Primary degenerative scoliosis (‘‘de novo’’ form), mostly located in the thoracolumbar or lumbar spine. Progressive idiopathic scoliosis in adult life of the thoracic, thoracolumbar, and/or lumbar spine

1. Adult ScoliosisAdult Scoliosis
IndicationsIndications
forfor
Operative TreatmentOperative Treatment
PROF. GEORGE SAPKAS
1st Orthopaedic Department
Medical School-Athens University
Attikon Hospital
Metropolitan Hospital
Athens Greece

2. Adult scoliosisAdult scoliosis

3. 11stst
TypeType
Primary
degenerative
scoliosis
(‘‘de novo’’
form), mostly
located in the
thoracolumbar
or lumbar spine
Grubb SA, et al (1992)
Aebi M. (2005)

4. 22ndnd
TypeType
Progressive idiopathic
scoliosis in adult life of
the thoracic,
thoracolumbar, and/or
lumbar spine
Ascani E, et al, 1986
Aebi M. , 2005
AA

5. BB

6. 33rdrd
TypeType
(a) Scoliosis following
idiopathic or other forms
of scoliosis or occurring
in the context of a pelvic
obliquity
(b) Scoliosis secondary to
metabolic bone disease
(mostly osteoporosis)
Aebi M. , 2005

7. 1. Body deformity
2. Pain
3. Neurological
disorders
Main problemsMain problems

8. Coronal –Sagittal imbalanceCoronal –Sagittal imbalance

9. Pain is due to:Pain is due to:

10. Intervertebral discsIntervertebral discs

13. Facet jointsFacet joints

14. InstabilityInstability

15. Automatic fusionAutomatic fusion

16. Muscles – LigamentsMuscles – Ligaments
S-I jointsS-I joints

17. Neurological disordersNeurological disorders
1. Lumbar canal stenosis
2. Foraminal stenosis

18. Imaging studiesImaging studies

19. Reduction of lumbar lordosisReduction of lumbar lordosis
Plain x-raysPlain x-rays

20. Sagittal alignmentSagittal alignment
Analysis of Sagittal Balance of the Spine and Pelvis using Shape and Orientation Parameters
Eric Berthonnaud,Pierre Roussouly et al. J Spinal Disord Techn February 2005 pp 40-47

21. This is assessed by the relationship ofThis is assessed by the relationship of
the C7 plump line to the sacrum in thethe C7 plump line to the sacrum in the
coronal and sagittal planescoronal and sagittal planes

22. Measurement Sagittal balanceMeasurement Sagittal balance
Spine 2005 pp E959-E967
Is the spinal deformityIs the spinal deformity
balanced or unbalanced ?balanced or unbalanced ?

23. C.T. - ScanC.T. - Scan

24. 3 mts p.op.
12
11
1
2
3
4
5/S1
10
12
11
1
2
3
4
5/S1
103D - Scan3D - Scan

25. M.R.I.M.R.I.

26. MyelogramMyelogram

27. DiscogramDiscogram

28. Facet BlockFacet Block

29. Pain patternPain pattern
Pa. Va. 03-2008
Pain pattern
Oswestry D.I.Oswestry D.I.
Rolland-MorrisRolland-Morris
etc …etc …

30. TreatmentTreatment

31. 1. Adults without indications for
conservative treatment
a. Mild pain
b. Elderly with pain
c. Unspecified type of pain
2. Cardio - respiratory insufficiency
3. Severe psychological problems
David Polly, Spine 2006
Conservative treatmentConservative treatment

32. 1. Anti-inflammatories
2. Physiotherapy
3. Belts-braces
4. Instructions
Local injections
a. anaesthetics
b. corticosteroids
Conservative treatmentConservative treatment
Va. Th.Va. Th.
M 77M 77

33. Operative treatmentOperative treatment

34. Purposes of the operative treatmentPurposes of the operative treatment
I. Prevention of progression
II. Maintenance of lumbar lordosis
III. Restoring global balance
IV. To reduce or to relieve the pain
V. To anticipate the neurological deficit

35. Key pointsKey points
Sagittal imbalance is
poorly tolerated in
elderly scoliosis
patients
Timothy Kuklo, Spine 2006

36. A fusion should not be
stopped adjacent to a
degenerated segment
Timothy Kuklo, Spine 2006
L5
L5
S1
S1
L5
S1

37. • Inadequate decompression
• Post-operative instability
• Deterioration of the deformity
Side effects
Decompression

38. NeuromonitoringNeuromonitoring
Navigation systemNavigation system

39. Γ.Π.
F 74
01-10-07
Decompression and stabilization
(short)

