60 year old female presented with Adult Idiopathic Scoliosis and Grade 2 Isthmic Spondylolisthesis. She was treated with an anterior and posterior spinal fusion.

1. Case Review:
60 year old female, with
Adult Idiopathic Scoliosis
and Grade 2 Isthmic
Spondylolisthesis
Robert S Pashman, MD
Scoliosis and Spinal Deformity Surgery
www.eSpine.com

2. Patient History & Pre-op X-rays
60-year-old female
Kim/SRP type 3
curved thoracic lumbar
Grade 2 Isthmic
Spondylolisthesis of
L5-S1.
The patient has
significant lumbosacral
obliquity.

3. Indications for Surgery
1. Kim/SRP type 3 adult idiopathic scoliosis.
2. Grade 2 isthmic spondylolisthesis L5-S1.
3. Severe frontal and sagittal plane decompensation of
thoracolumbar spine.
4. Osteopenia of thoracolumbar spine.
5. Failed conservative therapy with low back and leg pain.

4. Surgical Strategy
An anterior interbody fusion is indicated for the following
reasons: 1) spondylolisthesis, 2) there is significant rotation and
curvature, 3) the frontal and sagittal plane decompensation, 4)
and the need for horizontalization of the primary L4-5 and L5-
S1 interspace to gain posterior coronal balance.
Characteristic of the KIM 3 SRP classification, the patient will
need T3 to sacral pelvic fixation. Bilateral fixation is necessary
because of the high instability with the isthmic spondylolisthesis.
The patient has multiple challenges including some pulmonary
disease as well as osteopenia. The instability and progressive
curvature which is greater than 80 degrees, thoracic lumbar with
significant degeneration, facet arthropathy necessitates
osteotomy at multiple levels to induce flexibility of the spine to
guarantee sagittal and coronal plane balance.

5. Surgical Strategy – Stage 1
Subtotal vertebrectomy L5 for introduction of anterior lumbar
interbody fusion graft L5-S1.
Interbody complete evacuation of disk and diskectomy L5-S1.
Radical diskectomy L4-5.
Interbody fusion L4-5, L5-S1 with polyetheretherketone device
Alphatec 8-mm with allograft and recombinant human bone
morphogenetic protein centrally.
Anterior screw fixation L4-5, L5-S1.
Intraoperative fluoroscopic control.

6. Surgical Strategy – Stage 2
Segmental spinal instrumentation, T3, to the sacral pelvis using titanium
screw, cobalt chrome instrumentation.
Sacral pelvic fixation, bilaterally, through separate incisions.
Posterior spinal fusion, T3 to the sacral pelvis, using locally- harvested
autogenous bone and allograft putty.
Spinal osteotomy, Smith-Peterson osteotomy T12-L1, L1-2, L2-3, L3- 4,
L4-5.
Bilateral neural foraminotomy with complete facetectomy and a lateral
recess decompression, L1-2, L2-3, L3-4, L4-5 using high- intensity
illumination.
Reduction spondylolisthesis, L5-S1, using a reduction screw, pedicle
screw, and sacropelvic fixation of grade 2 isthmic spondylolisthesis.
Intraoperative somatosensory-evoked potential and motor-evoked
potential processing.
Neuro-navigation with stealth/O-arm intraoperative navigation.
Plastic closure of wound.

7. Post-Op Films
The patient is well balanced in
the sagittal and coronal plane.
She gained approximately 2
inches in height, and is thrilled
with her outcome.

8. Pre-Op/Post-op Comparison