) 1036–1041.
10. K. Adachi, et al., Spinal canal enlargement procedure by restorative laminoplasty for the
treatment of lumbar canal stenosis, Spine J. 3 (6) (2003) 471–478.
The Role of Spinal Fusion and the Aging
Spine: Stenosis with Deformity
Barton L. Sachs
51
k e y p o i n t s
Adult scoliosis with spinal stenosis is a progressive condition that has a
significant effect on the aging U.S. population.
Management is complicated by the general medical conditions associated
with aging and by metabolic bone disease.
e goal of surgery is to perform the least aggressive procedure, usually a
decompression, to treat the compressed neural elements.
e aim of surgery is to leave a patient with a balanced stable spine in
the coronal and sagittal planes. Fusion should not stop at an adjacent
degenerative level.
Adult scoliosis classification systems help establish the most appropriate
type of surgery and the appropriate anatomic levels to maximize clinical and
reconstructive outcome.
INTRODUCTION
Adult scoliosis is a common and sometimes disabling degenerative condition
of the spine, with an overall prevalence reported in up to 60% of the elderly
population.
health and well-being; it has been shown that scoliotic patients have a significantly depressed perception of their mental and physical health in comparison
with the general U.S. population. Even when individuals are compared with
those having additional comorbidities, the adult scoliosis patients rate lower
in clinical health assessment. In addition to the subjective considerations of
this progressive disease, severe pain and disability occur in this population.
nal stenosis is controversial. The greatest challenge confronting contemporary spine surgeons in management of the aging patient population is patient
selection; the surgeon must balance benefits, risks, complicatios, and the durability of various interventions. Analysis and application of these is difficult
because of the limited number of prospective outcome studies and because
there is a wide array of different interventions used in this patient population.
The spine surgeon is increasingly confronted with the older patient and must
decide on a suitable yet realistic treatment plan while considering the social
and psychological factors affecting this unique patient population.
1
Adult scoliosis has a marked impact on patients’ general medical
The management of patients with symptomatic spinal deformity and spi-
2
adjacent vertebral aligment in the lumbar spine, acquired secondary to years
of chronic disc disease and progressive facet incompetence. Disc degeneration leads to disc collapse and bulging of the annulus fibrosus and posterior
longitudinal ligament, thus triggering subperiosteal osteophyte formation.
Additionally, articulating facets undergo degenerative changes that result in
hypertrophy, calcification, and thickening of the ligamentum flavum. These
changes eventually result in forward and translational displacement of the
posterior elements that, in combination with degenerative disc changes,
result in severe narrowing of the spinal canal and neural foramen (spinal
stenosis) to cause symptoms of neurogenic claudication and radiculopathy.
DEFINITION OF STENOTIC DEGENERATIVE DISEASE IN DEFORMITY
Lumbar spinal stenosis is defined as a narrowing of the spinal canal that
produces compression of the neural elements before their exit from the neural foramen. The narrowing may be limited to a single motion segment (two
adjacent vertebrae and the intervening intervertebral disc, facet joints, and
supporting ligaments) or it may be more diffuse, spanning two motion segments or more.
Adult deformity of the spine with degenerative disease can be a major
contributing factor in the narrowing of the spinal canal. Adult degenerative scoliosis occurs on the right and left sides with equal frequency. Adult
degenerative scoliosis develops as a result of asymmetrical narrowing of
the disc space and vertebral rotation secondary to the instability caused by
degeneration of the disc.
Neural compression associated with adult lumbar scoliosis is commonly
manifested as a radicular pain that may be related to physical activity. As
the apex of a curve rotates, there is associated hypertrophy and subluxation
of the facet joints in the concavity of the curve. Additionally, collapse in the
concavity results in narrowing of a neural foramen between adjacent pedicles. As a result, symptoms occur in the anterior portion of the thigh and leg
(resulting from compression of the cephalic and middle lumbar nerve roots).
