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47 Degenerative Instability
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a
b
d
c
e
f
Fig. 47.2 This patient presented with severe back pain and bilateral L5 radicular pain. (a and b)
Extension and exion radiographs demonstrating unstable L4/5. (c and d) Axial and sagittal
T2-weighted MRI showing L4/5 spinal stenosis. (e and f) Postoperative radiographs after direct
decompression, transforaminal interbody fusion, and posterolateral fusion
decompression by restoring the intervertebral disc height (e.g., by anterior, oblique,
or lateral interbody fusion) is another alternative, but additional xation is necessary
to avoid nonunion (Fig.47.3a–h). The prerequisite of indirect decompression and
fusion is minimal facet hypertrophy.
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Y.-W. Wong
a
e
b
f
c
g
d
h
Fig. 47.3 (a and b) Standing anteroposterior and lateral X-ray showing grade 1 L4/5 spondylolis-
thesis before surgery. (c and d) T2-weighted MRI demonstrating L4/5 spinal stenosis mainly due
to ligamentum avum hypertrophy. (e and f) Anteroposterior and lateral radiographs after surgery
showing the restoration of disc height. The construct was reinforced by posterior instrumentation.
(g and h) Postoperative MRI illustrating the bigger spinal canal at L4/5. The spinal canal was
enlarged by ligamentotaxis, and it is regarded as indirect decompression since the spinal canal was
not entered during surgery
47.7 Expected Outcome
The surgical outcome is satisfactory for most patients with appropriate indications.
47.8 Potential Complications
Neurological complications are not common. Progression of instability may occur
if excessive decompression without fusion is done, with the consequence to perform
a more extended fusion area later on. For fusion, nonunion and implant malposition
may happen.
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47.9 What Patient andFamily Should Know?
The treatment selected depends on the patients’ symptoms. The natural history is
favorable for most patients with or without operation.
Further Reading
Patel VV, Patel A, Harrop J, Burger E. Spine surgery basics. Berlin, Heidelberg: Springer; 2014
ISBN 978-3-642-34125-0. p. P221–7.
Adult Idiopathic Scoliosis
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AliEren andAlpaslanŞenköylü
48.1 Definition
A lateral spinal plane deformity with a curve greater than 10° in a skeletally mature
individual is dened as adult idiopathic scoliosis (AdIS). It is a combination of
neglected adolescent scoliosis and progressive spine degeneration related to aging
(Video 48.10). An asymmetrical degeneration of the discs or facet joints and osteoporosis mainly lead to the deformity. However, iatrogenic, post-traumatic, congenital, post- paralytic, or secondary to infectious or neoplastic issues can also be the
other causes of AdIS which are relatively less frequent. Despite prevalence ranging
from 1.4% to 32%, the rate is on the rise due to increased life span.
48.2 Natural History
While adolescent idiopathic scoliosis progresses by 0.5° to 1° per year on average
(Chap. 17), AdIS is likely to progress more rapidly by 1° to 6° per year due to its
degenerative and imbalanced nature. Thoracic curves progress more rapidly compared to lumbar and thoracolumbar curves that are more disabling for patients with
pain, imbalance, and radicular impingement.
Supplementary Information The online version contains supplementary material available at
[https://doi.org/10.1007/978- 3- 030- 80356- 8_48].
A. Eren
Faculty of Medicine, University of British Columbia, Vancouver, Canada
e-mail: ali.eren@cw.bc.ca
A. Şenköylü (*)
Faculty of Medicine, Gazi University, Ankara, Turkey
e-mail: drsenkoylu@gmail.com
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
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A. Eren and A. Şenköylü
48.3 Physical Examination
Unlike adolescent idiopathic scoliosis, back pain (Chap. 41) is a common symptom in AdIS, and the main reason for the pain is mostly spinal stenosis which is
located particularly on the concave side of the curve. The stenosis typically does
not relive with sitting or forward exion. Radicular pain and neurologic claudication are also common symptoms caused by the impingement of nerve roots
(Video 48.4).
Following meticulous evaluation of spinal geometry including kyphosis, curve
magnitude (Video 48.6), exibility, and pelvic obliquity, a complete neurological
exam should be carried out.
48.4 Imaging
Anterior-posterior and lateral radiographs should be the rst step after a proper physical examination. In these radiographs, clavicle and pelvic vertebra, involving both
femoral heads, should be included for a proper evaluation of the spine as a whole.
Flexibility can also be evaluated with lateral bending radiographs and/or longitudinal
traction radiographs (standing or supine). The Cobb angle (Video 48.6) should be
measured together with central sacral vertical line (CSVL) and C7 plumb line.