40. Anterior correction and
Posterior Correction and Stabilization
Ε.Χ.
F – 45
1995
STAND
T10
L3
T9
40O
64O

41. Posterior Correction and Stabilization
Transpedicular Screws and TLIF L3-L4 & L4-L5

42. Hooks & Rods + transpedicular screws
Correction and stabilization
Hybrid System

43. Eρ. Ιορ
F 63
21-05-02
4 mts
POP
Eρ. Ιορ
F 63
21-05-02
4mts
POP
Decompression and stabilization

44. Adult Degenerative Scoliosis - Kyphosis

45. • Posterior 3 column stabilization
• Intervertebral cages

46. TLIFTLIF
Adult degenerative Kyphosis – ScoliosisAdult degenerative Kyphosis – Scoliosis
(+) Parkinson(+) Parkinson

47. Extension to pelvis
+
TLIF

48. Post – opPost – op
brace forbrace for
3 – 6 months3 – 6 months

49. ObservationsObservations

50. ExtensiveExtensive
Operative timeOperative time

51. Automatic fusion
Multiple osteotomies
for mobilization
Technical issuesTechnical issues

52. Loss of :
• Lumbar Lordosis
(flat back)
and
• Sagittal balance
Technical issuesTechnical issues
• Osteotomies to restore
sagittal balance
(e.g. S.P. osteotomies)
• Intervetebral cages

58. Lumbar corrective osteotomiesLumbar corrective osteotomies
for flat backfor flat back ± intervertebral spacers± intervertebral spacers
AnteriorAnterior
supportsupport

59. Vertebral rotation
Vertebral displacement

60. OsteoporosisOsteoporosis
Top-off

61. Π.Μ.
F 80
28-7-06
Π.Μ.
F 82
30-8-08
Loss of stabilization
above
bellowbellow
T-Score: -3.5

62. Extension ofExtension of
spondylodesiaspondylodesia
To fuse or not to fuseTo fuse or not to fuse
to the sacrumto the sacrum
The fate of theThe fate of the
L5 – S1 discL5 – S1 disc
sacrumalar

63. AdvantagesAdvantages
 Retention of lumbosacralRetention of lumbosacral
motionmotion
 Absence of S1 joint stressAbsence of S1 joint stress
 Decreased operating timeDecreased operating time
 Lower pseudarthrosis rateLower pseudarthrosis rate
 Decreased instances ofDecreased instances of
instrumentationinstrumentation
complicationscomplications
Stop at L5Stop at L5

64. The ability to fuse
at L5 does require
a relatively normal
L5 – S1 disc

65. 61% (19 pts) developed
advanced disc
degeneration
4 pts required revision
to the sacrum
Edwards et al, Spine 2003
Fate of the L5 – S1 discFate of the L5 – S1 disc
in patients undergoingin patients undergoing
long fusionslong fusions

66. Keith H. Bridwell ,Spine 2006
Extension ofExtension of
spondylodesiaspondylodesia
to the sacrumto the sacrum
oror
to the pelvisto the pelvis
Er. Ior.
F. 65
6 mts pop
16-07-02

67. Severe disc degeneration atSevere disc degeneration at
L5 - S1L5 - S1
SpondylolesthesisSpondylolesthesis
at L5 – S1at L5 – S1
Spinal stenosisSpinal stenosis
at L5 – S1at L5 – S1
Keith H. Bridwell ,Spine 2006
cont.
IndicationsIndications
35o

68. Absolute indication
 Oblique
take-off
at L5 – S1
>15o
E. Pant.
F. 75
7-4-02
6mts
pop
35o

69. Keith H. Bridwell ,Spine 2006
cont.
Disadvantages ofDisadvantages of
extending to theextending to the
sacrumsacrum
 Bigger operation isBigger operation is
neededneeded
 Usually anteriorUsually anterior
column support iscolumn support is
advocated at theadvocated at the
distal lumbar spinedistal lumbar spine
through either athrough either a
posterior or anteriorposterior or anterior
approachapproach
 If motion is lostIf motion is lost
at L5 – S1 this mightat L5 – S1 this might
alter the patients gaitalter the patients gait

70. Fusion to the sacrum
runs the risk of pullout
of the sacral screws
and a higher
pseudarthrosis rate
at L5 – S1
Keith H. Bridwell ,Spine 2006

71. Implants failure ~ 4%
Pseudarthrosis ~ 7% - 15%
Loss of correction
Complications relatedComplications related
to implants and fusionto implants and fusion
K.St.
F. 67
8 yrs pop
16-02-07
K.St.
F. 67
8 yrs pop
16-02-07

72. Eli M. Barton, Todd J. Albert ,
Spine 2006
MedicalMedical
complicationscomplications

73. ConclusionsConclusions

74. Conservative treatmentConservative treatment

75. DeformityDeformity
PainPain
NeurologicalNeurological
disordersdisorders
CorrectionCorrection
StabilizationStabilization
DecompressionDecompression
65

76. The 3 columnsThe 3 columns correction andcorrection and
stabilizationstabilization
Overall gives the best clinical resultsOverall gives the best clinical results

77. Key pointKey point
for the successfulfor the successful
operative treatmentoperative treatment
of the adultof the adult
spinal deformityspinal deformity
is the restorationis the restoration
of theof the
sagittal balancesagittal balance..

78. University Hospital “ATTIKON”