Radiating pain in the posterior portion of the lower extremity is more common on the side of the convexity of the lumbar curve; such pain is due to
compression of the caudal lumbar nerve roots and the sacral nerve roots,
well caudad to the apex, as the spine curves back to meet the pelvis.
2
PATHOANATOMIC CHANGES
Aging of the spine is similar to the degenerative process throughout the
body. The physiologic aging cascade affects the anatomic structures and
creates progressive changes that are biomechanical, biochemical, and physiologic. Changing pathophysiology affects the structure and function of the
spine, which becomes relatively important because of the spine’s role as the
central foundation for the human upright posture.
Degenerative adult scoliosis occurs as result of both macroinstabil-
ity and microinstability. There is segmental instability and translation of
336
CLINICAL COMPLEX OF SYMPTOM PRESENTATION
The degenerative aging spine with deformity creates the complex of four
major categories of clinical symptom presentation:
Neurologic pain (both peripheral and radicular)
Back pain
Activity-related limitations of lifestyle
Deformity-related issues
Neurologic pain occurs with activity-related claudication caused by
diminished blood flow to the nerves. It is incumbent upon the healthcare
C H A P T E R 5 1 e Role of Spinal Fusion and the Aging Spine: Stenosis with Deformity
F IG UR E 5 1 -1 A 66-year-old woman with an AO type 1 de novo scoliosis curve pattern. Myelogram
and intrathecal CT scan demonstrate typical pathoanatomic changes consistent with severe spinal stenosis at
the L4 vertebral level. Note the facet hypertrophy, facet malalignment, ligament flavum hypertrophy, thecal sac
compression, disc degeneration, and vertebral olisthesis.
337
provider to rule out common causes of leg pain such as peripheral vascular
disease, cardiac disease, arteriosclerotic vascular disease, and/or primary
neurologic disease. Compressive radicular pain occurs on the concave collapsing side of a degenerative scoliosis, from direct compression of the nerve
at the exiting foramen or subarticular space. Nerve stretch radicular pain
occurs on the convex nerve roots that are exiting from the stenotic collapsing
scoliotic spine. Therefore, a patient may present with either convex radicular
pain or concave nerve root pain, or both.
Back pain may be caused by arthrosis and normal aging body changes
of the discs, facets, or other structures. Another cause of back pain may
occur from abnormal restricted segmental spine motion, as referred to by
the term “mechanical pain.” Also, back pain may occur secondary to nerve
root compressive pain, which is secondary to decreased circulation and/or
nerve compression.
Activity-related complaints from the aging spine patient generally
involve lifestyle changes. Often the patient will present to the healthcare
provider with statements describing restriction of normal activities of living.
The patient may state that she or he cannot participate in dance, golf, normal work, recreational activities of hunting and fishing, or normal walking
and exercise.
Deformity-related issues include complaint of a cosmetic changing
appearance to the body, with or without a rib producing pressure on the
pelvis. The patient may be twisting and leaning more on one side relative to
the other side of his or her body. Less often, the patient will describe a shortness of breath secondary to restrictive lung capacity from scoliotic collapse
and degenerative changes around the chest. The final and probably the most
daunting problem is when the patient presents with complaints of balance
and instability that affect normal ambulation. The patient may have a spine
deformity that is so significant that he or she is not able to maintain normal
balance, and requires orthotic spine supports such as a cane or walker to
ambulate through daily activities.
ADULT SCOLIOSIS CLASSIFICATION
Adult Scoliosis is classified by Aebi 3 using an AO system based on a pathoanatomic etiology and on a temporal onset of deformity. His classification
defines adult scoliosis as spinal deformity in a skeletally mature patient with
a Cobb angle of more than 10 degrees in the coronal plane. Aebi separates
adult scoliosis into four types:
Type I: Primary Degenerative Scoliosis (“de novo” form), mostly
located in the thoracolumbar or lumbar spine. is occurs on basis of a
disc and/or facet joint arthritis, affecting structures asymmetrically, and
presents with back pain symptoms, often with or without signs of spinal stenosis (central and/or lateral stenosis) (Figures 51-1 and 51-2).