A computed tomography scan can be requested to evaluate bone and rotational
anatomy in more detail and to detect rotatory dislocation (Chap. 47); it is particularly helpful for preoperative planning and operation.
Based on neurological examination, magnetic resonance imaging can be done for
either a specic level or entire spine evaluation in order to identify any related pathologies such as disc degeneration, hernia, and intraforaminal and central stenosis.
The degree of osteoporosis, one of the contributors to AdIS, can be evaluated by
dual-energy X-ray absorptiometry (DEXA); it should be suspected if there are associated compression fractures.
48.5 Differential Diagnosis
AdIS is a combination of idiopathic deformity and degeneration of skeletally mature
patients and should be differentiated from adolescent idiopathic scoliosis in which
curve starts developing in an immature skeleton (Chap. 16). This differentiation is
crucial since the treatment of both conditions varies considerably.
In addition to this, the patient’s main concern and its source should be differentiated from other reasons. In other words, back pain, for example, may not stem from
a spinal deformity but from something else like a spinal tumor, infection (Chap. 65),
Schmorl’s node (Chap. 27), or myalgia and this should be addressed meticulously.
Otherwise, the further intervention might not relieve the symptoms and result in
unsatisfying outcomes.
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48.6 Treatment Options
The majority of patients can be managed by conservative means such as antiinammatory medication, pain medication, exercises and activity modication, epidural steroid injections, and bracing. NSAIDs and non-opioid pain killers can be
used for pain relief. The ideal initial treatment should be full-body exercises with
strengthening but not stretching exercises. Exercises can delay curve progression
while decreasing the symptoms. Epidural steroid injections could be reasonably
benecial for those who have spinal stenosis or radiculopathy signs together with
contribution to the diagnosis. Even though bracing can alleviate symptoms, it does
not affect curve progression. In some patients, radiofrequency denervation of the
facet joints could be an alternative treatment despite not being enough support
regarding long-term results.
The main reasons for surgery are persistent pain despite conservative treatment,
rapid increase in curve magnitude, symptomatic coronal and sagittal imbalance, and
cardiopulmonary limitations.
The surgical treatment can be divided into three main categories, considering the
nature of the deformity, the symptoms, and the surgical planning.
1. Patients with isolated spinal stenosis with an acceptable and stable spinal bal-
ance can be managed with decompression without fusion. Patients should be
selected carefully since decompression alone can cause further instability in the
unstable spine which may lead to localized fusion.
2. Patients with stenosis, instability and moderate malalignment, no kyphosis, and
plumb line no more than 5 cm from S1 can be treated with decompression,
instrumentation, and fusion with minimally invasive surgery (Videos 48.3 and
48.7). Slight correction can be sufcient for this type of deformity.
3. Patients with severe curvature and instability should be managed with decom-
pression, correction of the sagittal-coronal alignment, and long fusion, regardless of the presence of spinal stenosis (Videos 48.3 and 48.7). Osteotomies
(pedicle subtraction and Smith-Petersen technique) can also be performed when
necessary. Due to higher complication rates of osteotomies, the use of intraoperative neuromonitoring and high-level experience are strongly recommended
(Fig.48.1).
Correction of the deformities is performed through anterior and posterior
approaches. Despite solely posterior approach along with osteotomies being sufcient in the vast majority of cases, extremely rigid curves may require previous
anterior release through multiple levels discectomy and hemivertebrectomies before
performing posterior osteotomies and fusion. Besides, overcorrection of huge
curves, greater than 80°, might end up with severe tension on spinal cord, which
may lead to intraoperative neuromonitoring issues and postoperative disabilities. In
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Fig. 48.1 (a and b) Preoperative X-ray images of a patient with AdIS with the thoracic Cobb
angles of 82°. (c and d) After surgical correction, the thoracic Cobb angle was decreased to 22°
A. Eren and A. Şenköylü
order to prevent this potential complication, anterior spinal column shortening
through multiple level anterior discectomy and hemivertebrectomies should be considered before going through posterior fusion surgery. In certain cases, even only
discectomies could sufce for appropriate release without additional vertebrectomies. Anterior release through multiple level discectomies is also viable through
thoracoscopic approach in thoracic levels, making it advantageous in terms of lowering the morbidity on patients.
Thoracic curves should be treated with selected thoracic fusion with avoiding
fusing lumbar level as much as possible to preserve lumbar motion. Proximally, as
high as T2 or T3 should be included in a fusion in order to provide better shoulder
balance.
Fusion level in thoracolumbar and lumbar curves should be extended to the neutral vertebra proximally, while L3–L4 levels being included distally if they are not
part of the curve. In case L3–L4 levels are part of the curve, the fusion should be
extended to L5 level.
