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188 IV Deformity
1. Spinal deformity is more rigid. The curve may progress, especially if
the curve is greater than 50 degrees. The curve may progress 1 to 2 de-
grees per year.
a. Risk factors for lumbar curve progression
(1) Lateral and rotatory listhesis
(2) Large apical rotation
2. Spinal stenosis, disk disease, and osteopenia are associated pathology:
asymmetrical loss of disk height and vertebra may contribute to the in-
crease in Cobb angle.
3. Etiology of pain in adult scoliosis may be multifactorial.
a. Pain often originates on the convexity of the curve due to muscle
fatigue. This is followed by facet degeneration on the concave side.
b. There is increased incidence of low back pain if lumbar curve is
greater than 45 degrees.
c. It is necessary to rule out other sources of pain such as abdominal
aneurysm, renal stones, tumors, as well as disk disease and spinal
stenosis.
d. Pain, in the absence of a progressive curve, is rarely an indication
for surgery.
4. Sciatica may result from nerve root compression in the concavity of the
curve.
5. Respiratory compromise may occur resulting in dyspnea, pulmonary
hypertension, and cor pulmonale.
6. Adults often have other medical comorbidities that make the surgery
more risky.
B. Evaluation
1. Careful history and examination including previous evaluations for
scoliosis
2. X-rays: standing anteroposterior and lateral to measure magnitude of
curve. These X-rays should be compared with any previous X-rays to
document progression. Bending films are useful for determining the
flexibility of the curve for preoperative planning. Further diagnostic
testing, such as myelogram and computed tomography or MRI scan, is
indicated when signs of nerve root compression are present.
3. Discography is sometimes utilized to localize pain in selected cases.
4. Ferguson view X-rays
a. Special view X-ray used to examine the lumbosacral junction
b. Beam is directed 30 degrees cephalad and focused on the L5–S1
junction.
C. Treatment
1. Conservative treatment is indicated for nonprogressive curves caus-
ing localized back pain. The treatment plan incorporates the general
principles of treating back pain including brief period of rest, nons-
teroidal antiinflammatory drugs, stretching, exercise program, and
nerve blocks.
2. Bracing is occasionally helpful for pain relief but not for sciatica, curve
progression, or respiratory compromise.
Chapter 17 Scoliosis 189
3. Surgery is indicated for progressive thoracic or thoracolumbar curves
above 50 to 60 degrees, curves with unrelenting pain and sciatica, or
progressive respiratory compromise.
4. Techniques
a. Relatively flexible thoracic curves or balanced double major curves
require posterior fusion and instrumentation.
b. Rigid and severe unbalanced thoracic curves (greater than 80-degree
curves) require anterior release and fusion followed by posterior fu-
sion and instrumentation.
c. Relatively flexible thoracolumbar or lumbar curves require anterior
fusion with instrumentation (if there is no kyphosis and the curve
is limited to T10 to L4).
d. Severe and rigid thoracolumbar or lumbar curves 75 degrees re-
dundan statement and associated kyphosis require anterior release
and fusion followed by posterior fusion and instrumentation.
e. Degenerative scoliosis with radiculopathy requires posterior
laminectomy and fusion with transpedicular instrumentation of the
lumbar spine with or without anterior fusion.
5. Complications
a. Higher than adolescent spine, especially pulmonary problems
b. Pseudarthrosis is less for combined anterior and posterior approach
than posterior fusion alone.
c. Flatback syndrome (loss of lumbar lordosis) may result if the poste-
rior surgical techniques produce a distractive force or if the anterior
technique produces significant compression force along the lumbar
spine. Segmental instrumentation and preservation of the lumbar
lordosis and sagittal balance are critical.
d. Infection
(1) Incidence of 0.5 to 8%
(2) More common with posterior surgery
e. Neurological complications
(1) Incidence 1 to 5%
(2) Most common with combined posterior and anterior surgery
f. Pulmonary embolism
(1) Incidence 1 to 20%
XIII. Neuromuscular scoliosis (Fig. 17–4)
A. General considerations
1. Bracing does not prevent the natural progression of the scoliosis.
2. Differences in surgical approach include longer fusions and operating
on smaller curves.
3. Hooks and screws are used more frequently.
4. Segmental Luque are wires used.
5. Increased rates of complications
B. Cerebral palsy
1. Scoliosis affected by the imbalance of the paraspinal muscles
2. Surgery
a. Curves greater than 50 degrees
190 IV Deformity
Figure 17–4 A 13-year-old boy with neuromuscular scoliosis: (A) anteroposterior; (B) lateral
radiographs. There appears to be lumbar hyperlordosis and a compensatory thoracic kyphosis.
Postoperative radiographs (C,D) demonstrate a combination of pedicle screw, hook, and sub-
laminar wiring fixation.