Type II: Idiopathic Adolescent Scoliosis of the thoracic and/or lumbar
spine, which progresses in adult life and is usually combined with secondary degeneration and/or imbalance.
Type III: Secondary Adult Curves:
a) In the context of an oblique pelvis (i.e., due to a leg length discrep-
ancy or hip pathology), or as a secondary curve in idiopathic, neuromuscular, and congenital scoliosis or asymmetrical anomalies at
the lumbosacral junction.
b) In the context of metabolic bone disease (mostly osteoporo-
sis combined with symmetric arthritic disease and/or vertebral
fractures).
3
Schwab et al.4 proposed a three-tier classification system for adult scoliosis based on parameters of coronal and sagittal plane. These radiographic
criteria include lumbar lordosis, location of coronal curve apex, olisthesis
of vertebra segments relative to each other, and sagittal balance on x-ray
(Figures 51-3 through 51-6). The classification system has accurately correlated radiographs with clinical significance, in an attempt at suggesting the
most appropriate successful treatment in the adult patient. The rate of disease progression is influenced by the magnitude of the curve, the degree of
lateral listhesis, the quality of the bone and the severity of associated spondylotic disease. Table 51-1 shows two classification schemes.
CONSIDERATIONS FOR NONSURGICAL OR SURGICAL MANAGEMENT
Nonoperative treatment should always be the initial form of management.
However, attempts to alleviate symptoms, including physical therapy and
steroid injections, oral medications, diet and protein supplements, orthotics,
and active muscle training, rarely yield satisfactory long-term results because
the underlying pathology remains unchanged.
Surgical management of spinal disorders in the elderly poses challenges not
faced in younger patients. Poor bone quality, the possibility of extensive spinal
degenerative changes, and changes in sagittal alignment with increased thoracic
338
P A R T V I I Surgical Treatment Modalities: Lumbar Spine
F IG UR E 51 - 2 A 66-year-old woman with an AO type 1 de novo scoliosis curve pattern. Sagittal view
shows postoperative fusion from T10 to L5 with maintenance of lumbar lordosis for standing balance.
F IG UR E 5 1 -3 A 66-year-old female with symptoms of back pain and pseudo-radicular leg pain plus neu-
rogenic claudication. She had an AO (Aebi) type 1 de novo scoliosis curve pattern, also categorized as a Schwab
type 5, A+ pattern. After work-up and failure of extended nonoperative treatment, she underwent a posterior
multilevel spine decompression /laminectomy and stabilization reconstruction / realignment with fusion and segmental pedicle screw implant instrumentation. Follow-up evaluation demonstrated excellent clinical improvement
with resolution of symptoms and an excellent radiographic result, similar to that demonstrated in Figure 51-6.
kyphosis and loss of lumbar lordosis all complicate surgical management. The
presence of multiple coexisting medical conditions, reduced wound-healing
potential, and malnutrition can markedly increase the risk of complications
for extensive surgical procedures. Osteoporosis and osteopenia complicate fixation options. The option of harvesting large quantities of autogenous iliac crest
bone graft is not practical in patients with poor bone stock and osteopenia.
Additionally, complications of fusion procedures in the elderly may lead to
adjacent segment degeneration and the development of junctional kyphosis.
GOALS OF TREATMENT (See Table 51-2)
The accepted and basic general goals of surgical management of the spine
should include:
Decreased pain
Improved neurologic symptoms
Improved activity status
C H A P T E R 5 1 e Role of Spinal Fusion and the Aging Spine: Stenosis with Deformity
339
F IG UR E 5 1 - 4 A 45-year-old female with AO (Aebi) type 2 adult scoliosis curve. She met
the Schwab criteria of type II, A0. Therefore, she was treated with a limited thoracic (T3-T12)
posterior spine reconstruction fusion with segmental pedicle screw instrumentation; she had an
excellent result with improvement of clinical pain and correction of deformity.
