A presentation on adult degenerative scoliosis: presentation, diagnosis, and treatment options based on the best available evidence as of 2008.

1. Adult Scoliosis
Sohail Bajammal, MBChB, MSc, FRCS(C)
Nov 17, 2008

2. Adult Scoliosis
• Terminology
• Incidence & Prevalence
• Pathophysiology
P th h i l
• Clinical presentation
• Evaluation
• Treatment strategy and controversies
• Complications

3. Terminology
• Scoliosis (>10º) in an adult patient:
(>10 )
– Pre-existing from adolescence:
• Idiopathic: most common
• Less common: congenital or paralytic
– De novo:
• Degenerative: most common
• Less common: osteoporosis, iatrogenic

4. SRS Classification
Lowe et al. The SRS Classification for Adult Spinal Deformity. Spine 2006;
31:S119–S125

5. Incidence
• Kobayashi et al 2006:
– Community volunteers
– 60 subjects aged 50 84 years
50-84
– Followed 12 years
– Scoliosis developed in 22 subjects (37%)
– Predictors of de novo scoliosis:
• > 20% d
decrease i unilateral di h i ht
in il t l disc height
• > 5 mm longer osteophyte on one side

6. Prevalence
• Schwab et al 2005:
– Volunteers, Inclusion criteria: >60, no known
history of scoliosis
– Health survey questionnaire, AP spine and
nutritional parameters
– Mean age: 70.5
– 68% met the definition of scoliosis (Cobb
angle >10°)

7. Pathophysiology of
Degenerative S li i
D i Scoliosis
• Degenerative disc disease
• Facet joint arthropathy
j p y
• Spinal stenosis
• Osteoporosis
• Lumbar hypolordosis
• Segmental instability: including rotatory

8. Clinical Presentation
Cli i l P t ti

9. Back Pain
• The most common complaint, 85%
• Back pain in the area of curvature is related to:
– the degree of disc degeneration
– facet arthropathy
p y
– rotatory subluxation and lateral listhesis
• Generalized back pain: related to muscle fatigue
from either coronal or sagittal imbalance

10. Claudicatory Leg Pain
• Can be due to central, lateral recess
and/or foraminal stenosis
– Often corresponds to the concavity of the
p y
curve, especially at L3 or L4
• Or due to rotatory subluxation
• Both dynamic pathologies:
– Might not show up on MRI
– Consider CT/myelogram

11. Radiculopathy
• 22 consecutive patients of scoliosis
• MRI, CT/myelography, discography
• L3 or L4 roots: by foraminal or extra-
y
foraminal stenosis at the concave side
• L5 or S1 nerve roots: by lateral recess
stenosis at the convex side
Liu et al. Characteristics of nerve root compression caused by degenerative
lumbar spinal stenosis with scoliosis. Spine J. 2003;3(6):524-9.

12. Curve Progression
• Weinstein and Ponseti 1983:
– 40-year follow-up data on idiopathic curves
– Thoracic curves > 50 degrees at skeletal maturity
g y
progressed an average of 29.4 degrees
– Thoracolumbar curves between 50 and 75 degrees
increased an average of 22 3 degrees
22.3 degrees.
– Lumbar curves had the most progression, especially
when the L5 vertebra was not well seated and when
the apical rotation was greater than 33%.

13. Evaluation

14. Clinical Evaluation
• General:
– General health, comorbidities, nutritional,
psychological,
psychological disabilities
• Specific:
– Spine & lower extremities
–VVascular status
l t t

15. Radiographic Evaluation
• Radiographs:
– 36-in standing AP & lateral Spine X-ray
– Supine side-bending X ray
side bending X-ray
• MRI
• Myelogram & post ye og a C
ye og a post-myelogram CT
• DEXA scan: to assess BMD

16. Treatment
T t t

17. Non-
Non-operative Treatment
• Goals:
– Core (abdominal & lumbar) strengthening
– Gluteal strengthening
– Hamstring and iliopsoas flexibility
– Improvement in cardiovascular endurance
p
• Modalities:
– Physiotherapy, aqua & chiropractic therapy
– NSAIDs
– Nerve root injections

18. Systematic Review of
Non-
Non
N -operative T
i Treatment
• There is indeterminate, Level III/IV evidence on
the effectiveness of any conservative option
• Level IV evidence on the role of physical
therapy,
therapy chiropractic care and bracing
care,
• Level III evidence for injections in the
conservative treatment of adult deformity
Everett & Patel. A systematic literature review of nonsurgical treatment in
adult scoliosis. Spine. 2007;32:S130-4.