Chapter 17 Scoliosis 191
b. Levels to be repaired
(1) Ambulatory patient
(a) proximal to distal stable vertebra
(2) Nonambulatory patients
(b) T2 to pelvis
c. Usually posterior approach but anterior approach may need to be
performed for curves greater than 100 degrees.
C. Myelomeningocele
1. Due to birth defect and exposure of the meninges and spinal cord may
result in bowel, bladder, motor, and sensory deficits
2. Incidence of 1 in 1000, and correlated with folate deficiency in preg-
nancy
3. Fifteen percent of patients with this deficit have latex allergy.
4. MRI used for diagnosis due to the neurological complications
5. Surgery
a. Indicated for patients who have problems sitting or developing
pressure sores
b. Combined posterior and anterior approach used
D. Spinal deformity
1. Causes
a. Congenital
b. Muscle imbalance
c. Tethered cord
d. Hydrocephalus
E. Spinal muscular atrophy
1. Progressive weakness due to loss of anterior horn cell neurons
2. Three types
a. Type I (Werdnig-Hoffmann disease)
(1) Onset in neonatal period and death by age 2
b. Type II
(2) Onset around 5 to 6 months of age
c. Type III
(1) Onset before age 3 and progressive weakness with loss of am-
bulatory strength by age 15
3. Surgery
a. Indicated in progressive scoliosis
b. Approach should be anterior and posterior for young patient with large
curves and only posterior for the older patient with smaller curves.
F. Duchenne’s muscular dystrophy
1. X-linked recessive disorder
2. Spinal deformity develops due to muscle imbalance only after loss of
ambulation.
3. Increased incidence of malignant hypertension with general anesthesia
4. Pulmonary function and cardiac contractility assessment necessary be-
fore surgery
5. Surgery
a. Indicated in progressive scoliosis greater than 25 to 30%
b. T2 to sacrum posterior approach used
192 IV Deformity
Suggested Reading
Aebi M. The adult scoliosis. Eur Spine J 2005;14:925–948
Bollini G, Docquier PL, Viehweger E, et al. Lumbar hemivertebra resection. J Bone Joint Surg Am
2006;88:1043–1052
Kobayashi T, Atsuta Y, Takemitsu M, et al. A prospective study of de novo scoliosis in a community based
cohort. Spine 2006;31:178–182
Kuklo TR, Potter BK, Schroeder TM, et al. Comparison of manual and digital measurements in adolescent
idiopathic scoliosis. Spine 2006;31:1240–1246
Lenke LG. Lenke classification system of adolescent idiopathic scoliosis: treatment recommendations.
Instr Course Lect 2005;54:537–542
Lenke L, Betzr, Clements D, et al. Adolescent idiopathic scoliosis: a new classification to determine
extent of Spinal arthrodenis. J Bone Joint Surg Am: 2001 83A(8):1169–1181
Lenke LG, Edwards CC II, Bridwell KH. The Lenke classification of adolescent idiopathic scoliosis: how it
organizes curve patterns as a template to perform selective fusions of the spine. Spine 2003;28:
S199–S207
Lonstein JE. Scoliosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res 2006;443:248–259
Pateder DB, Park YS, Kebaish KM, et al. Spinal fusion after revision surgery for pseudarthrosis in adult
scoliosis. Spine 2006;31:E314–E319
Weigert KP, Nygaard LM, Christensen FB, et al. Outcome in adolescent idiopathic scoliosis after brace
treatment and surgery assessed by means of the Scoliosis Research Society Instrument 24. Eur Spine J
2006;15(7):1108–1117
18
Kyphotic Spinal Deformities in
Children and Adults
I. General considerations
A. Anatomic variation
1. Cervical lordosis, thoracic kyphosis, and lumbosacral lordosis
2. Sagittal plumb line (odontoid) should normally cross C7–T1, T12–L1,
and posterior aspect of the sacrum (S1).
B. Normal thoracic kyphosis
1. Twenty to 45 degrees, mean 34 degrees
C. Normal lumbar lordosis
1. Forty to 60 degrees
2. Two thirds of lordosis occurs between L4–L5 and L5–S1.
II. Biomechanics
A. Anterior column failure results in compression, and posterior column fail-
ure results in tension.
B. Posterior structures
1. Lamina and ligamentum flavum are relatively stronger in resisting ten-
sion than facets, capsules, and interspinous ligaments.
C. Deformity increases moment arm, resulting in further decompensation.
D. Eccentric loading can affect cartilaginous growth.
1. Compression decreases growth anteriorly.
2. Tension increases growth posteriorly, resulting in increased kyphosis.
III. Classification
A. Postural
B. Congenital (Fig. 18–1)
1. Defect of formation
2. Defect of segmentation
3. Mixed
193
194 IV Deformity
C. Scheuermann’s disease (Fig. 18–2)
D. Neuromuscular
E. Myelomeningocele
1 Developmental (late paralytic)
2. Congenital (present at birth)
F. Traumatic
1. Due to bone, ligament, and/or cord injury
G. Postsurgical
1. Postlaminectomy
2. Following excision of a vertebral body
Figure 18–1 Images of a 44-year-old man with neurofibromatosis who presented with severe
kyphoscoliosis and paraplegia. A simultaneous anterior and posterior approach was performed on
this patient to combine anterior and posterior procedures. The steps of the procedures included a
posterior osteotomy, anterior vertebrectomy, and spinal cord decompression, anterior fusion with
strut grafting, posterior compression instrumentation, and anterior instrumentation in this order.