F I G UR E 51 - 5 62-year-old female with AO (Aebi) type 3a adult scoliosis curve classification. This
patient was also categorized as a type IV, B+ according to the Schwab criteria. She was treated with an
anterior spinal release with implant interbody arthrodesis reconstruction followed by a posterior multilevel
laminectomy /foraminotomy and long reconstruction / realignment fusion from T4 to sacrum using segmental pedicle screw fixation and implant stabilization. She had an excellent clinical and radiographic outcome.
340
P A R T V I I Surgical Treatment Modalities: Lumbar Spine
FI G U RE 5 1- 6 55-year-old female with AO (Aebi) type 1 de novo adult scoliosis classified as
type IV, B++ by Schwab criteria. Patient was treated with anterior and posterior spine reconstruction
and realignment with implant segmental pedicle screw instrumentation from T4 to sacrum. Also, she
had multilevel posterior laminectomy /foraminotomy of the lumbar spine to complete the neurologic
decompression. She showed excellent clinical and radiographic outcome.
Improvement of balance and stability in both the coronal and sagittal
plane deformity
Prevention of further deformity
Improvement of cosmetic appearance and body image
In essence, surgery for these patients should primarily address improvement of the spinal stenosis that is causing clinical and lifestyle issues. Stabilization, realignment, and/or reconstruction of the deformity is a secondary
surgical consideration.
SURGICAL PROCEDURES
The types of surgical procedures include:
Decompression operation alone (generally epitomized by the laminec-
tomy bone removal)
A stabilization procedure (rarely performed alone and usually per-
formed with implant instrumentation)
A decompression and stabilization procedure with arthrodesis
○ Rarely, an in situ procedure with bone alone, without metal implants
○ Typically, with metal implant instrumentation
Realignment and reconstruction
○ A decompression (either direct or indirect) with implant instru-
mentation for stabilization and fusion
Anterior versus posterior versus combined anterior and posterior
approaches
OUTCOMES ASSOCIATED WITH SPINAL DEFORMITY TREATED WITH SURGICAL DECOMPRESSION
Frazier, Lipson, Fossel, and Catz5 published their report in 1997,
of a series of 90 patients with preoperative scoliosis associated with
back pain, who were treated surgically and followed at 6 months and
TA BL E 51 -1 Adult Spin e Deformi ty Cla ssif icat ions
Aebi – Eur. Spine J, 2005 Schwab et al. – Spine, 2006
Type 1: “De novo” scoliosis
Primary degenerative scoliosis
Disc and/or facet joint
arthritis
Type 2: Idiopathic scoliosis
Progresses in adult life
Combines with degenerative
imbalance
Type 3: Secondary adult curves
a) Related to oblique pelvis,
leg length discrepancy, or
hip pathology
b) Related to metabolic bone
disease (mostly osteoporosis)
Type
I oracic curve only
II Upper thoracic major (T4-T8)
III Lower thoracic major (T9-T10)
IV oracolumbar major (T11-L1)
V Lumbar major curve (L2-L4)
Lumbar Lordosis Modifier
A Marked lordosis (>40°)
B Moderate lordosis (0° to 40°)
C No lordosis present (Cobb <0°)
Subluxation Modifier
+ Maximum measured subluxation
(1-6 mm)
++ Maximum subluxation
(>7 mm)
24 months after surgery. These authors show that there was an increase
in olisthesis, but this fact was associated with greater improvement in
walking capacity at 6 months and at 24 months after surgery. Their data
indicated that minor increases in the olisthesis after surgery for spinal
stenosis generally were well tolerated by the patients. These authors
showed that results support that preoperative scoliosis is associated with
less favorable outcomes in patients who undergo decompression alone
for spinal stenosis.