19. Indications for Surgery
1.
1 Back pain failing conservative care
2. Progressive leg pain or neurologic deficit
3. Muscle f ti
3 M l fatigue secondary t spinal
d to i l
imbalance
4. Curve progression
5. Progressive p
g pulmonary compromise
y p
secondary to deformity
6.
6 Severe deformity

20. Goals of Surgery
• To decrease pain
• T halt progression or i
To h lt i improve neurologic
l i
symptoms
• To stabilize the curve

21. Surgical Planning
• Overall health of the patient
• Patient's expectations
Patient s
• Different from adolescent scoliosis:
– Presence of disc degeneration, facet
arthropathy, and osteopenia
– Problem of adjacent segment problems:
degeneration, junctional kyphosis

22. Preparing for Surgery
Hu & Berven. Preparing the Adult Deformity Patient for Spinal Surgery.
Spine 2006; 31: S126–S131

23. Preparing for Surgery
Hu & Berven. Preparing the Adult Deformity Patient for Spinal Surgery.
Spine 2006; 31: S126–S131

24. Surgical Options
• Decompression alone
• Decompression and posterior
instrumented fusion
• Decompression, combined anterior and
posterior i t
t i instrumented fusion
t df i

25. Controversy in Decision Making
• Role of decompression alone or limited
arthrodesis
• Role of combined anterior and posterior
• Choice of fusion level (how high and how
low)
l )

28. Operative Management of Degenerative
Scoliosis: An Evidence-Based Approach to
Evidence-
Surgical Strategies Based on Clinical and
Radiographic Outcomes
• Retrospective study (Level III)
• 60 consecutive patients
• Data available for 38 patients
– 30 posterior only fusion
– 4 anterior only surgery
– 4 combined anterior and posterior
• Improvement in pain is more reliable than
improvement in function

29. L5-
L5-S1: To fuse or not to fuse
Swamy et al. The Selection of L5 Versus S1 in Long Fusions for Adult
Idiopathic Scoliosis. Neurosurg Clin N Am 18(2007): 281–288

30. L5-
L5-S1: To fuse or not to fuse
Swamy et al. The Selection of L5 Versus S1 in Long Fusions for Adult
Idiopathic Scoliosis. Neurosurg Clin N Am 18(2007): 281–288

31. L5-
L5-S1: To fuse or not to fuse
Swamy et al. The Selection of L5 Versus S1 in Long Fusions for Adult
Idiopathic Scoliosis. Neurosurg Clin N Am 18(2007): 281–288

32. How High?
Upper I
U Instrumented V
d Vertebra (UIV)
b
• Ai for a stable, neutral vertebra
Aim f t bl t l t b
• Should not end instrumentation at a segment with:
– Posterior column deficiency
– Listhesis in any direction
y
– A rotated spinal segment
– A region of junctional kyphosis, or
– At the apex of deformity in coronal and sagittal plane.
Shufflebarger et al. Debate: Determining the Upper Instrumented Vertebra in
the Management of Adult Degenerative Scoliosis. Spine 2006: S185–S194

33. When to go from the front?
• A long fusion to the L-S junction
LS
• A large coronal deformity: > 60° structural
60
curve or >5cm decompensation
• The need to improve sagittal alignment
significantly with anterior structural support
Mok & Hu. Surgical Strategies and Choosing Levels for Spinal Deformity: How
High, How Low, Front and Back. Neurosurg Clin N Am 18 (2007) 329–337.

34. MIS Scoliosis

35. • Retrospective chart reviews
• Si l surgeon
Single
• MIS LIF without decompression (XLIF or
DLIF) ± Axial Lumbar Interbody Fusion
(AxialLIF)
• MIS pedicle screw fixation (Longitude)

36. XLIF
Ozgur et al. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique
for anterior lumbar interbody fusion. The Spine Journal. 6(4): 435-43, 2006.

39. XLIF
Ozgur et al. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique
for anterior lumbar interbody fusion. The Spine Journal. 6(4): 435-43, 2006.

40. AxiaLIF
Marotta et al. A novel minimally invasive presacral approach and instrumentation
technique for anterior L5–S1 intervertebral discectomy and fusion. Neurosurg
Focus 20 (1): E9, 2006

41. 73yr, 35 degree curve
73yr

42. 73yr, 35 degree curve
73yr

43. Primary Measure(s)
• Blood loss
• Length of surgery
• Post
P t operative hospital stay
ti h it l t
• Preoperative and post-operative visual
analog score (VAS) and the Treatment
Intensity Score (TIS)

44. Results
• 12 patients
• Age: 50-85 (mean 73)
• Number f levels: 2 8 (mean 3.5)
N b of l l 2-8 ( 3 5)
• Mean hospital stay: 8.6 days
• Mean Cobb angle: 18.93° preop  6.19°
p
postop
p

45. Results

46. Results

47. Complications
• 3 thigh dysathesias postoperatively
resolved in 6 weeks
• Hip flexor weakness and pain: resolves
within 2 weeks
• Transient quadriceps weakness: 1 p
q p patient
who had L4-5 interbody fusion: resolved
completely in 6 weeks
p y

48. Complications
p
Mortality, Medical & Surgical

49. Mortality after Deformity Surgery
• 361 adults with spinal deformity
p y
• Underwent 407 corrective procedures
– 146 primary, 261 revision
– 211 scoliosis, 65 kyphosis,
, yp ,
– 89 scoliosis with pseudoarthrosis, 42 kyphosis
with pseudoarthrosis
• Age: 20 to 86 (mean 48)
Pateder et al. Short-term Mortality and Its Association With Independent Risk
Factors in Adult Spinal Deformity Surgery. Spine 2008.