(A) Preoperative magnetic resonance image showing 170-degree kyphosis with cord compres-
sion. (B) CT Myelogram demonstrating severe kyphotic deformity with signal cut-off distal to the
T9 vertebra. (C) Intraoperative photograph showing anterior vertebrectomy, fibular strut graft,
and anterior instrumentation. (D) Postoperative radiograph showing 65 degrees of kyphosis.
Chapter 18 Kyphotic Spinal Deformities in Children and Adults 195
Figure 18–2 Preoperative radiographs of an 18-year-old woman with Scheuermann’s kyphosis.
(A) Anteroposterior radiograph demonstrating no coronal plane deformities. (B) Lateral radiograph
measuring 80 degrees of kyphosis from T1–T12. Because of her relative flexibility, an all posterior
approach was performed, restoring her sagittal balance (C,D).
196 IV Deformity
H. Postirradiation
I. Metabolic
1. Osteoporosis
a. Senile
b. Juvenile
2. Osteomalacia
3. Osteogenesis imperfecta
J. Skeletal dysplasia
1. Achondroplasia
2. Muchopolysaccharidoses
3. Neurofibromatosis
K. Collagen disease
1. Marie-Strumpell disease
L. Tumor
1. Benign
2. Malignant
a. Primary
b. Metastatic
M. Inflammatory and infectious
IV. Specific kyphotic deformities
A. Postural kyphosis
1. Most common in adolescents and young adults
2. Round back deformity
3. Modest kyphosis (40 to 60 degrees)
4. Smooth and flexible
5. No radiographic changes
B. Congenital kyphosis
1. May be single or multilevel
a. Type I
(1) Failure of formation (hemivertebra)
(2) Worse prognosis for progression and paraplegia
(a) Upper spinal levels have a worse prognosis than lower
levels.
b. Type II
(1) Failure of segmentation (bar)
c. Type III
(1) Combination of I and II
2. Treatment
a. Nonoperative treatment is ineffective.
b. Surgery
(1) Type I lesions
(a) Posterior in situ fusion if 50 degrees at 1 to 5 years
(b) Anterior and posterior fusion if 50 degrees and older
children
(i) Better correction and maintenance
(ii) Lower rate of pseudarthrosis
Chapter 18 Kyphotic Spinal Deformities in Children and Adults 197
(c) Anterior decompression
(i) Release of all the tethering structures
* Anterior longitudinal ligament
** Intervertebral disk and end plate
*** Posterior longitudinal ligament
(ii) Intraoperative distraction and correction of the deformity
* Rib, fibula, or iliac crest strut grafts
(iii) Simultaneous or second-stage posterior fusion with
compression instrumentation
(iv) Postoperative bracing is recommended.
(2) Type II lesions
(a) Posterior fusion only if less than 55 degrees of kyphosis
(i) For severe deformity, an anterior osteotomy and correc-
tion and fusion may be attempted followed by a poste-
rior fusion.
(b) Skeletal traction is contraindicated as it may cause paraplegia.
C. Scheuermann’s disease (juvenile kyphosis)
1. Scheuermann first described radiological manifestation of this disease
in 1920.
2. Incidence is 0.4 to 8.3% of the population, but only 1% seeks medical at-
tention.
3. Pathogenesis is unknown.
a. Familial tendency with no genetic link
b. Collagen weakness and stunted ossification of the vertebral end
plate are characteristic.
c. Osteopenia
d. Nutritional deficiencies
e. Mechanical alterations and muscle weakness have been theorized.
(1) No scientific evidence exists.
(2) Growth centers adjacent to the vertebral end plate (not ring
apophyses)
(a) Anterior cartilaginous columns experience stunted growth
with axial loading.
(b) Posterior physis hypertrophy due to tensile forces
(3) With kyphotic deformity, spinal flexors become stronger than
extensors because of moment arm.
4. Pathoanatomy
a. Thickened and contracted anterior longitudinal ligament
b. Wedging of the anterior vertebral bodies
c. Nucleus pulposus
(1) Protrusion anteriorly and into the bony spongiosa (Schmorl’s
nodes)
5. Clinical findings
a. Onset is commonly between 12 and 14 years of age.
b. Equal male:female ratio
c. Deformity is the most common presenting complaint.
d. Pain occurs in 50% among those who seek medical attention.