C H A P T E R 5 1 e Role of Spinal Fusion and the Aging Spine: Stenosis with Deformity
341
TA BL E 51 -2 Surgical Planni ng Goal s
Decompression of neurologic structures
Stabilization of spinal segmental anatomy
○ Fusion
⦁ In situ without implant instrumentation
⦁ With implant instrumentation
○ Sagittal balance (imperative)
Deformity correction (as indicated)
○ Realignment/reconstruction
Minimizing complications
Maximizing:
○ Function
○ Quality of life
OPERATIVE TREATMENT OF DEGENERATIVE LUMBAR SCOLIOSIS ASSOCIATED WITH SPINAL STENOSIS
Patients who present with symptoms of spinal stenosis and who have
degene rative scoliosis less than 20 degrees and without instability may be
treated with spinal decompression only. Male patients with large vertebral
structures and stabilizing osteophytes can tolerate more than two-level
laminectomy without fusion. Otherwise, patients with degenerative scoliosis more than 15 to 20 degrees, lateral subluxation, or dynamic instability
should be treated with decompression and fusion. Simmons
6
selects different fusion strategies according to his classification types of degenerative scoliosis; pedicle screws are considered the most appropriate fixation
method for the aging osteoporotic bone with absent posterior elements
after decompression. It is often imperative to extend the fusion to the
sacrum with the addition of multiple fixation points in the sacrum and
the pelvis to reduce increased strains to the implants and help healing of
the fusion.
In referencing an article published by Poloumis, Transfeldt, and Denis,
a modification of their proposed treatment algorithm for patients can be
established (shown in Figure 51-7). An extensive study of their patients was
made, for which treatment was determined by using their algorithm, which
included statistical significant improvement outcomes measured by SF 36,
Oswestry, and VAS scores postoperatively.
The important consideration for surgery is whether or not the spinal
segments are:
Stable (less than 2 mm motion in dynamic x-rays),
Unstable (greater than 2 mm of motion in dynamic x-rays), or
If there is coronal or sagittal imbalance preoperatively.
If the initial spine is stable, then a decompressive operation is indicated.
The decompression alone would be sufficient unless iatrogenic instability is produced at the time of surgery. If iatrogenic instability is produced,
then a selective fusion of the major curve should be performed over the area
of decompression. If the spine shows instability of the segments prior to
commencing surgery, then a selected fusion of the major curve with decompression should be planned and carried out. In contrast, if the preoperative
analysis of the patient shows a coronal or sagittal plane imbalance, then a
long fusion from the thoracolumbar area, along with decompression of the
lumbar area, is planned and carried out (see Figure 51-7).
PRINCIPLES FOR SELECTING FUSION LEVELS IN ADULT SPINAL DEFORMITY WITH LUMBAR CURVES
An article by Kuklo8 suggested some key points for consideration of surgical
levels. Kuklo stated that sagittal imbalance is poorly tolerated in the adult
scoliosis patient (Figure 51-8). Surgery should leave the patient with a good
sagittal alignment; preoperative workup should include evaluation of adjacent segment disease with discographic evaluation of the degenerated discs
as well as pain provocative injection tests of the facet joints in determining
fusion levels.
Kuklo stated that a fusion should not be stopped adjacent to a degenerated segment. Additionally, he suggested that stopping long fusions at L5
Adult Spine Deformity
Stable
segments
Decompression
Iatrogenic
instability
No
Nonfusion
F IG UR E 5 1 - 7 Algorithm for adult spine deformity. (Adapted from
Ploumis A, Transfeldt EE, Denis F: degenerative lumbar scoliosis associated with
spinal stenosis, Spine J 7(4):428-36, 2007.)
Yes
Unstable
segments
Selective fusion of
the major curve or the
unstable segments +
decompression
Coronal or
imbalance
Long fusion to
thoracolumbar
decompression
would frequently lead to subsequent degeneration. Lastly, Kuklo stated that
fusion to the sacrum was associated with increased complications and pseudoarthrosis at the lumbosacral junction.
SPINAL STENOSIS WITH SCOLIOSIS
In 1992, Simmons and Simmons6 published in Spine their retrospective
review of a series of 40 patients who had lumbar scoliosis associated with
spinal stenosis and symptoms of neurogenic claudication and were treated
with posterior decompression and pedicle screw fixation techniques. In
follow-up at an average of 44 months, 38 patients (93%) reported mild or
no pain. These workers reported no deaths and no instrumentation-related
7
failures or pseudoarthrosis in their series.