50. Mortality after Deformity Surgery
• 30-day mortality
y y
• Examined for possible predictors:
– Demographic ( g , g
g p (age, gender))
– ASA classification
– Operative time
– Surgical approach
– Number of fusion levels
– Primary versus revision surgery
– Intraoperative blood loss
Pateder et al. Short-term Mortality and Its Association With Independent Risk
Factors in Adult Spinal Deformity Surgery. Spine 2008.

51. Mortality after Deformity Surgery
• 30-day mortality: 10/407 (2.4%)
y y ( )
Pateder et al. Short-term Mortality and Its Association With Independent Risk
Factors in Adult Spinal Deformity Surgery. Spine 2008.

52. Mortality after Deformity Surgery
• Only ASA class was strongly associated
y gy
with 30-day mortality
• The rest of factors were not statistically
different between the two groups
Pateder et al. Short-term Mortality and Its Association With Independent Risk
Factors in Adult Spinal Deformity Surgery. Spine 2008.

53. Medical Complications
Baron & Albert. Medical Complications of Surgical Treatment of Adult Spinal
Deformity and How to Avoid Them. Spine 2006. 31: S106–S118

54. Baron & Albert. Medical Complications of Surgical Treatment of Adult Spinal
Deformity and How to Avoid Them. Spine 2006. 31: S106–S118

55. Medical Complications
Baron & Albert. Medical Complications of Surgical Treatment of Adult Spinal
Deformity and How to Avoid Them. Spine 2006. 31: S106–S118

56. Surgical Complications
• Pseudoarthrosis
• Proximal junctional kyphosis
• Loss of sagittal b l
L f itt l balance
• Deep wound infection
• Neurovascular injury
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392

57. Pseudoarthrosis
• The most common complication
• Associated with lower functional outcomes
• Most common at L-S & T-L junctions
• Risk factors:
– Age > 55yr
– Thoracolumbar kyphosis > 20
– Fusion > 12 segments
g
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392

58. L5-
L5-S1 Pseudoarthrosis
• Luque-Galveston rods: 36% - 41% (
q % % (Emami
2002, Boachie-Adjei 1991)
• Current recommended technique: bicortical
sacral screws, iliac screws, interbody fusion
• Islam 2001: sacral screws only 53%, iliac screws
only 42%, both 21%
• Tsuchiya 2006: 33 scoliosis patients, bilateral
sacral & iliac screws, 2/33 (6%) pseudoarthrosis

59. Proximal Junctional Kyphosis
• Most commonly at thoracolumbar junction
• Rates: 26% to 42%
• DeWald 2006, Glattes 2005, Yang 2003
D W ld 2006 Gl tt 2005 Y
• Risk factors:
– 5°-10° kyphosis at adjacent level cephalad to
the upper instrumented vertebra
– osteoporosis
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392

60. Loss of Sagittal Balance
(Sagittal D
(S i l Decompensation) i )
• C7 plumb line ≥5 cm anterior to the
posterior aspect of S1 superior end plate
• Glassman et al 2005:
– 752 patients, multicentre, retrospective
– All measures of health status showed
significantly poorer scores as C7 plumb line
deviation increased.
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392

61. Causes of
Sagittal Decompensation
S i lD i
• O t
Osteoporotic compression fractures within or
ti i f t ithi
adjacent to a deformity construct
• Ankylosing spondylitis
• Posttraumatic kyphosis
• Di t ti instrumentation
Distraction i t t ti
• Adjacent segment disease
• Poor correction based on pre-existing sagittal
balance
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392

62. Treatment of Sagittal
Decompensation
D i
• R i i surgery with a S ith P t
Revision ith Smith-Peterson
osteotomy or pedicle subtraction
osteotomy
t t

63. Deep Wound Infection
• Lonstein et al 1973: 80 patients
patients,
Harrington instrumentation, 20% in adults,
7.5%
7 5% in adolescent
• K et al 2004: 3230 cases, i t
Kuo t l 2004 instrumented
t d
spine, 2.2%
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392

64. Neurovascular Injury
• Bridwell et al 1998: 1090 cases, 4 major
j
complications
– All 4 combined anterior & posterior, with
p ,
harvesting of convex segmental vessels
– All 4 had hyperkyphosis
y y
• Guigui et al 2005: 3311 patients, 1.8%,
increased risk with initial angle and double
thoracic and lumbar curves
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392

65. Neurovascular Injury
• Pedicle screws: irritation of nerve roots
(0.15% to 1%)
• L5-S1 ALIF: sexual dysfunction 0.42% to
5%
• Vascular complications: 1.4% to 20%,
anterior approach, most common @ L4
i h L4-5
– Left common iliac vein, iliolumbar vein
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392

66. Thank You