Whether S1 is included or not in the fusion level is a controversial issue. It is a
well-known fact that preserving the L5–S1 level provides retention of lumbosacral
motion, lowers pseudoarthrosis rate, reduces operation time, and stress on the SI
joint. However, in case of severe disc degeneration, spinal stenosis, spondylolisthesis, and laminectomy at L5–S1 level, including this level in the fusion is mandatory.
48 Adult Idiopathic Scoliosis
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When L5–S1 is included in the fusion, anterior fusion may be necessary, and this
can also be utilized through the posterior approach with posterior (transforaminal)
lateral interbody fusion.
Selection of levels to be fused is of utmost importance, and proximal junctional
kyphosis (PJK) is possible.
48.7 Expected Outcomes
The outcomes of AdIS surgery are highly satisfying as the pain relief occurs postoperatively in most patients.
48.8 Potential Complications
General postoperative complications such as pneumonia, atelectasis, ileus, delirium, and pulmonary embolism can be seen. Spinal surgery-related complications
include hardware failure, failure of fusion (pseudoarthrosis) (5% to 25%), infection
(0.5% to 8%), and neurological compromise (0.5% to 5%). On the other hand, the
involvement of neuromonitoring intraoperatively has decreased complications
considerably.
48.9 What Patient andFamily Should Know?
Surgical treatment methods of AdIS are promising and sometimes very satisfying in
carefully selected patients who do not respond to conservative treatment.
Further Readings
Aebi M.The adult scoliosis. Eur Spine J. 2005;14(10):925–48.
Baron EM, etal. Medical complications of surgical treatment of adult spinal deformity and how to
avoid them. Spine. 2006;31(19):106–S118.
Kuklo TR.Principles for selecting fusion levels in adult spinal deformity with particular attention
to lumbar curves and double major curves. Spine. 2006;31:132–8.
De Novo Deformity
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KennyY.H.Kwan andKennethM.C.Cheung
49.1 Definition
De novo deformity refers to spinal deformity in patients with no history of scoliosis
during childhood or adolescence. Although traditionally this refers to a deformity in
the coronal plane that spontaneously develops during adulthood, we now understand that adult spinal deformity can affect all three planes (Video 49.10). De novo
deformity arises from degenerative changes in the spine, and aging, osteoporosis
(Chap. 10), degenerative disc disease (Chaps. 44, 45, and 47), facet joint arthrosis,
and sarcopenia can all contribute to its development.
49.2 Natural History
Little information is available on the prevalence, incidence, and risk factors associated with curve progression in de novo degenerative scoliosis in the general population. In a community-based cohort study with 12-year follow-up, de novo deformity
has developed in 29.4% of patients during the study period, and the risk factors for
de novo deformity development were smaller L4 size, unilateral osteophyte formation, and lateral disc wedging. In terms of it natural history, in a systematic review of
the literature in which 12 studies were included, strong evidence indicated that
increasing intervertebral disk degeneration, lateral vertebral translation ≥6mm, and
an intercrest line through L5 (rather than L4) were associated with curve progression.
Supplementary Information The online version contains supplementary material available at
[https://doi.org/10.1007/978- 3- 030- 80356- 8_49].
K. Y. H. Kwan · K. M. C. Cheung (*)
Department of Orthopaedics and Traumatology, The University of Hong Kong,
Hong Kong, China
e-mail: kyhkwan@hku.hk; cheungmc@hku.hk
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_49
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K. Y. H. Kwan and K. M. C. Cheung
Moderate evidence suggested that apical vertebral rotation grade II or III was associated with curve progression. However, no clinical risk factors were identied. It is
also unknown if these risk factors are directly applicable to individual patients.
49.3 Physical Examination
Patients with de novo scoliosis present with complaints ranging from debilitating
back or lower extremity pain and spinal imbalance to incidental ndings on lumbar
radiographs (Chap. 41). Hence, physical examination should focus on what the
clinical complaints are. With the patient standing, an inspection of the patient’s
back, noting any coronal imbalance, abnormal posture including the sagittal plane,
and presence of rib-on-pelvis deformity that may lead to inefcient breathing and
decreased appetite (Fig. 49.1). The general muscle mass and nutritional status
should be noted, and palpation of the back should be performed to identify the
site(s) of pain. Gait and peripheral nerve examination and special tests for sciatica
should be performed (Video 49.4).
The purpose of the physical examination is to identify any clinical problem that
can be correlated with the relevant imaging, hence formulating a targeted management plan.
Fig. 49.1 Clinical appearance of a female patient with de novo deformity. The patient has typical
sagittal alignment problems such as at back besides the coronal deformity
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