With regard to correction and stabilization with fusion, they recommended that pedicle screw instrumentation systems offered the most advantageous method of handling the difficult problems after removal of posterior
elements. Simmons and Simmons believed that long fusions incorporating
the entire scoliotic curve were necessary in most patients, because a fusion
from the lower portion of the thoracic spine down to the sacrum would
often be required. They felt that it was important to end the fusion at a disc
space that appeared level. (Table 51-3 shows the operative treatment guidelines
and principles described by Simmons and Kuklo.)
RATE OF COMPLICATIONS IN SCOLIOSIS SURGERY
Weiss and Goodall9 published a report in Scoliosis in August 2008 that
stated that a meta-analysis review of scoliosis surgery checking for complications revealed 2590 titled articles. Although the rates varied, scoliosis surgery had a very high rate of complications, averaging 44% for adults (range
10% to 78%) as published in 11 different studies. (Table 51-4 summarizes
surgical complications in treatment of adult scoliosis.)
Guigui and Blamoutier
the review of orthopedic surgery. Their review of 3311 patients during a
12-month period who underwent surgical treatment of spine deformity
found that 704 patients (21.3%) had one or more complications (850 complications) during or shortly after the index operation. The categories of
complications were listed as:
General
Infectious
Neurologic
Mechanical
Older patients have an overall higher rate of complications. Ocular
blindness is a serious complication that requires special note. A review by
Myers and Stevens implies a relationship of blindness to operative time,
blood loss, and operative hypotension, as well as an association with direct
compression of the eye.
10
published a treatise in French in 2005 in
sagittal
area +
342
P A R T V I I Surgical Treatment Modalities: Lumbar Spine
F IG UR E 5 1- 8 A 68-year-old woman treated with anterior and posterior four-level spine fusion in 2005.
No pain-free interval. She developed kyphotic sagittal imbalance and T12 fracture collapse and vertebral angular
instability, with inability to stand and function upright. She was treated with posterior pedicle subtraction osteotomy at T12 and sagittal realignment and extension of fusion with implant instrumentation to T5. She had excellent clinical and radiographic outcome.
TA BL E 51 -3 Op erat ive Treatmen t Guideli nes and
Principl es
Indications for Surgery
Pain
How much do symptoms affect lifestyle?
Progressive neurologic deficit
Increasing leg weakness
Paresthesias (nonvascular)
Consider metabolic bone quality
Key Considerations (Kuklo – 2006)
Don’t stop fusion adjacent to degenerated segment.
Fusion to L5 leads to further degeneration.
Fusion to sacrum is associated with increased complication rate and
pseudarthrosis at L/S junction.
Simmons et al.
Spinal decompression only
Scoliosis <20%
Without instability
Lumbar lordosis maintained
Decompression and fusion
Scoliosis 15-20 degrees
Lateral subluxation
Dynamic instability
If fusion performed
Use implant instrumentation with pedicle screws
TA BL E 51 -4 Surgical Complica tions : Rate and Cate gori es
Adult Scoliosis**: 11 published studies
Average rate ∼44% (SD 24) (Range 10%-78%)
**Weiss and Goodall: Meta-analysis review, Scoliosis, 2008.
2590 references reviewed, 287 rated complications
Categories of Complications
(Guigui et al., Revue de Chirurgie Ortho, 2005: 3311 patients over 12 months
for deformity; 704 patients [21.3%] had one or more complication [850
complications])
General
Infectious
Neurological
Mechanical
of surgery is to decompress the compromised neural elements, in cases of
symptomatic spinal stenosis, and to end with a balanced and stable spine
in the coronal and sagittal plane, when there is imbalance. The idea is to
proceed with the least aggressive procedure, usually posterior only, that
would involve both decompression and stabilization of the spine. The
important points are that fusions should not be stopped adjacent to a
degenerated level and that sagittal imbalance is not tolerated by the elderly
patient. The operative surgeon must make a decision as to whether the
fusion should be stopped at L5, which may necessitate future surgery, or
carry the fusion to the sacrum, which would in turn lead to greater risk for
perioperative complications.
SUMMARY
Scoliosis is a progressive disease that is associated with significant back
pain and decreased bone mass in most patients. Because both problems
complicate the management of the neurogenic claudication, decompression is indicated for the symptoms of spinal stenosis, along with adequate
stabilization and fusion. A correction of deformity can also be attempted,
but it is technically very difficult and fraught with great hazard. The aim
References
1. A.S. Kanter, A.R. Asthagiri, C.I. Shaffrey, Aging spine: challenges & emerging techniques:
chap. 3, Clin. Neurol. 54 (2007) 10–18.
2. J.M. Spivak, Current concepts review: degenerative lumbar spinal stenosis, J. Bone Joint
Surg. Am. 80 (1998) 1053–1066.
3. M. Aebi, The adult scoliosis, Eur. Spine J. 14 (2005) 925–948.
4. F. Schwab, J.P. Farcy, K. Bridwell, S. Berven, S. Glassman, J. Harrast, W. Horton, A clinical
impact classification of scoliosis in the adult [deformity], Spine 31 (18) (2006) 2109–2114.
C H A P T E R 5 1 e Role of Spinal Fusion and the Aging Spine: Stenosis with Deformity
343
5. D.D. Frazier, S.J. Lipson, A.H. Fossel, J.N. Katz, Associations between spinal deformity and
outcomes after decompression for spinal stenosis, Spine 22 (17) (1997) 2025–2029.
6. E.D. Simmons, Surgical treatment of patients with lumbar spinal stenosis with associated
scoliosis , Clin. Orthop. Relat. Res. (348) (2001) 45–53.
7. A. Ploumis, E.E. Transfeldt, F. Denis, Degenerative lumbar scoliosis associated with spinal
stenosis, Spine J. 7 (4) (2007) 428–436.
8. T.R. Kuklo, Principles for selecting fusion levels in adult spinal deformity with particular
attention to lumbar curves and double major curves, Spine 31 (19 Suppl.) (2006) S132–
S138.
9. R.R. Weiss, D. Goodall, Rate of Complications in Scoliosis Surgery-A Systematic Review of
the Pub Med Literature. Scoliosis. 3(9)(2008) 1-18.
10. P. Guigui, A. Blamoutier. Complications of Surgical Treatment of Spinal Deformities: A
Prospective Multicentric Study of 3311 Patients. Rev. Chir. Orthop. Reparatrice. Appar.
Mot. (Groupe d’Etude de la Scoliose), 91(4)(2005) 314-327.
A Case Study Approach to the Role
of Spinal Deformity Correction
in the Aging Spine
Oheneba Boachie -Adjei and Satyajit Marawar
52
k e y p o i n t s
Primary adult scoliosis: De novo appearance of deformity in a previously straight
adult spine resulting from degenerative disc disease, osteoporosis, or both.
Secondary adult scoliosis: An untreated adolescent scoliotic curve that either
continues to progress in adulthood or worsens because of superimposed
degenerative changes.
oracic idiopathic curves progress at 1° per year, thoracolumbar at 0.5° per
year. Factors associated with curve progression include Cobb angle more than
30°, apical vertebral rotation more than 30%, presence of lateral olisthesis,
and a poorly seated L5 vertebra over S1 in lumbar curves.
Risk factors for progression of degenerative curves include lateral olisthesis,
a high Harrington factor (Cobb angle divided by the number of vertebrae
involved in the curve), and the disc index.
Surgical indications and techniques vary and are patient-to-patient
dependent. Relative indications include: (1) younger patients less than
50years old who present with mostly untreated idiopathic curves that have
progressed to greater than 50° to 60° and are painful and symptomatic,
and(2) patients over the age of 50 with mostly degenerative curves or
idiopathic curves worsened by superimposed degenerative changes. In these
patients, surgery is most likely indicated for progressive deformities with
sagittal or coronal plane imbalance, or refractory back or radicular pain with
or without symptoms of spinal stenosis.
INTRODUCTION
Adult scoliosis, by definition, is spinal deformity presenting in adult life.
Adult scoliosis may be untreated adolescent idiopathic scoliosis that presents after skeletal maturity, or it may be a de novo spinal deformity in an
adult. Thus adult thoracic or lumbar scoliosis can be classified as:
Primary adult scoliosis: de novo appearance of deformity in a previ-
ously straight adult spine resulting from degenerative disc disease,
osteoporosis, or both.
Secondary adult scoliosis: an untreated adolescent scoliotic curve that
either continues to progress in adulthood or worsens because of
superimposed degenerative changes (
The incidence of adult scoliosis increases with age. In adults, rightand left-sided curves are equally prevalent. Unlike in adolescent scoliosis
where cosmesis is the major issue, in adults, pain and disability present as
significant problems in addition to the deformity. With increasing longevity
and increasing expectations regarding physical activity and quality of life in
older patients, increasing number of adult patients with symptomatic thoracolumbar deformity seek surgical treatment.
Adult degenerative deformity usually presents as a mild curve, which is
rarely greater than 30 degrees unless it is superimposed on an adolescent-onset
Figure 52-1).
344
curve. Symptomatic lumbar curves tend to be larger in the idiopathic group
than in the degenerative group.
sis are major contributing factors in adult-onset deformity. In these adult
deformities, vertebral structural changes with lateral olisthesis are typically
associated with degenerative disc and facet joint arthrosis. Adult deformity
may also present as a sequela after a decompression for spinal stenosis or
spinal fusion for degenerative disc disease. In primary as well as secondary
deformities, the degenerative process plays a central role and leads to loss of
lumbar lordosis, not infrequently progressing to thoracolumbar kyphosis.
1
Degenerative disc disease and osteoporo-
NATURAL HISTORY
Idiopathic Curves
Untreated adolescent idiopathic curves are known to progress after skeletal
maturity
at the University of Iowa, Weinstein et al reported that 68% of the curves
progressed after maturity. Thoracic curves progressed at 1 degree per year,
thoracolumbar at 0.5 degree per year. Factors associated with curve progression were Cobb angle greater than 30 degrees, apical vertebral rotation more
than 30%, presence of lateral olisthesis, and a poorly seated L5 vertebra over
S1 in lumbar curves
2-4
. On long-term follow-up of patients with adolescent scoliosis
4
.
Degenerative Curves
Pritchett and Bortell reported on the natural history of degenerative scoliosis in 200 patients. The number of vertebrae involved in the curve were
from 3 to 6 (mean 3), with the apex commonly located between L2 and L3,
and with 68% of the curves being left-sided. While degenerative spondylolisthesis was noted in half the patients, lateral listhesis was even more common (78%). They found that all the curves with the intercrestal line passing
through L5 or the L4-5 interspace with vertebral rotation of 2 or more on
the Nash and Moe scale progressed, as did curves greater than 30 degrees
with lateral listhesis of 6 mm or more
Korovessis et al. followed up 91 adults with de novo spinal deformity for
a period of 3.7 years. The average curve size was 16.5 degrees (range 10° to
36°). Risk factors for progression were lateral olisthesis, a high Harrington
factor (the Cobb angle divided by the number of vertebrae involved in the
curve), and the disc index
a curve progression of 10 degrees or more in 73% of their patients over a
follow-up period of 10 to 30 years, at an average of 3 degrees per year 7.
6
. In a similar study, Perennou et al. also reported
5
.
IMAGING EVALUATION
Radiographic studies for diagnosis and evaluation of adult scoliosis include
full-length standing radiographs, bending films, hyperextension films, CT
myelograms, and MRI. Assessment of bone mineral density will provide
information regarding the presence and severity of osteporosis.